was chronic sickle-cell related pain , much of the previous opioid use was directed toward acute pain issues such as menstrual cramps and dental complications . The clinic staff was able to coordinate care with an OB / GYN and a dentist to address those issues appropriately . Opioid rotation , attention to psychosocial pain , and treating acute reversible issues all contributed to the ability to decrease her daily opioids .
Table 3 : Pain Regimen After 10 Visits Over Five-Month Period
Drug Dose MME / day Ibuprofen Duloxetine Oxycodone
800 mg PRN 60 mg QD
10 mg X 2 / day [ 20mg / day ]
~ 30 MME / day Methadone 20mg / day ~ 100 MME / day
Discussion Opioid use
Long-term opioid use to treat non-cancer pain is debated and does not have strong evidence for chronic pain management in SCD ( Carroll et al . 2016 ) and its effectiveness is unproven in SCD . Yet , it remains the frontline treatment and standard of care for both chronic and acute SCD-related pain ( U . S . Department of Health and Human Services 2014 ).
Barriers to adequate opioid prescribing practices include the innate difficulties that exist with the clinical management of acute and chronic pain , clinicians ’ limited knowledge of SCD , inadequate assessment of pain , and biases against opioid use . In addition , unnecessary concern for addiction among SCD patients and caregivers exists . Opioid addiction rates among SCD patients are comparable to national opioid addiction rates ( Ruta and Ballas 2016 ). Due to the clinical uniqueness of SCD pain , biases about opioid tolerance and physical dependence may hinder efficacious use of opioids to offer pain relief and / or control .
Psychosocial needs and considerations
Despite the fact that SCD affects other ethnicities and regions , it has been viewed as a “ Black disease ” ( Baskin et al . 1998 ). This places SCD patients at an increased risk for stigmatization . More , SCD patients have an increased risk for psychological distress and psychosocial impairments . Further increasing stigmatization , SCD patients are disproportionally lower socioeconomic status ( SES ) and , therefore , the majority of SCD patients rely on Medicare and other government-based programs for health care coverage ( Steiner and Miller 2006 ). These may coalesce and lead to decreased medical adherence and compliance ( Baskin et al . 1998 ).
UAMS Adult Sickle Cell Clinical Program
Specific to UAMS , the adult program began with a palliative care physician and a registered
Prescribed MME / day ~ 130 MME / day
nurse . Since its inception , the adult program has grown into a multidisciplinary team that includes a registered nurse , advanced practice nurse , licensed certified social worker , pharmacist , and rotating hematology providers . In complex cases such as this one , palliative care physicians are often asked to serve as consultants . SCD patients face multiple barriers to appropriate health care and the multidisciplinary teams continuously work to ameliorate these issues and provide appropriate care to SCD patients across the state .
Conclusion
Patients with SCD face a multitude of barriers to health care . They experience stigmatization and mismanagement of care . The patient presented in this case study initially came to the UAMS Adult Sickle Cell Clinical Program with prescribed levels of MME / day characterized as high morphine equivalents . Much of her pain was determined to be unrelated to her SCD ; yet , her SES prevented the patient from affording proper dental care to address one of the primary sources of pain . She was subsequently prescribed high levels of MME / day by her previous provider . Upon clinical transition to UAMS , the multidisciplinary SCD team and the patient were able to negotiate a clinical plan to greatly reduce her opioid consumption while improving safety and maintaining pain control . SCD is fraught with complications . Attuning care to both SCD-related complications as well as psychosocial needs and QoL provides comprehensive and effective care .
References
ASH . 2016 . “ State of Sickle Cell Disease .” The American Society of Hematology , 1 – 27 . http :// www . scdcoalition . org / pdfs / ASH State of Sickle Cell Disease 2016 Report . pdf .
Maxwell , Krista , Allison Streetly , and David Bevan . 2014 . “ Evidence-Based Management of Sickle Cell Disease ,” 1 – 161 . https :// www . nhlbi . nih . gov / sites / default / files / media / docs / sickle-cell-disease-report 020816 _ 0 . pdf .
CDC . 2017 . “ Guideline for Prescribing Opiod for Cronic Pain ,” 3 – 4 . www . cdc . gov / drugoverdose / prescribing / guideline . html % 0D .
Carroll , C . Patrick , Sophie Lanzkron , Carlton Haywood , Kasey Kiley , Megan Pejsa , Gyasi Moscou-Jackson , Jennifer A . Haythornthwaite , and Claudia M . Campbell . 2016 . “ Chronic Opioid Therapy and Central Sensitization in Sickle Cell Disease .” American Journal of Preventive Medicine 51 ( 1 ): S69 – 77 . https :// doi . org / 10.1016 / j . amepre . 2016.02.012 .
US Department of Health and Human Services . 2014 . “ Evidence-Based Management of Sickle Cell Disease : Expert Panel Report 2014 .” https :// www . nhlbi . nih . gov / sites / default / files / media / docs / sickle-cell-disease-report 020816 _ 0 . pdf . Accessed June 30 , 2020 .
Ruta , Nadia S ., and Samir K . Ballas . 2016 . “ The Opioid Drug Epidemic and Sickle Cell Disease : Guilt by Association .” Pain Medicine ( United States ) 17 ( 10 ): 1793 – 98 . https :// doi . org / 10.1093 / pm / pnw074 .
Baskin , Monica L ., Marietta H . Collins , Fontina Brown , Jeana R . Griffith , Denisse Samuels , Anissa Moody , Martha P . Thompson , James Eckman , and Nadine J . Kaslow . 1998 . “ Psychosocial Considerations in Sickle Cell Disease ( SCD ): The Transition from Adolescence to Young Adulthood .” Journal of Clinical Psychology in Medical Settings 5 ( 3 ): 315 – 41 . https :// doi . org / 10.1023 / A : 1026206204009 .
Steiner , C A , and J L Miller . 2006 . “ Healthcare Cost and Utilization Project Statistical Brief # 21 : Sickle Cell Disease Patients in U . S . Hospitals 2004 ” 332 ( 20 ): 9 .
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