might include opioid analgesics( e. g. morphine, hydromorphone, oxycodone, hydrocodone) and nonopioid analgesics( e. g. ibuprofen, ketorolac, acetaminophen).
Pain is the final common denominator associated with the vast and varied array of bodily harms due to sickle cell disease. The first goal of managing SCD pain is prevention. Secondly, during the inevitable frequent and painful sickle cell crises that arise, aggressive and effective pain care is paramount. Next, it must be determined if the crisis is due to acute illness / infection, or is simply a new vaso-occlusive crisis. Finally, the chronic pain due to SCD should be managed in a multimodal and multidisciplinary manner.
From: Evidence-Based Management of Sickle Cell Disease Expert Panel Report, 2014: Guide to Recommendations, Chapter 4.
National Heart, Lung, and Blood Institute( NIH)
https:// www. nhlbi. nih. gov / sites / default / files / media / docs / Evd- Bsd _ SickleCellDis _ Rep2014. pdf
MANAGING CHRONIC COMPLICATIONS OF SICKLE CELL DISEASE CHRONIC PAIN
1. Determine the cause and type of SCD-related chronic pain. This includes chronic pain with objective signs such as avascular necrosis( AVN) and leg ulcers, and chronic pain without objective signs due to neuroplasticity of the peripheral or central nervous system.
2. Use a combination of the patient’ s response to treatment, including pain relief, side effects and functional outcomes, to guide the long-term use of opioids.
3. Encourage people to use deep tissue / deep pressure massage therapy, muscle relaxation therapy and self-hypnosis as indicated.
4. Use long- and short-acting opioids to manage chronic pain that is not relieved by non-opioids.
5. Assess all people with SCD for chronic pain annually, or more often as needed. This assessment should include descriptors of the pain; its severity on a numerical scale; its location; factors that precipitate or relieve it, including biopsychosocial factors; and its effect on the patient’ s mood, activity, employment, quality of life and vital signs.
6. Use a partnership agreement leading to a written, individualized treatment plan( to include risks, benefits and side effects) with the patient if long-term opioids are indicated. The partnership agreement should list the patient’ s rights and responsibilities, and the treatment plan should list the type, amount and route of administration of the opioid in question, including random drug urine testing.
7. Appoint one physician or other clinician to write the biweekly to monthly prescriptions for long-term opioids. Refills without seeing the patient should be kept to a minimum, and people
SICKLE CELL on chronic opioid therapy must be evaluated in person every two to three months.
8. Document all encounters with a patient, including medical history, physical exam, diagnosis, plan of management, type and amount of opioids prescribed and their side effects, if any, and lab data as needed.
9. Encourage people receiving opioids to increase their fluid intake, maintain dietary fiber intake per the current dietary fiber recommendations, and to use stool softeners and bowel stimulant laxatives such as senna and / or docusate as needed.
10. Believe the patient’ s report of pain and optimize therapeutic outcomes to achieve adequate pain relief and improve the patient’ s quality of life.
11. Refer patients for evaluation by a mental health professional such as a psychiatrist, social worker or addiction specialist as needed.
12. Assess all people for other types of non-SCD related chronic pain including postoperative pain, pain due to trauma, pain due to therapy, iatrogenic pain, and pain due to comorbid conditions.
References: Pain Management in Sickle Cell Disease, from TIP 54( SAMHSA)
https:// store. samhsa. gov / product / TIP-54-Managing-Chronic-Pain-in-Adults- With-or-in-Recovery-From-Substance-Use-Disorders / SMA13-4671
Sickle Cell Disease in Adults: Developing an Appropriate Care Plan. Clin J Oncol Nurs. 2015 Oct; 19( 5): 562 – 567.
Nadine Matthie, PhD, RN, CNL and Coretta Jenerette, PhD, RN, CNE https:// www. ncbi. nlm. nih. gov / pmc / articles / PMC5565201 / Sickle cell pain: a critical reappraisal Samir K. Ballas, Kalpna Gupta and Patricia Adams-Graves
Blood 2012 120:3647-3656; doi: https:// doi. org / 10.1182 / blood-2012-04-383430 http:// www. bloodjournal. org / content / 120 / 18 / 3647. long? sso-checked = true
Evidence-Based Management of Sickle Cell Disease Expert Panel Report, 2014: Guide to Recommendations. National Heart, Lung, and Blood Institute( NIH) https:// www. nhlbi. nih. gov / sites / default / files / media / docs / Evd-Bsd _ SickleCellDis _ Rep2014. pdf
James Patrick Murphy, MD, MMM, FASAM, is a board-certified Pain Medicine and Addiction Medicine specialist and represents the American Society of Addiction Medicine on the American Medical Association’ s newly formed Pain Care Task Force.
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