Event 4: Post-Discharge

Summary of a Possible Post-Discharge Medication Plan

Maximize non-opioids 

  • Acetaminophen 650 mg or 975 mg by mouth every 8 hours on a scheduled basis (limit to les than 3,000mg/day)
  • Celecoxib 100 mg by mouth twice a day (if covered by insurance, otherwise consider ibuprofen or other NSAID if no contraindications)
  • Topical agent (e.g. lidocaine or diclofenac) to be applied over rib fractures
  • Consider gabapentinoid or serotonin norepinephrine reuptake inhibitor (SNRI) if pain has neuropathic features

Divide daily dose of buprenorphine (2 to 3 divided doses, e.g. 8mg TID), with plan to reduce back to baseline dose as quickly as possibly

Educate patient on role of naloxone to prevent/treat opioid overdose and prescribe this at discharge

Case Summary

Alison was in stable treatment for opioid addiction, managed with buprenorphine/naloxone 8mg/2mg 2x/day, peer support from her Recovery Coach, and behavioral support from her counselor, when she suffered a car accident, fracturing multiple ribs and her jaw.

She was admitted to the hospital for surgical management of her jaw fracture and pain control.

Inpatient medications for post-operative pain management included increasing her buprenorphine/naloxone dose to 3x/day, a thoracic epidural, perioperative ketamine, and maximizing other adjuvant medications including ketorolac (an IV NSAID) and acetaminophen. She applied ice to her injuries.

Inpatient consult teams, nurses, social workers and other staff provided emotional support for Alison.

Alison used a smartphone app to guide her in meditation strategies during her hospitalization.

A team-based approach provided the support Alison needed for improved pain control while at the same time minimizing stress and possible OUD set-back.

Careful coordination of multidisciplinary and multimodal care after hospital discharge will help Alison to maintain recovery and achieve improved pain control as her injuries heal.

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