Abstract
Pain is a limiting factor in the daily life activities of sickle cell disease (SCD) patients. Opioid analgesics are widely used for management of SCD-related chronic pain in the community. To date there have been no studies on the use of opioids and their impact on quality of life (QoL) measures in this population. Patients on long-term opioid pain management may also be on hydroxyurea (HU), which is often used to decrease the frequency of painful episodes and other SCD sequelae. HU is also known to affect some QoL measures. The aim of this study was to determine the effect of opioid analgesia on QoL measures in an adult SCD population. This study included 185 patients, 92 females and 93 males, from the outpatient clinic at Duke University Medical Center. 117 patients either had homozygous SCD or were doubly heterozygous for Sβ0 thalassemia; 68 patients were of different genotypes. Data were collected by patient interviews as well as review of medical records after informed consent. The Medical Outcome Study 36-item Short Form (SF-36) was used to determine QoL measures, and the results were scored in standard fashion. Differences in variables of interest between narcotic users and narcotic non-users were analyzed using t-tests. ANOVAs were used to identify combined effects of narcotics, HU and their interaction with SF-36 scores. Gender, age and genotypes were included as covariates. Patient data were classified in 4 groups based on report of regular use of opioids (at least 30 days within the preceding year) and HU (any use during the preceding year) as follows: no HU or narcotics (none); narcotics only; HU only; and narcotics and HU. SF-36 scores for all physical and mental domains were significantly lower in individuals on opiates vs those not on opiates, in all age groups (p<.01). Controlling for HU use did not affect the association of opioid use with lower SF-36 scores. We also examined the relationship between hemoglobin, white blood cell count (WBC) and oxygen saturation in the different medication groups. WBC counts were significantly higher in individuals using opioids when compared to those who were not on opioids. Patients on HU and narcotics also had higher WBC than those on HU alone. The frequency of hospitalization was significantly higher in the opioid only group, as compared to the other 3 groups (p=.02). While HU was found to have a positive impact on certain aspects of QoL, it added very little to QoL in individuals who were on both HU and narcotics. Since the efficacy of HU was strongly related to the decrease in WBC, we compared the mean values of WBC in all medication groups. HU significantly lowered the WBC count, but the concurrent use of opioids partially obliterated this effect. This cannot be explained by poor compliance, as the mean WBC were lower in the HU and opiates than in the opiate only group. Our results suggest that further studies are needed to determine whether other factors play a role in QoL outcomes. Other pain management strategies should also be investigated due to the apparent association of opioid analgesia with lower QoL in this patient population.
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