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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Identify the typical signs and symptoms of withdrawal associated with the use of opioids

  • Determine the appropriate treatment measures to produce a desired outcome following an episode of opiate withdrawal

  • Determine when a patient meets criteria for substance dependence

  • Choose specific pharmacotherapeutic options based on patient-specific factors

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PATIENT PRESENTATION

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Chief Complaint

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"I hurt my knee playing with the kids yesterday. I'm in a lot of pain."

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History of Present Illness

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RG is a 44-year-old man who presents to the emergency department (ED) on a Sunday afternoon complaining of knee pain. The patient states that he was playing with his girlfriend's children yesterday and accidentally stepped into a hole in the yard and "twisted" his right knee. Per the patient, he tried acetaminophen but it did not work for him. He rates his pain as a 9 on a 10 point scale. The patient states that he has had problems with this knee before and is concerned that he may have triggered an old injury. He offers that he has had prior success with both oxycodone and hydromorphone for a similar injury.

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Past Medical History

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Knee surgery 3 years ago

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Depression × 8 years

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Generalized anxiety disorder (GAD) × 6 years

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Family History

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Patient was adopted and does not have any health-related information regarding his birth family

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Social History

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The patient is divorced and lives with his girlfriend and her two children. He is currently employed as an insurance agent.

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Tobacco/Alcohol/Substance Use

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Social drinker; denies tobacco or illicit substance use.

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Allergies/Intolerances/Adverse Drug Events

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Patient states that he has anaphylaxis to all NSAIDs

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Medications (Current)

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Bupropion 75 mg PO daily

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Sertraline 50 mg PO daily

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Lorazepam 2 mg PO q 6 h prn

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Zolpidem 15 mg PO q hs prn

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Review of Systems

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Overall physical health good; (+) mild abdominal cramping; (−) chest pain, shortness of breath; (+) depression, anxiety

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Physical Examination

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General
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Patient is a well-developed, 44-year-old male who appears to be in mild distress and is moderately agitated.

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Vital Signs
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BP 152/93 mm Hg, P 93, RR 18, T 37.5°C, pain score = 9

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Weight 164.6 lb (74.8 kg)

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Height 72 in. (183 cm)

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HEENT
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(+) Rhinorrhea, lacrimation, dilated pupils

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Chest
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Clear to auscultation

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