Treatment of Sickle Cell Pain

Karen F. Marlowe, PharmD., Michael F. Chicella, PharmD.

Disclosures

Pharmacotherapy. 2002;22(4) 

In This Article

Barriers to Pain Management

Several psychosocial factors influence the management of sickle cell pain. First, and possibly most common, is the care provider's fear that the patient will become addicted to the prescribed analgesic. A survey of health care workers treating patients with sickle cell pain as well as other pain found that physicians and nurses perceived a much higher percentage of addiction than actually existed.[18] Undertreating pain because of fear of addiction predisposes patients to the development of pseudoaddictive behavior. This behavior is characterized by seeking and hoarding drugs due to fear of pain and usually disappears when pain is adequately managed.[19,20] Patient actions or attitudes that health care professionals may characterize as drug-seeking behavior may be best described as pain-avoidance behaviors.[19] Although many patients with sickle cell disease may complain of severe pain, they engage in activities that are inconsistent with the traditional image of the patient in severe pain, such as watching television or talking on the telephone. This is often perceived as exaggerating their pain to receive additional narcotics, whereas these activities may actually be learned distractions or coping mechanisms. Another example is the sleeping patient who, when awakened, reports unrelenting pain. Two points need to be addressed in this situation. First, this behavior pattern may be due to an imbalance between the sedative and analgesic effects of opiates.[21] Second, patients with pain still need to sleep; therefore, it is inappropriate to use this situation as an end point to decide if the patient is being truthful about the pain. Despite many health care workers' perceptions, the frequency of drug addiction in patients with sickle cell disease is only 1-3%.[6]

Communication barriers and lack of trust in the care provider also contribute to improper pain management. After experiencing suboptimal pain management, many patients develop a poor relationship with their providers. In a survey of more than 100 patients with sickle cell disease, most reported that their provider did not under-stand the amount of pain they experienced, and that they did not receive an analgesic drug when they needed it.[22] Many patients watch the clock or request an analgesic before administration time to ensure that they receive it promptly. Other patients who feel dependent on the health care system for pain control may display immature behavior, somatic complaints, hostile withdrawal, abusiveness, and dependency.[23] Patient age may also affect communication regarding pain. A comparison of pain ratings by children and adolescents found that children tended to report less pain.[24]

The type of institution providing care to patients with sickle cell disease also affects pain management. A survey of patients revealed that a system of inpatient admissions for treatment of pain encouraged dependence on inpatient care and discouraged self-reliance.[22] Many patients are treated at teaching institutions and interact with many residents, interns, and attending staff at each admission. Each physician approaches pain control in a different way, which results in various levels of care.[19,23] Some specialists advocate sickle cell teams who follow patients continually. Continuity of care could result in better patient-provider relationships and more individual care based on patient history.[6,25]

Some institutions report success with day treatment centers specializing in sickle cell pain crises. In one, 80% of patients went home after treatment; average length of stay was 4-5 hours. The inpatient admission rate was only 8.3% versus a previous rate of 42.7% based on emergency department treatment.[26] Therapy is determined through a combination of treatment algorithms and the patient's pain history. Center management of pain crises may involve intermittent intravenous injections, patient-controlled analgesics, hydration, and adjunctive therapies.

Despite these advances, most patients still are treated in emergency facilities and as inpatients. Patients report long waiting periods before they are assessed in emergency facilities. Emergency departments could improve continuity of care by maintaining patient records describing medical history, drug therapy, and usual pain treatments.[19,23] Although this approach has been widely suggested, it has not been evaluated in a controlled manner.

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