Managing pain in sickle cell crisis with Dr. Ifeyinwa Osunkwo

Ifeyinwa (Ify) Osunkwo, MD, MPH, joins us to talk about her approach to pain management in patients suffering from sickle cell crisis as well as the cognitive and behavioral effects of long-term opioid use in these patients. She and our host David H. Henry, MD, cover these topics and more in this episode.

Dr. Osunkwo is a professor of medicine at Atrium Health and the director of the Sickle Cell Enterprise at the Levine Cancer Institute, part of Atrium Health, in Charlotte, N.C.

• Over the course of a decade, the life expectancy of patients with sickle cell disease has increased.
• Today 99% of children with sickle cell disease will live to become adults.
• When treating patients with sickle cell pain it is important to consider their disease trajectory, and to weigh the pros and cons for initiation of opioid therapy.

Management of sickle cell disease in the acute setting:

• In children, therapy usually includes use of intravenous fluid and intravenous opioids, then an eventual transition to oral opioids and NSAIDS.
• In adolescents, exposure to a prolonged course of high-dose opioids actually has been shown to exacerbate their pain.
• PCA (patient-controlled analgesia) versus “PRN” or as-needed medications removes the dependency on the external environment to receive pain medications and lessens the degree of psychological stress in these patients.
• Use of intravenous ketamine as an adjuvant to opioids in patients with an acute exacerbation has been shown to improve outcomes in patients (i.e., better pain control, decreased hospital stay, and management of anxiety and stress of a pain crisis.)
• In the acute pain setting, it is important to go through all differentials to get to where you are treating the right cause of pain.
• Following hospitalization, these patients often present back to the hospital in subacute opioid withdrawal. The key here is to engage patients in long term treatment plans.
• For opioid-induced itching, it has been shown that in patients who receive intravenous Benadryl have worse outcomes than in patients that receive oral Benadryl.

Long-term side effects of chronic opioid therapy use:

• Psychological and behavioral side effects including insomnia, reduced libido, tolerance, oppositional behavior, poor memory, psychosis, paranoia, increased depression/anxiety and confusion.
• The opioid risk score is a helpful screening test that looks at the risk of adverse opioid outcomes. Specifically, family history of substance abuse, personal history of substance abuse, history of person abuse or psychological diagnosis results in a higher score which correlates with a higher risk of negative outcomes.
• Use of suboxone has proved to be very beneficial in patients on chronic opioid therapy in preventing frequent hospitalizations.

Show notes written by Alesha Levenson, MD, a resident with Penn Medicine, Philadelphia.

Disclosures

Dr. Osunkwo disclosed relationships with Terumo, Global Blood Therapeutics, Acceleron, FORMA Therapeutics, Health Resources and Services Administration, Patient Centered Outcomes Research Institute, Micella Biopharma, Pfizer, and Novartis. Dr. Henry has no relevant disclosures.

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David Henry