Case Study by Sarah K . Council , PhD ; 1 Collin Montgomery , APRN ; 2 Leigh Ann Wilson , LCSW ; 2 Sarah E . Harrington , MD 3
1
Division of Hematology / Oncology , UAMS ; 2 Adult Sickle Cell Program , UAMS ; 3 Division of Palliative Medicine , UAMS
Opioid Use Reduction in a Sickle Cell Disease Patient : A Case Report
Background
Sickle cell anemia or sickle cell disease ( SCD )
is a group of genetic blood disorders characterized by abnormal hemoglobin . The hemoglobin molecules are misshapen , or “ sickled ,” and tend to aggregate after releasing oxygen . This results in unhealthy hemoglobin ( sickle cell anemia ). It can block blood flow and lead to pain ( acute pain episodes ). Because pain is the hallmark symptom of SCD , pain control is , in turn , one of the leading clinical foci . Opioids are the frontline therapy for SCD pain control . Indeed , patients with SCD often experience lifelong complications that may include debilitating and painful symptoms and complex treatment needs resulting in an impaired quality of life ( QoL ) ( ASH 2016 ). Moreover , SCD is an orphan disease that is often burdened with stigmatization , including beliefs that patients are drug-seeking , which contributes to suffering ( Maxwell , Streetly , and Bevan 2014 ). The current opioid epidemic further complicates opioid use among SCD patients as they may be branded as addicts and / or opioid abusers .
Case Report
We present a case study of a 40-year-old , African American , female patient who presented at the Adult Sickle Cell Clinic at UAMS to establish care . She was previously seen by a community physician . On the first clinic visit , the patient ’ s clinical presentation was daily SCD-related pain that varied in location , duration , and quality . The patient reported low back pain and described it as diffuse , dull , achy , and constant with aggravating / exacerbating factors denied . She also reported adequate pain management with current pain regimen . The patient was able to complete her own activities of daily living ( ADLs ) and had no recent emergency department visits or hospitalizations . The current pain regimen was categorized as high morphine equivalents / day ( MMEs /
Table 1 : Pain Regimen Upon Initial Clinic Presentation
Drug Dose Quantity / month MME / day Hydromorphone 4 mg 160 / month ~ 80 mg / day
Morphine Sulfate ER
day ) at ~ 655 MME / day ( CDC 2017 ). ( See Table 1 .) Per the patient , this was due to rapid escalation of opioids to manage cramps related to menses and tooth pain ( patient was unable to afford extraction ). However , patient reported daily use of ~ 679 – 772 MME / day ( See Table 2 below ). Cholecystectomy was the only SCD-related complication reported in patient ’ s history . Her social history included : lives independently , unemployed , social security disability recipient , enrollment in Medicare / Medicaid , unmarried , no children . Physical examination was unremarkable . The patient was slightly somnolent on exam , but otherwise participated well and answered questions appropriately .
100 mg Q6H
The multidisciplinary team created a plan to meet all the patient ’ s clinical needs . The first
160 / month ~ 500 mg / day
Oxycodone-acetaminophen 10 / 325 mg 160 / month ~ 75mg / day Prescribed MME / day Patient reported daily use
Table 2 : Patient Reported MME / Daily Use
Hydromorphone 4 mg PRN : – 16 MME x 9 tablets = 144 MME / day – 16 MME x 12 tablets = 192 MME / day Morphine Sulfate ER 100 mg Q6H : – 400 MME / day Oxycodone-acetaminophen 10 mg PRN : – 15 MME x 9 tablets = 135 MME / day – 15 MME x 12 tablets = 180 MME / day
Patient reported MME / daily use ~ 679 – 772 / day
~ 655 MME / day
priority was to simplify and rotate her opioids . After the first visit , the patient was advised to discontinue hydromorphone 4mg PRN ( patient reported good symptom control with Percocet ), discontinue Percocet 10mg / 325mg due to the large amount of Tylenol , and decrease Morphine ER 100mg from q6h to TID ( with goal of weaning off and rotating to methadone only ). She was prescribed oxycodone IR 10mg every four hours PRN ( MAX 2 / day ), along with methadone 5mg QHS . After the first visit in clinic , the patient was given one-week prescriptions and seen the following week to monitor her closely after such a large change . After frequent follow-up visits , the patient was prescribed adjuvants that included ibuprofen 800 mg PRN and duloxetine 60 mg QD . Her MS Contin was gradually weaned off while her methadone was gradually increased . She had close supervision and her pain became well-controlled on methadone 20mg daily , with oxycodone 10 mg every four hours PRN ( MAX 2 / day ). This resulted in an MME / day reduction from ~ 679 -722 to ~ 130 . ( See Table 3 .)
~ 679 to 772 MME / day
While the patient ’ s opioids were being changed and closely monitored , the patient ’ s psychosocial needs were addressed and treated by the interdisciplinary team including the clinic ’ s social worker . She was started on an antidepressant and encouraged to participate in counseling . While some of the patient ’ s pain
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