What are the ASH guidelines on the use of chronic opioid therapy (COT) in the treatment of sickle cell disease (SCD)?

Updated: May 12, 2021
  • Author: Joseph E Maakaron, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

As the benefit of COT in SCD is largely unknown and the harms have been established via indirect evidence, ASH advises that shared decision-making is essential before initiating a trial of COT. The decision-making process should include discussion of failure criteria for the trial, along with development of a plan for opioid cessation and alternative treatments to try in the case of failure.

ASH remarks regarding COT include the following:

  • The profile of each opioid drug under consideration for use in a given patient should be reviewed, as individual opioid drugs have different specific toxicity profiles and interactions with end-organ injury.
  • Prescribe the lowest effective opioid dose.
  • Patients on COT should avoid the use of benzodiazepines, sedating medications, and alcohol.
  • Providers should be aware that patients may inadvertently end up on COT if episodic pain is frequent enough that patients are receiving frequent opioid treatment of recurrent pain. Therefore, providers should make efforts to reduce or eliminate scheduled opioid doses between acute episodic pain events, which may reduce the likelihood of unintentional COT.
  • Acute pain events may still be treated with opioid analgesia if this serves the overall pain treatment plan, but this should be done in conjunction with the primary outpatient management team. Furthermore, nonopioid medications and integrative therapies should also be offered; strategies for these can be developed through collaboration with a pain specialist.
  • Patients on COT require careful monitoring with regard to functional status and risk assessment for the development of aberrant opioid use and medical, social, behavioral, or psychological complications, as a precursor to opioid dose reduction or weaning.
  • Weaning and/or withdrawal from COTpotentially poses higher risk in patients with SCD (ie, it may trigger vasoocclusive events or other medical complications) and should be done carefully.
  • The risk of adverse events related to COT rises as the total dose increases. Therefore, patients on high doses of opioids need close monitoring for complications and adverse effects.

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