Pain Medication Addiction

Patient Report

A 71-year-old female with a past medical history significant for lung cancer, breast cancer, COPD, chronic heart failure with preserved ejection fraction (last EF 63%), chronic abdominal pain, opioid use disorder on methadone, prior pulmonary embolism, and prior COVID infection. 

She was recently admitted for abdominal pain, at which time GI was consulted and felt the etiology was most likely constipation colic. At that time, she underwent an MRCP which showed a mildly dilated biliary duct without evidence of choledocholithiasis. She was encouraged to avoid additional opioid use.

The patient now presents with persistent severe abdominal pain, similar to her recent admission. She describes the pain as epigastric and ongoing despite prior management. She is maintained on methadone 35 mg daily, although she reports that her dose was reduced two weeks ago and states her goal is eventual discontinuation.

On assessment, she is alert and oriented. She reports pleuritic chest pain in addition to her abdominal discomfort. Given her history of constipation and increased stool burden, additional opioids are being avoided.

Principal Problem:

• Abdominal pain (SNOMED CT: Abdominal pain)

Assessment and Plan:

1. Epigastric abdominal pain / chronic abdominal pain

   • Persistent symptoms resembling prior admission.

   • GI previously consulted; MRCP showed mildly dilated biliary duct without choledocholithiasis.

   • Plan: follow up repeat CT abdomen and pelvis, consider GI consult for EGD ± ERCP, continue MiraLAX BID and senna nightly, document all bowel movements, avoid additional opioids, obtain post-void bladder scan ×1, obtain chest X-ray for pleuritic pain.

2. Opioid use disorder on methadone

   • Currently on methadone 35 mg daily.

   • Will need to confirm dose with APT foundation.

   • Patient reports recent dose reduction and goal to taper off methadone.

3. History of breast cancer

   • On anastrozole.

4. Prior pulmonary embolism

   • On Eliquis for anticoagulation.

5. Chronic HFpEF

   • Maintained on torsemide 40 mg daily.

Comorbidities present on admission:

• Chronic heart failure with preserved ejection fraction (EF 63%).

• COPD.

• Lung cancer.

• Breast cancer.

• Prior PE.

• History of COVID infection.

Medications:

• Eliquis 5 mg BID

• Celecoxib 100 mg BID

• Vitamin D3 1000 units daily

• Cyanocobalamin 1000 mcg daily

• Methadone 35 mg daily

• Pantoprazole 40 mg daily

• Torsemide 40 mg daily

• Tylenol 975 TID 

Other Orders:

• DVT prophylaxis: Eliquis

• Diet: Regular

• Code status: FC

• Medication reconciliation completed