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.
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.
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.
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.
Blinder:Novartis Pharmaceuticals: Consultancy, Research Funding.
