Sickle Cell Adult Provider Network - SCAPN

Case Study 3:
Pain Management

Other studies

1. Sickle cell patient complains about shortness of breath
2. Patient considering discontinuing Desferol therapy
3. Pain Manangement
4. Sß+ Thalassemia patient with acute infarct
5. Patient with proteinuria
6. Pregnancy and sickle cell care

Adult Sickle Cell Care Provider: CASE STUDY #3 (Total repondents=5)

Questions: (results presented below question section)

You have been contacted by a care provider in your community because a 32-year-old woman with sickle cell disease (HbSS) has been hospitalized or seen in various ERs 3-4 times/month for complaints of sickle cell pain over the last "several years". She hasn't apparently had any acute complications with her pain (e.g. acute chest syndrome) during this time and has been taking whatever pain medications she can get each time she's seen, usually the short-acting narcotic oxycodone with Tylenol (e.g. Percocet).

In evaluating the patient, you find she reports pain every day in her back and legs which is only partially controlled with 8-10 Percocet tablets a day. A medical evaluation reveals some mild pulmonary hypertension, but no other apparent chronic complication from her sickle cell disease or evidence of other back or intra-abdominal disease as a source of pain.

Given the patient is willing to work with you to manage her pain (as always, more than one answer can be selected if you'd do more than one thing at once):

1. What would be your first therapeutic approach to her ongoing pain?
   • Drug rehabilitation with gradual withdrawal of all narcotic therapy
   • Use anti-inflammatory therapy (e.g. Ibuprofen, Toradol) instead of narcotics
   • Add anti-inflammatory therapy to narcotic therapy
   • Long-acting narcotics (with short-acting for breakthrough)
     1. Methadone
     2. Sustained-release oxycodone (ie Oxycontin)
     3. Sustained release morphine
     4. Other
   • Short acting narcotics alone
     1. Oxycodone (with or without Tylenol)
     2. Oral codeine (with or without Tylenol)
     3. Hydromorphone (Dilaudid)
     4. Oral morphine sulfate
     5. Other
   • Hydroxyurea therapy
   • Transfusion therapy
     1. Simple transfusion
     2. Exchange transfusion
   • Other
2. In your experience, how often does this approach work?
   • Almost always
   • Most of the time
   • About half the time
   • Occasionally
   • Almost never, but I always try
3. If this first line of therapy fails, what will be your second approach?
   • Drug rehabilitation with gradual withdrawal of all narcotic therapy
   • Use anti-inflammatory therapy (e.g. Ibuprofen, Toradol) instead of narcotics
   • Add anti-inflammatory therapy to narcotic therapy
   • Long-acting narcotics (with short-acting for breakthrough)
4. Methadone
5. Sustained-release oxycodone (ie Oxycontin)
6. Sustained release morphine
7. Other
   • Short acting narcotics alone
8. Oxycodone (with or without Tylenol)
9. Oral codeine (with or without Tylenol)
10. Hydromorphone (Dilaudid)
11. Oral morphine sulfate
12. Other
    • Hydroxyurea therapy
    • Transfusion therapy
      1. Simple transfusion
      2. Exchange transfusion
    • Other
13. How often does this treatment approach work for you?
    • Almost always
    • Most of the time
    • About half the time
    • Occasionally
    • Almost never, but I always try

What Regional/National Meetings do you attend annually?

Would you be interested in attending a meeting of Adult Sickle Cell Providers:

• informal/formal part of a meeting you already attend annually?
• a Saturday group meeting?

Results of Case #3

Because there were only about 5 responses to this case, I thought I'd forward the specific responses, which were thoughtful and informative. The main theme seems to be:

• add nonsteroidal anti-inflammatory medications
• try longer-acting narcotics
• if/when that doesn't work (or concomitantly), try treating the underlying sickle cell disease with hydrea or even transfusion.

Everyone acknowledges this is a tough area.

Responses received:

• I would start NSAIDS. It improves pain control about half the time. My next choice would be to add hydrea which will improve chronic pain occasionally. If this did not work, I would switch to long acting opiates continue the patient on them if she improved and maintained a stable dose. If this does not work I would add chronic transfusion and see if pain improves.
• My first approach would be to try anti-inflammatory added to narcotics usually percocet if possible and then to add long acting narcotics if this does not work. I use hydrea in patients who come in for recurrent crises not for chronic pain. I find the pain management very difficult and have not yet figured out how to do it well.
• First therapeutic approach to ongoing pain would be Methadone to try to stabilize pain and med usage first, along with hydroxyurea for longer term. This works about half the time. If first line fails I would add transfusions for hydroxyurea, which works occasionally.
• First therapeutic approach would be anti-inflammatory therapy to narcotic therapy, hydroxyurea for long-term pain control. If this fails I would try exchange transfusion, which seems to work in most cases.
• I have about 20 patients just like the one you present in this case. They were all considered drug seekers and problem patients before they started seeing me. I validate their pain and do not argue with them about its severity (when my arthritis flares up I don't expect anyone to doubt or argue with me). Their narcotic use, ER use, and hospitalization has fallen substantially with this approach, while their regular clinic visits have gone up. On the other hand, 4 of them tried to forge prescriptions. They were discharged from my clinic on the spot, and they have not been able to form a professional relation with any other physician. Their care resembles the vignette you show, and if there is a good approach for them, I can't seem to find it.

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