You are seeing a 35-year-old man whom you have not treated before. He reports that 5 days ago he twisted his left ankle while playing softball. When he continued to have marked pain the next day, he went to the emergency department of a local hospital. An X-ray was taken there and was negative. He was sent home with recommendations to rest, elevate the foot, ice, and to use acetaminophen or ibuprofen for the pain. He was instructed to follow-up with his primary care physician.
He tells you that he has tried both medications and although the pain has been reduced a little, it is still significant and he needs to return to his job in a warehouse which requires a fair amount of walking.
He has no primary care physician as he has been in good health and has never felt the need to have one. A friend of his who is a patient of yours recommended you. His only health problem is a history of depression for which he takes paroxetine 40 mg once daily, prescribed by a psychiatrist.
He reported that about 10 years ago he was prescribed a painkiller for a similar problem and it worked well. He believes it was Vicodin and recalls that he only had to take it for about 10 days before no longer needing it. He denies using any opioids since either for medical reasons or recreationally. He does report occasionally smoking marijuana.
You check your state prescription drug monitoring program and find that he has not received any prescriptions for opioids. With his permission you contact his psychiatrist who says she has followed the patient for about 5 years and he has done well with paroxetine but that when she has tried to discontinue it, the depressive symptoms have returned.
The results of your physical exam reveal a slightly swollen left ankle with some tenderness to palpation. It is apparent that the patient is in discomfort when he walks. You decide that a brief course of an opioid analgesic is indicated.
1. Based on his current problem and history, which of the following would most likely be effective for his pain?
Holmquist GL. Opioid metabolism and effects of cytochrome P450. Pain Med. 2009;10(Supplement 1):S20-S29