Evaluation of a Pain Management Protocol Used to Deescalate Opioid Use in Adult Patients Hospitalized with Vaso‐occlusive Crisis due to Sickle Cell Disease

2021 ◽  
Author(s):  
Domenique Ciriello ◽  
Nicole E. Cieri‐Hutcherson ◽  
Stephanie Seyse ◽  
Jennifer Abeles ◽  
Erin Conway‐Habes ◽  
...  
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Adult Patients ◽  
Cell Disease ◽  
Opioid Use ◽  
Management Protocol

Outpatient Opioid Use In Adult Patients With Sickle Cell Disease

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 4699-4699
Author(s):  
Morey A. Blinder ◽  
Mikala Barnes ◽  
Kimberly French ◽  
Catherine Rogers ◽  
William Berger
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Adult Patients ◽  
Poor Compliance ◽  
Cell Disease ◽  
Opioid Use ◽  
Short Acting ◽  
Urine Drug ◽  
Long Acting ◽  
Chronic Use

Introduction Treatment of sickle cell disease (SCD) has often required the use of opioids for the treatment of pain. While guidelines for specific medications and dosing are available for inpatient and emergency department use, less is known about the outpatient treatment of adult SCD patients. The aim of this study is to evaluate the role of outpatient opioids in adults with sickle cell disease. Method The Adult Hemoglobinopathy Resource Center at Washington University provides care for adult SCD patients throughout the St. Louis, Missouri metropolitan area. All patients have confirmed SCD (Hgb SS, Hgb SC, Hgb Sβ+, Hgb Sβ0, Hgb SOther) and have been seen at least once since 2011 to be included in the study. Patients were considered to be compliant with their outpatient care if they were seen at least once per year and did not miss more than three consecutive appointments. The type of opioid that was used was determined based on the most recent filled prescription. Patients were considered to be on chronic opioids if they received >1 prescription/month or were over a 3 month period. Patients were considered to be on no opioids if they received ≤1 prescription in 3 months. Results Three hundred and seventeen patients have been evaluated between January 2011 and June 2013 of which 9 (2.8%) have died during that time period. Of the surviving patients, 33 (10.7%) have not been actively followed (poor compliance/disruptive behavior-29, incarcerated-2, moved out of town-1, transfer of care-1). Of the patients actively followed, the mean age is 32 years (range 17-72); 148 patients (53.8%) are female and 127 (46.2%) are male. The hemoglobinopathies include SS-175, SC-80, Sβ+-14, Sβ0-5, SCHarlem-1. Long-term red cell transfusions were performed in 25 patients (automated RBC exchange-13, partial manual exchange-8 and simple transfusions-4) and hydroxyurea was prescribed in 101 patients (Hgb SS-92 patients). At present, 151 patients (54.9%) are prescribed chronic long and short acting opioids and 76 patients (27.6%) are on chronic short acting opioids with a much smaller number of patients (40 pts) not receiving opioids. Notably 18 of 40 patients not receiving opioids were effectively treated with either hydroxyurea or transfusion therapy. Of the 104 patients ≤25 years of age, 60 (57.7%) were on chronic long and short acting opioids at the time of their initial care. The most commonly prescribed long-acting opioid used was extended release morphine sulfate and the most common short acting opioid was oxycodone. Because of recent concerns about non-compliance and diversion, urine drug screens have been utilized with increasing frequency to assess opioid use and of the last 30 patients receiving long-acting therapy who were tested, 17 samples did not identify the prescribed medication suggesting some degree of opioid misuse. Conclusions While opioids have been an important adjunctive treatment for patients with sickle cell disease, their most effective use in adult patients is difficult to define. Strategies to decrease the use of opioids in the adolescent and young adult population along with disease-modifying therapy such as hydroxyurea and RBC transfusions would seem to be helpful to decrease the chronic use of opioids. Furthermore, chronic use of opioids is frequently associated with poor compliance. The use of urine drug screens may be helpful to improve compliance and decrease diversion. Disclosures: Blinder: Novartis Pharmaceuticals: Consultancy, Research Funding.

scholarly journals Pediatric residents’ perceived barriers to opioid use in sickle cell disease pain management

2018 ◽  
Vol 66 (2) ◽  
pp. e27535 ◽  
Author(s):  
Amber Fearon ◽  
Anne Marsh ◽  
Jennifer Kim ◽  
Marsha Treadwell
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Perceived Barriers ◽  
Cell Disease ◽  
Opioid Use ◽  
Pediatric Residents

scholarly journals L-Glutamine Decreases Opioid Use in Individuals with Sickle Cell Disease and Chronic Pain: A Case Series

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4849-4849
Author(s):  
Samuel Wilson ◽  
Frances Wright ◽  
Marcus A. Carden
Keyword(s):  
Chronic Pain ◽  
North Carolina ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Care Utilization ◽  
Cell Disease ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Over Time

Background: Sickle cell disease (SCD) is the most common inherited blood disorder in the United States (US), affecting approximately 100,000 individuals in the country who are primarily of African descent. One of the most prevalent complications of SCD is pain as a result of episodic vaso-occlusive crises. Over time, many individuals with SCD develop chronic pain and opioid dependence for pain management. L-glutamine (EndariTM) was approved by the US Food and Drug Administration in 2017 for patients 5 years-old and older to reduce complications from SCD after reviewing a phase-III placebo-controlled trial. In this study, L-glutamine led to a reduction in median number of pain crises and increased time to first pain crisis when compared to placebo (Niihara et al, NEJM, 2018). However, the impact of L-glutamine on opioid use over time remains unknown. In this study, we evaluated the effect on opioid use in individuals who were started on L-glutamine for worsening SCD related pain. Methods: After institutional review board approval, we retrospectively reviewed the electronic medical record (EMR) of individuals with SCD followed at the University of North Carolina Pediatric and Adult Sickle Cell clinics prescribed L-glutamine in 2018-2019 for worsening acute and chronic SCD-related pain. The North Carolina state controlled substance reporting system, an online clinical tool which collects information on dispensed controlled substance prescriptions to patients that is freely available to prescribers, was also reviewed for filled opioid prescriptions (and milligram morphine equivalents - MME) for each patient. Data, including health care utilization (e.g. hospitalizations and emergence room (ER) visits) and hemoglobin levels for each patient were also evaluated in the EMR for the four months preceding and the four months after L-glutamine was started to determine if changes were sustained. Results: We identified four female patients (ages ranging from 9 to 24 years-old) with SS genotype and chronic pain with acute exacerbations who had significant opioid prescription reduction after starting L-glutamine. Three individuals were taking the maximum tolerated dosing of hydroxyurea and experiencing escalating pain crises prior to initiation of L-glutamine. One patient was intolerant of hydroxyurea and was on a chronic transfusion program for chronic pain management when she was started on L-glutamine for worsening chronic pain. All patients, or caregivers, reported a reduction in acute on chronic pain after initiating L-glutamine. Each patient had a reduction in 4-month total opioid prescription use (in MME) after starting L-glutamine, ranging from a 21% reduction to 100% reduction (Figure 1). Heath care utilization significantly decreased in 1 patient after starting L-glutamine, with 3 ER visits and 2 hospitalizations in the pre-treatment period and no ER visits or hospitalizations in the post-treatment period. There was no difference in the average hemoglobin levels pre-and-post L-glutamine initiation among the patients (9.8g/dL vs. 9.7g/dL). Discussion: L-glutamine appears to have some benefit in reducing pain and opioid use, as well as healthcare utilization, in a subset of patients with SCD and chronic pain. Although we evaluated a small number of patients, all individuals (or caregivers) reported decreased pain very soon after starting L-glutamine. One patient stopped opioid use altogether in the time period evaluated. Future studies should investigate if effectiveness of L-glutamine may be based on unique red cell metabolic profiles, SCD genotype, or timing of drug initiation in these and similar patients. Future investigations will also determine long-term tolerability of L-glutamine and if the reduction in opioid use is sustained for longer periods among these patients and other responders. Disclosures Carden: GBT: Honoraria; NIH: Research Funding.

Pressure Pain Threshold and Pain Diary Data in Patients with Sickle Cell Disease

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1007-1007 ◽  
Author(s):  
Steffen E. Meiler ◽  
Leigh G Wells ◽  
Latanya Bowman ◽  
Pritam Bora ◽  
Hongyan Xu ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Quantitative Sensory Testing ◽  
Pain Threshold ◽  
Adult Patients ◽  
Sensory Testing ◽  
Cell Disease ◽  
Opioid Use ◽  
Pain Diary ◽  
And Control

Abstract Abstract 1007 Pain is a common and serious complication of sickle cell disease (SCD), which is frequently disabling and difficult to treat. Acute painful crises account for the vast majority of healthcare encounters (> 90% of hospitalizations), and many patients with SCD suffer from chronic pain. Despite several well designed clinical studies, which have brought to light the high incidence and severity of pain in this patient population, sickle cell pain remains an understudied, undermanaged, and poorly understood condition. Previous work has largely relied on self-reporting instruments, such as carefully designed pain diaries to study the epidemiology of pain in this patient cohort. In contrast, very little is known about the usefulness of methods that measure pain in response to a standardized stimulus and the correlation of experimentally induced pain to more traditional instruments such as pain diaries and opioid use. In this study we explored the use of pressure algometry to measure pain thresholds in adult patients with SCD. Our study enrolled 167 adult patients with SCD [163 SS, 1 SD Los Angeles, 3 Sβ0-thal; 108 on Hydroxyurea (HU), 59 off HU; 83 females and 84 males; mean age 31 years (range 16–61)] and forty racially matched controls (23 females and 17 males; mean age 35 years (range 17–61). The pain threshold, defined as the lowest pressure at which pain is induced, was measured by pressure algometry in three anatomic muscle groups (masseter, trapezius, and ulnar). Four measurements were obtained at each site and averaged for analysis. 118 patients were tested with a manual algometer (Wagner FDIX™, Wagner Instruments, Greenwich, CT) and 49 patients with a computerized model (Algomed, Medoc Ltd., Israel). The data sets for the two algometer groups were highly correlated for each anatomic site and were therefore combined for the final analysis (Pearson's correlation coefficients: masseter readings, r=0.78, p=2.73E-09; trapezius readings, r=0.85, p=4.28E-12; ulnar readings, r=0.68, p=3.26E-06). In addition, self-reported pain and distress were monitored prospectively for six months using a validated pain diary (ordinal scales of 0–9, respectively; J Natl Med Assoc. 2005 February; 97(2): 183–193). Opioid use, expressed as morphine equivalents, and the frequency of vaso-occlusive events are being recorded prospectively for twelve months. Algometer readings were compared using a linear model with age and gender as covariates. Data are reported as mean ± SEM. A p-value of < 0.05 is significant. Adult patients with SCD experienced pain at significantly lower pressures at all anatomic sites tested compared to racially matched controls. Pain threshold measurements in the ulnar muscle group achieved the best discrimination between sickle cell and control subjects. (Patients vs. controls (KPa): Masseter: 150± 4.35 vs. 193± 13.24, p= 1.99E–05; trapezius: 265±10.23 vs. 383± 37.99, p= 2.78E–05; ulnar: 371±10.26 vs. 518±34.59, p= 6.28E–09). Ulnar algometer readings also correlated with self-reported pain scores (r=-0.226, p=0.0097). There was no correlation between pain threshold measurements and self-reported distress or the use of hydroxyurea. Quantitative sensory testing revealed that adult patients with SCD are hyperalgesic in response to a standardized pressure stimulus. Of the three anatomic sites tested, ulnar pain threshold readings produced the strongest separation between sickle cell and control subjects and correlated with self-reported pain. Quantitative sensory testing may provide a useful research and clinical tool to study the biological mechanisms of pain in SCD and the therapeutic efficacy of psychosocial and pharmacological interventions. Disclosures: Fillingim: Algynomics: Consultancy, Shareholder Other.

scholarly journals The Role of Cognitive Behavioral Therapy in Opioid Use Reduction in Pediatric Sickle Cell Disease: Protocol for a Systematic Review (Preprint)

2018 ◽  
Author(s):  
Ashaunta T Anderson ◽  
Nhu Tran ◽  
Kathryn Smith ◽  
Lorraine I Kelley-Quon
Keyword(s):  
Systematic Review ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Cognitive Behavioral Therapy ◽  
Sickle Cell ◽  
Behavioral Therapy ◽  
Cognitive Behavioral ◽  
Cell Disease ◽  
Opioid Use ◽  
Eligibility Criteria

BACKGROUND Sickle cell disease (SCD) is a genetic disorder of red blood cells that results in acute and chronic health problems, including painful syndromes. Opioid analgesia is the mainstay of moderate to severe pain management in SCD, although adjunctive psychosocial approaches such as cognitive behavioral therapy (CBT) are increasingly incorporated. CBT has been used in populations of various ages to address a wide range of issues, such as mood disorders and chronic pain. It is unclear if effective CBT reduces the use of opioids to manage pain in pediatric SCD. OBJECTIVE The aim of this study is to evaluate the association between CBT and decreased opioid use in children with SCD. METHODS In this systematic review protocol, we describe our approach to applying predetermined eligibility criteria to searches of PubMed (including Medline), Embase, Cochrane, Web of Science, and PsycINFO databases, as well as Google Scholar and grey literature. In particular, we will use keywords to search for English-language studies of individuals with SCD aged 21 years old and younger published before November 2018. Keywords will allow us to assess for the primary outcome—total use of opioid medications—and the secondary outcomes—pain intensity and emotional functioning—during pain management using a combined opioid and CBT approach, opioids alone, or CBT alone. The review team will use standardized abstraction forms to review articles at the title, abstract, and full-text levels. Finally, reviewers will assess the risk for bias, quality of evidence, and adequacy of data for quantitative versus qualitative synthesis. If meta-analysis is deemed inappropriate, a narrative review will be conducted. RESULTS We will report a summary of findings across studies that meet eligibility criteria to compare the extent to which adjunctive CBT is associated with decreased opioid use among children with SCD. CONCLUSIONS This systematic review will present the current state of the evidence on CBT and opioid use in pediatric SCD, which may inform clinical practice and health policy to support optimized pain management. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/13211

Experience of Respect and Pain Management among Adult Patients with Sickle Cell Disease during Vaso-Occlusive Crisis.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3341-3341
Author(s):  
Mary Catherine Beach ◽  
Patrick Duggan ◽  
Sophie Lanzkron
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Patient Experience ◽  
Academic Medical Center ◽  
Adult Patients ◽  
Interpersonal Processes ◽  
Cell Disease ◽  
Management Quality ◽  
Doctors And Nurses

Abstract BACKGROUND. Adults with sickle cell disease (SCD) have reported adversarial relationships with health professionals in qualitative studies, but there are no quantitative data. We sought to examine experiences of respect among patients with SCD seeking acute care for vaso-occlusive crisis (VOC), and to relate these experiences to quality of pain management. METHODS. We surveyed 54 adult patients upon discharge from the Emergency Department (ED) at an urban academic medical center. We measured patient experience of respect using items from the Interpersonal Processes of Care Instrument and summed responses to form a ‘respect’ scale from 0–100 (alpha 0.89). We measured pain management quality by asking patients whether doctors and nurses brought them their pain medicines as soon as they needed them and changed their pain medicines if they were not working (‘all’ and ‘most’ of the time were considered favorable responses while ‘some’ or ‘none’ of the time were considered unfavorable). RESULTS. Patients generally reported low levels of respect and poor pain management. A small proportion of patients reported (‘all of the time’) that doctors and nurses seemed to care about them as a person (19%), listened carefully to what they had to say (17%), and took their concerns seriously (13%). A substantial proportion reported (‘all, ‘most’ or ‘some of the time’) that their doctors and nurses had a negative attitude towards them (63%), made them feel inferior (74%), made them feel as if they weren’t welcome (65%) and behaved rudely towards them (50%). Only 34% of patients reported timely receipt of pain medication and 48% reported that ineffective medication was changed. Patient experience of respect and pain management quality were not significantly related to patient age, sex, or employment status; however patients seen more frequently in the ED reported less respect (mean respect scores 74.1, 62.7, and 54.6 for patients seen <5 times/year, 5–15 times/year, and >15 times per year respectively, p=0.04). Patients who experienced lower respect also reported poorer pain management quality. Compared to patients who reported timely receipt of and changes in ineffective medication, patients who reported delays in receipt and no change in ineffective medication had lower respect scores (mean 71.9 vs. 53.9, p=0.001 for timely vs. delayed; 65.6 vs. 53.7 for change vs. no change). CONCLUSION. Interventions are needed to improve the experiences of adult patients with SCD who present to the ED with VOC. Further research is needed to determine the causes of poor experiences of respect and pain management, and to determine their further consequences.

Effects Of GMI 1070, a Pan-Selectin Inhibitor, On Pain Intensity and Opioid Utilization In Sickle Cell Disease

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 775-775 ◽  
Author(s):  
Laura M. De Castro ◽  
Ted Wun ◽  
Sophie Lanzkron ◽  
Wally R. Smith ◽  
Kathryn L. Hassell ◽  
...  
Keyword(s):  
Placebo Group ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Pain Intensity ◽  
Sickle Cell ◽  
Research Funding ◽  
Study Drug ◽  
Cell Disease ◽  
Opioid Use ◽  
Vas Scores

Abstract Background Management of acute, painful vaso-occlusive crisis (VOC), the hallmark of sickle cell disease (SCD), continues to be limited to symptomatic relief with oral and/or intravenous (IV) opioids. The efficacy of GMI 1070, a novel pan-selectin inhibitor, was recently evaluated in SCD patients hospitalized for VOC. We report in-depth analysis of pain intensity variation, duration and extent of pain management and other pain-related responses in this study. Methods A multi-center, randomized, double-blind, placebo-controlled Phase 2 trial of multiple IV doses of GMI 1070 in subjects (12-60 yrs) hospitalized for VOC was conducted. A loading dose to achieve steady state drug level was followed by q12 hours (h) maintenance doses. Study drug dose was doubled per protocol after interim PK analysis. Pain intensity was assessed by a 10 cm Visual Analog Scale (VAS); sustained reduction of 1.5 cm or higher and transition to oral analgesics were included in the composite primary endpoint “time to resolution of VOC,” as were readiness for discharge and time to discharge. Opioid utilization was recorded, converted to Morphine Equivalent Units (MEU) based on standard guidelines, and normalized by body weight. Patient controlled analgesia (PCA), oral analgesic and other therapies were not mandated and reflected institutional and individual practices. Comparisons were made between pooled GMI 1070 (low and high dose) and placebo. Analysis of covariance (ANCOVA), adjusting for sex and age, was used to determine differences between groups. Kaplan-Meier (KM) analysis (log rank test) was performed to compare time to event between treatment groups. Results Mean (SD; range) VAS at presentation to ED for all subjects was 8.6 (1.6; 5-10) and decreased before study drug start (baseline) to 6.7 (2.3; 0.8-10), reflecting initial pain management. Mean VAS scores at presentation and at baseline were not different between GMI 1070 and placebo groups. However, VAS changes from baseline by elapsed hours since drug start and probability of sustained 1.5 cm reduction in VAS over time showed that patients receiving GMI 1070 had earlier changes than those in the placebo group, starting at 48 h, (p=0.43, Fig 1a). Similarly, pain intensity reduction was greater by ∼1.5 cm and more rapid within the first 100 h of study treatment for those on GMI 1070 (p=0.58, Fig 1b). In subjects still hospitalized 48 h after study drug initiation, the GMI 1070 group with concomitant hydroxyurea (HU) had the lowest VAS scores. Mean (SD; range) VAS at discharge was 4.03 (2.97; 0-10) in the placebo group and 3.02 (2.75; 0-9.8) in the GMI 1070 group. ANCOVA analysis showed that time to resolution of VOC and time to discharge were shorter in the GMI 1070 group compared to placebo, independent of HU use. Not only was mean [SE] time to transition from parenteral to oral pain medications reduced in the GMI 1070 group vs placebo (108.6 [20.8] vs 155.6 [23.8] h; p=0.14), but active drug exposure was associated with a significant reduction in initial (24 h) and cumulative (during hospitalization) opioid use (oral, IV or both routes) as compared to placebo (Table). Opioid use decreased compared to baseline in the GMI 1070 group within 4 h, while the placebo group did not go below baseline rate until 96h. Duration of IV or oral non-steroidal anti-inflammatory drug (NSAID) use was also lower in the GMI 1070 group vs placebo. Conclusion GMI 1070 therapy was associated with a significant reduction in IV opioid requirement and overall pain medication utilization in subjects hospitalized for SCD VOC. There was also an early decrease in pain intensity as measured by VAS, although this did not reach statistical significance. These effects were independent of HU use and suggest that GMI 1070 has a rapid onset of action and should be investigated for initial and early treatment of VOC in SCD, with the goal of reducing pain intensity and duration, as well as need for opioid therapy. Disclosures: De Castro: Novella Clinical: Consultancy; GlycoMimetics, Inc.: Research Funding. Wun:Emmaus, Inc.: Clinical Adjudication Committee Other; Pfizer, Inc.: Consultancy; GlycoMimetics: Research Funding. Lanzkron:GlycoMimetics, Inc.: Research Funding. Smith:GlycoMimetics, Inc.: Research Funding. Hassell:Glycomimetics, Inc: Research Funding. Kutlar:GlycoMimetics, Inc: Research Funding. Smith-Whitley:GlycoMimetics, Inc: Research Funding. Rhee:GlycoMimetics, Inc.: Research Funding; Rho, Inc.: Employment. Telen:GlycoMimetics, Inc.: Research Funding; Dilaforette, NA: Research Funding; Pfizer, Inc.: Consultancy. Thackray:GlycoMimetics, Inc.: Employment, Equity Ownership.

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