Protocolized vs Discretionary Use of Opioids in Acute Pain

Inclusion Criteria: 1. Age 21 to 64 years. 2. Pain with onset within 7 days. 3. Emergency Department attending physician's judgment that patient's pain warrants use of intravenous opioids. 4. Normal mental status. Exclusion Criteria: 1. Prior use of methadone. 2. Use of other opioids, tramadol, or heroin in the past seven days. 3. Prior adverse reaction to morphine, hydromorphone, or other opioids. 4. Chronic pain syndrome. 5. Alcohol intoxication. 6. Systolic Blood Pressure \< 90 mm Hg. 7. Use of monoamine oxidase (MAO) inhibitors in past 30 days. 8. Weight less than 100 pounds. 9. Baseline room air oxygen saturation less than 95%. 10. C02 measurement greater than 46: In accordance with a number of similar studies that we have performed, four subsets of patients will have their CO2 measured using a handheld capnometer prior to enrollment in the study. If the CO2 measurement is greater than 46, then the patient will be excluded from the study. The 4 subsets are as follows: 1. All patients who have a history of chronic obstructive pulmonary disease (COPD) 2. All patients who have a history of sleep apnea 3. All patients who report a history of asthma together with greater than a 20 pack-year smoking history 4. All patients reporting less than a 20 pack-year smoking history who are having an asthma exacerbation