Multidisciplinary Pain Control Including the use of Methadone in a Critical Trauma Patient with Unidentified Polysubstance Use

Michael Lu, BA; Taylor Bentz, MD; Anirudh

Bhimavarapu, BS; Clara Goldberger, BS; Vincent

Bargnes III, MD; Adrian Fischl, MD;

Amruta Desai, DO, MPH, MBA

Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY

Dual Clinical Challenge,

Dual Therapeutic Opportunity

Introduction

Effective perioperative pain control in trauma patients is often complicated by limited history and individualized responses. We present a complex case of a young male with flail chest and multisystem trauma whose severe pain and agitation revealed previously unrecognized opioid use disorder (OUD). This case highlights methadone’s role in managing both acute pain and withdrawal, and underscores the importance of a multidisciplinary approach in trauma care.

Case Description

A 28-year-old male presented by ambulance after being struck by a vehicle at 40 mph. He was intubated on arrival with limited history available. Imaging revealed a subarachnoid hemorrhage, flail chest from left rib fractures (1–10), and a ruptured spleen requiring emergent splenectomy. Initial analgesia with fentanyl and adjuncts proved inadequate. He later underwent video-assisted thoracoscopic surgery with decortication and rib plating. Preincision methadone and cryoablation improved pain control and facilitated extubation by post-op day 2. Shortly after, he developed agitation, autonomic instability, and worsening pain. Psychiatry diagnosed acute opioid withdrawal due to previously unrecognized opioid use disorder. Initiation of methadone maintenance led to rapid stabilization, improved analgesia, and eventual transition to buprenorphine prior to discharge.

Intraoperative Management

  - Cryoablation by surgical team

  - 15 mg methadone,  100 mcg Fentanyl, 3.5 mg Hydromorphone

  - Intravenous 800 mg ibuprofen, Q6H acetaminophen peri-op

Postoperative Management

  - Clinical stabilization

  - Improved analgesia

  - Weaned off short-acting opioids