Clinical Case No. 1. Postoperative Pain and Opioid Use Disorder

Injury and postoperative pain relief

Mark, 47, installs kitchen cabinets. He lives with his wife, Lisa, in a rented apartment in New Westminster; their adult daughter studies nearby. Before his injury, his working day consisted of stairs, heavy cabinets, travel between jobs and rather improvised lunches. He judged his health mainly by whether he could put on his work boots in the morning.

In March 2025, Mark falls awkwardly on the stairs at home and sustains a complex fracture around the ankle. He undergoes reduction and internal fixation. After surgery, he receives acetaminophen and a short course of oxycodone as needed; the other components of analgesia depend on his postoperative condition. Initially, oxycodone helps exactly where it is expected to: Mark can sleep, move his leg from the bed to the floor and get to the bathroom.

When renewing prescriptions, the physician assesses pain relief alongside mobility, sleep, actual medication use and tolerability. Mark's recovery is prolonged: medication helps him do his exercises, while a return to physical work recedes. [108]

Six weeks later, the wound has healed and the fixation is satisfactory, but installing kitchens is still a distant prospect. By evening, the ankle swells; movement is restricted and exertion increases the pain. The orthopaedic surgeon monitors healing. The family physician continues analgesia through small prescriptions. A physiotherapist sees Mark several times; the family cannot afford regular private sessions.

Each contact has its own logic. Yet no one has brought together sleep, actual tablet use, the family budget and return to work. Lisa keeps three sheets of advice on the refrigerator. Clinically, this is already multidisciplinary care. Administratively, the refrigerator is still in charge.

Development of opioid use disorder

At first, Mark takes oxycodone before exercises or at night. Then he takes it before leaving home so that he will not think about his ankle. Later, he notices that a tablet makes it easier to answer customers' calls. Neither the debts nor the pain disappears, but for a while the feeling that he is letting everyone down at once retreats.

The prescribed quantity increasingly runs out. He takes more than agreed with the physician and requests a new prescription early. Twice he tries to reduce his use on his own. Sweating, yawning, abdominal discomfort and restlessness appear, together with increased pain. Within a few days, he returns to the previous pattern.

Physical dependence manifests through withdrawal. Assessment of opioid use disorder, or OUD, focuses on loss of control, craving and the consequences of use for work and relationships.¹⁰ [108, 109]

In autumn, Mark buys tablets outside the pharmacy that are sold to him as oxycodone. At first, he explains that he could not get an appointment in time. Later, he spends part of his working day looking for tablets. He misses agreed measurement visits, conceals spending and declines family outings during which he could not take a tablet unnoticed. Lisa is angry about more than money: she no longer knows which answers she can trust.

In January 2026, he agrees to seek help. One morning, his daughter asks him to drive her to class, and he realizes that he first has to find tablets. That reversal of priorities frightens him more than the word "addiction."

"I want to stop looking for them," he tells Lisa. "But if they simply take everything away, I don't know how I'll manage the ankle."

First contact with addiction medicine

Mark and Lisa attend Rapid Access to Addiction Care, or RAAC, in New Westminster. This Fraser Health service accepts direct presentations for assessment, initial stabilization and transition to ongoing community treatment. [110]

Their first contact is on a weekday. A nurse assesses intoxication, sedation and urgent needs, then arranges medical review. On weekends, the RAAC pathway begins with nursing assessment; physician access depends on clinical need and availability. [110]

The physician has a family medicine background and practises addiction medicine. She begins OUD treatment and later involves a psychiatrist to assess persistent mood symptoms.

Part of the discussion takes place without Lisa. Mark clarifies what he was embarrassed to say in front of his wife: the time spent searching, the strength of craving and the symptoms after a missed dose. With his consent, Lisa then returns and adds information about sleep, spending and missed commitments.

On examination, he is alert and coherent, with no psychosis or manic features. Sleep is fragmented, mood is low and guilt is prominent. Thoughts such as "I can't keep this up much longer" require direct clarification; he describes no suicidal intent or plan. The physician also asks about alcohol, benzodiazepines, sleeping medication and previous overdoses. Mark reports no regular sedative use; recently, he has drunk alcohol only occasionally.

The pharmacy dispensing history is reconstructed through PharmaNet and reconciled with Mark's account of prescribed and non-pharmacy medication. Confirmatory urine testing detects fentanyl. Mark thought he was buying oxycodone; the treatment initiation plan now takes fentanyl exposure and the risk of precipitated withdrawal into account.

Liver and kidney function and medication interactions are reviewed, and HIV and hepatitis C testing are offered. Mark denies injecting drugs. His physical condition permits the selected treatment to begin. [111]

Distinguishing pain, physical dependence and OUD

The clinical plan addresses persistent postoperative pain, physical dependence and OUD. Each has its own goal: mobility and analgesia, control of withdrawal, reduced craving and restored everyday functioning.

Six behavioural features have emerged over recent months: taking more than intended; unsuccessful attempts to cut down; substantial time spent obtaining opioids; intense craving; repeated failure to meet work obligations; and continued use despite conflict with his wife. Together, these meet DSM-5-TR criteria for severe OUD. [109]

Mark can cooperate, has housing and support, and can attend repeated contacts. There is no acute indication for admission at assessment. The team begins outpatient treatment with frequent contact while medication is selected and adjusted.

The joint, imaging, scar, range of motion, sensation and response to loading are reassessed. The fracture has united, but localized pain and stiffness remain. Their relationship to movement and the metalwork guides further orthopaedic investigation.

The most useful sentence of the appointment is delivered without ceremony: "We can treat the addiction and keep working out what is happening with the pain." Both problems now belong in one treatment plan.

Choosing OAT and starting treatment

Mark asks about a few days of "detox." The physician discusses sustained control of craving, protection against return to unregulated opioids and maintaining tolerance under medical supervision. The 2024 Canadian guideline recommends maintenance treatment for OUD; completing withdrawal alone increases the risk of resumed use and overdose. [112]

They discuss opioid agonist treatment, or OAT. The national guideline's two principal first-line options are buprenorphine and methadone. The choice considers previous experience, craving, tolerability, co-occurring conditions, personal preferences and the practical ability to obtain treatment. [112]

Mark chooses sublingual buprenorphine/naloxone. Its safety profile and the prospect of a more convenient dispensing routine matter to him. Methadone remains a fully appropriate alternative if the chosen option is ineffective or unsuitable. He has heard the name Suboxone, but the physician also writes down the generic names of both components. [113]

Buprenorphine initiation is planned according to the clinical course of withdrawal, taking the last fentanyl use into account. Starting a standard induction too early can precipitate withdrawal. They discuss standard initiation once sufficiently clear objective symptoms are present, and a gradual low-dose transition overlapping with another opioid. Each approach requires an agreed schedule and accessible follow-up. [79]

Mark agrees to a standard induction with in-person assessment. At review, sufficiently marked objective withdrawal is present, assessed clinically and with COWS. Initiation proceeds without precipitated withdrawal. The dose is adjusted to craving, symptoms and tolerability; after titration, he takes 16 mg buprenorphine with 4 mg naloxone daily. [113]

Illustration (Case No. 1 · Pain and OUD)Zoom

The morning search for tablets stops. Mark gradually returns the freed time to exercise and household tasks. Ankle pain, shame and lost income remain subjects for later appointments.

Pharmacy dispensing, family and everyday costs

After stabilization, a physician at an outpatient addiction clinic takes over OAT prescribing. RAAC agrees the first appointment date and medication coverage until then. The family physician continues general medical care and pain treatment. [110]

With active MSP coverage, PharmaCare Plan Z pays for Mark's medication. The family still faces travel costs, private physiotherapy expenses and earnings lost through reduced work. [18]

Initially, Mark attends the agreed pharmacy for witnessed dosing. The pharmacist knows whom to contact about a missed dose or unusual drowsiness. Mark knows where to call if he becomes ill or cannot attend. Later, the physician and pharmacist agree on some take-home doses with safe storage.

Work begins at seven, but the pharmacy opens later. The physician and pharmacist discuss collection times and take-home doses, considering sedation, other substances, storage and Mark's ability to follow the regimen. The BCCSU guideline provides for individualized assessment of take-home dose safety. [79]

Lisa asks whether she needs to supervise the tablets. They agree which signs of deterioration they will discuss immediately, what the team may tell Lisa with Mark's consent, and whom to contact about missed doses or drowsiness. Medical decisions remain with Mark and the clinical team.

Both are offered free Take Home Naloxone training: recognizing opioid poisoning, calling emergency services, supporting breathing and administering naloxone. They receive a kit for home. [114]

Lisa puts it in the agreed place. She is still angry about concealed spending; restoring trust will require more time and everyday agreements.

Psychiatric assessment after OAT begins

After several weeks, physical withdrawal no longer accounts for all of Mark's low mood. He is less restless but rarely leaves home without a reason. He says he has become "someone who only goes for treatment." The family physician arranges a psychiatric consultation.

The psychiatrist reconstructs the course of his mood before the injury and its changes alongside pain, intoxication and withdrawal. They clarify previous depressive or manic episodes, anhedonia, hopelessness, suicidal thoughts and daily functioning.

There is no history of mania or hypomania. On serial assessment, mood symptoms diminish as sleep stabilizes and activity resumes; a full persistent depressive syndrome does not develop. Mood and risk continue to be assessed at follow-up.

Mark agrees to psychological work on avoidance of movement, catastrophic expectations of pain and daily rhythm. OAT continues alongside it. Psychosocial care is matched to his capacity and willingness to participate. [112]

The psychiatrist sends the report to the family physician and addiction physician. They agree who monitors mood, who changes OAT and how they will exchange information after a new prescription.

Specialized care for persistent pain

The family physician refers Mark to the Jim Pattison Chronic Pain Clinic in Surrey. The service's published description includes physiotherapists, occupational therapists, psychologists, pharmacists and social workers, as well as pain specialist consultations. Entry requires referral by a physician or nurse practitioner. [115]

The JPO referral is made after OAT has begun and stabilized, in accordance with the clinic's addiction-treatment criteria. Fraser Health's public handbook provides for the family physician to manage pain while specialist consultation is pending. [116]

While Mark waits, orthopaedic follow-up continues. The family physician clarifies permitted activity and reviews analgesia: acetaminophen, the possibility of a short ibuprofen course after assessing renal and gastrointestinal risks, and interactions with other medications.

At consultation, it becomes clear that Mark alternates between barely walking for several days and trying to catch up on everything in one day. Pain intensifies after a burst of activity, and he fears further injury. The physiotherapist works on graded loading; the occupational therapist examines cabinet lifting, kneeling, stairs and breaks. The psychologist helps restore activities Mark limits because he expects pain.

Mark also uses Pain BC materials and free support programs. These are combined with orthopaedic follow-up and physical rehabilitation. [117]

His first agreed goal is a task he can perform consistently: walking to the shop and back without spending the next two days recovering in bed. Short shifts on lighter duties follow. A colleague temporarily takes on heavy lifting while Mark prepares measurements and drawings. Machinery use and driving are discussed separately in light of his actual condition, drowsiness and medication changes.

Money remains tight in spring. Lisa takes extra shifts. A social worker helps with benefit applications and available resources. Additional earnings and deferred spending allow the family to keep the apartment.

Resumed use and treatment review

In April, Mark takes on too much work. Pain and anxiety intensify sharply on two consecutive evenings. Craving returns at the end of the day after previously being almost absent. Once, he fails to reach the pharmacy in time; dosing resumes the following day after consultation. During that week, he buys unregulated tablets twice.

At the next appointment, this comes to light through more than a test: Mark describes what happened himself. His first question is whether he will now be removed from treatment. The physician clarifies recent doses, other substances, drowsiness, poisoning risk, mood and the precise timing of craving. The pharmacy confirms his dispensing history.

The team reviews OAT safety and effectiveness: dose adequacy, other sedating substances, medication storage and the feasibility of the pharmacy routine. Treatment continues after renewed fentanyl use, with more frequent contact. A positive urine test alone is not a reason to stop OAT. The physician interprets it alongside clinical assessment; take-home arrangements depend on storage safety, sedation, dosing regularity and support needs. [79]

Mark reports recurrent end-of-day craving even on days when he took his medication. After assessment and titration, the daily dose rises to 24 mg buprenorphine with 6 mg naloxone. He and the physician review pharmacy dispensing times, workload and access to the next contact so that the agreed routine is workable on working days. [113]

Lisa sees this episode as a return to concealment. At a joint meeting, Mark agrees to report increasing craving before money goes missing. Lisa speaks directly about financial anxiety. They develop a shared response plan for the next deterioration.

Perioperative care during a further procedure

In summer 2026, the orthopaedic surgeon reassesses persistent focal pain and irritation over the metalwork. After confirming union and discussing expected benefit, they agree on elective removal of some fixation hardware. Mobility rehabilitation and treatment of residual pain will continue afterwards.

The incision is not Mark's greatest worry. "If they hear about the addiction, will they give me any pain relief at all?" Lisa fears the opposite: that another opioid prescription will undo the work already achieved.

The anaesthesiologist agrees on continuation of buprenorphine/naloxone, multimodal analgesia and an additional short-acting opioid when needed. The plan specifies monitoring of analgesia, sedation and breathing, and transition to outpatient prescriptions. This approach is described in BC guidance and the perioperative expert consensus. [79, 118]

During admission, regional analgesia and non-opioid medications are used. Hydromorphone is used briefly for breakthrough pain under clinical observation. Dosing is guided by effect, consciousness and respiration, taking tolerance and buprenorphine's action into account. [118]

The hospital confirms the last dose actually received with the pharmacy. They coordinate dispensing on the admission day and, before discharge, the next supply and prescription validity. Telephone reconciliation adds information about hospital administrations to PharmaNet. [53]

Discharge is planned for Friday. The nurse obtains pharmacy confirmation that the updated prescriptions have arrived and medication will be available over the weekend.

Hydromorphone is stopped after the brief postoperative period according to the agreed plan. OAT continues. The addiction physician and family physician receive information about the operation and analgesic changes. For Mark, the most important outcome is simple: he has undergone another procedure without concealing his addiction or being left without pain treatment.

Treatment outcome and continuing follow-up

By autumn, Mark works part-time. His ankle still limits some tasks, but he can plan a week without constantly searching for tablets. He reports no unregulated use in recent months, consistent with clinical observation and testing when indicated. He continues buprenorphine/naloxone, gradually rebuilds stamina and sleeps better.

"When can I manage without the medication?" he asks. He wants to free his day from treatment-related tasks. The physician discusses craving, stability at work, the previous return to use and the risks of stopping. For now, he chooses to continue OAT and review the decision later.

In a BC cohort study of 55,347 OAT recipients from 1996 to 2018, mortality was lower during treatment than during periods outside it. After fentanyl became widespread, mortality outside OAT increased, while mortality during treatment remained more stable. This gives sustained retention in care clinical importance alongside return to work and family life. [119]

Further dose changes will take account of craving, functioning, tolerability and Mark's preferences. If he moves, the team will transfer prescribing information and connect him with a new provider.

Lisa judges the outcome somewhat differently. She can again agree ordinary expenses with her husband without checking every answer. Their daughter no longer has to establish each time whether Dad is able to help that day. Mark says he has regained not his old ankle, but the freedom to think about something else during the day.

Continuing treatment between countries

If Mark were treated in Ukraine, his pathway would combine orthopaedic follow-up with a methadone- or buprenorphine-based opioid substitution treatment program. Before another operation, the addiction specialist and anaesthesiologist would coordinate the last dose, its continuation and additional analgesia. Ukraine's Public Health Centre publishes information on substitution treatment sites and patient transfers, helping arrange care after relocation. [120]

In the opposite direction, from Ukraine to BC, the key elements would be a confirmed regimen and last dose, assessment by the local OAT prescriber, medication coverage and an agreed pharmacy. Avoiding a gap between the last dispensing at one location and the first at another preserves the stability already achieved.