Louisville Medicine Volume 66, Issue 4 | Page 23

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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