patient care perspectives

Opioid-Sparing Approaches in Sickle Cell Disease

by Michael Rutledge DeBaun, MD, MPH

Overview

Patients with sickle cell disease (SCD) experience extremely severe and debilitating acute and chronic pain. Efforts to successfully treating that pain without an overreliance on opioids benefit from preventive and nonpharmacologic interventions.

Expert Commentary

Michael Rutledge DeBaun, MD, MPH

Professor of Pediatrics and Medicine
Vice-Chair for Clinical and Translational Research
J.C. Peterson Endowed Chair in Pediatrics
Director, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease
Vanderbilt University Medical Center
Nashville, TN

“To reduce opioid use, the standard of care should prioritize the use of these preventive and nonpharmacologic approaches to help avoid turning to opioids as a first option.

Michael Rutledge DeBaun, MD, MPH

The severity of pain in patients with SCD is typically unimaginable to individuals without the disease, and the unpredictable onset of painful events wreaks havoc on patients’ daily schedules for school or work, relationships, and other activities. Clearly, the use of opioids is needed for the management of acute pain in SCD, and so is the implementation of preventive strategies and nonpharmacologic approaches. To reduce opioid use, the standard of care should prioritize the use of these preventive and nonpharmacologic approaches to help avoid turning to opioids as a first option. This involves acknowledging the role of pain triggers, which include stress, dehydration, overexertion, and extremes of either cold or hot. An awareness of pain triggers enables individuals with SCD to actually decrease the likelihood of experiencing an acute occlusive pain event.

Nonpharmacologic management strategies include relaxation techniques, cultivating mindfulness, good dietary habits, and other healthy practices, all of which can help decrease episodes of pain and, therefore, the need for opioids. Mental health also plays a clear role in SCD-related pain. Comorbid depression and anxiety may lower a patient’s threshold for pain, so managing these comorbidities should be a cornerstone of our efforts to avoid the routine use of opioids in this population.

Typical pain episodes in SCD, if there actually are “typical” episodes, occur over a period of 3 to 10 days. The average length of hospitalization for a child with SCD is approximately 4.5 days; this time frame is slightly longer for adults.

There is a prodrome state in which patients can often sense that they are going to have a vaso-occlusive pain event, and this is an excellent time to use nonpharmacologic tools. When they get that initial sense, they can begin to employ mental relaxation techniques, including yoga, deep breathing, music, and tools of that nature. However, once they are in the midst of a severe acute vaso-occlusive pain episode, very few patients are going to be able to focus on such techniques. Accordingly, these nonpharmacologic approaches may have been exhausted, in which case opioids may be needed.

One of the challenges in managing pain is the partitioning between outpatient pain management and inpatient pain management. In the outpatient setting, you want to use the stepwise approach for patients with SCD. When they present to an Emergency Department or an office setting, the first option is to ensure that they have followed their own individualized pain action plan, which may include a short-acting morphine derivative and a long-acting morphine derivative. In a patient who is admitted to the Emergency Department, nonsteroidal anti-inflammatory drugs are not used; further, intravenous acetaminophen does not reduce the opioid requirement. Treatment begins with short-acting morphine or oxycodone. These agents have a peak time to onset of 30 to 40 minutes and last up to 12 hours, after which a long-acting opioid may be used.

References

Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4(12):2656-2701. doi:10.1182/bloodadvances.2020001851

Dhebaria T, Sivitz A, Tejani C. Does intravenous acetaminophen reduce opioid requirement in pediatric emergency department patients with acute sickle cell crises? Acad Emerg Med. 2021;28(6):639-646. doi:10.1111/acem.14149

Osunkwo I, O’Connor HF, Saah E. Optimizing the management of chronic pain in sickle cell disease. Hematology Am Soc Hematol Educ Program. 2020;2020(1):562-569. doi:10.1182/hematology.2020000143

Osunkwo I, Veeramreddy P, Arnall J, et al. Use of buprenorphine/naloxone in ameliorating acute care utilization and chronic opioid use in adults with sickle cell disease. Blood. 2019;134(suppl 1):790. doi:10.1182/blood-2019-126589

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