Inpatient pain management in sickle cell disease

Zassman, Stefanie; Zamora, Francis; Roberts, John D.

doi:10.1093/ajhp/zxz228

Cited by 5 publications

(5 citation statements)

References 12 publications

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“…The use of oral opioids prior to discharge may have also allowed for prescribers to identify appropriate opioid discharge regimens, as has been described in previous literature. 8 We found a significant reduction in hospital readmissions within 30 days, which may demonstrate that by identifying effective oral regimens, patients had better pain control following discharge. Alternatively, patients may have chosen to seek care at other institutions; however, we expect that most institutions had similar restrictions on IV opioid use due to the national shortage.…”

Section: Discussionmentioning

confidence: 59%

“…One case series of 3 patients reported successful transition of patients from PCAs to oral opioids during admissions for VOC pain. 8…”

Section: Introductionmentioning

confidence: 99%

“…One case series of 3 patients reported successful transition of patients from PCAs to oral opioids during admissions for VOC pain. 8 During the shortage, our Pharmacy and Therapeutics Committee approved IV opioid limitations on ordering that was implemented at the time of order verification. All IV push doses were limited to one-time orders if patients had an active diet order or were able to take oral medications.…”

Section: Introductionmentioning

confidence: 99%

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Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

2022

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Introduction: In October 2017, the Food and Drug Administration announced a shortage of intravenous (IV) opioid medications. Patients with sickle cell disease (SCD) are particularly vulnerable, as high amounts of IV opioid medications are standard therapy during vaso-occlusive crises (VOC). Our institution responded to the crises by implementing IV to oral (PO) conversions of opioid therapies and encouraging multimodal pain management with non-opioid medications. Objectives: The primary objective was the assessment of IV opioid medication utilization before and during the shortage. Secondary objectives included total opioid consumption, length of stay, and prescribing of non-opioid analgesics. Methods: This single-institution retrospective study included patients >18 years of age admitted to adult medicine teams with VOC during February 2017 or February 2018. The amount of opioid medication administered to patients during both periods was assessed, and quantities were then converted to PO morphine milligram equivalents and compared between years. The number of patients receiving scheduled non-opioid medications were also compared. Length of stay and readmissions were compared between years. Results: Between 2017 and 2018, IV opioid use for VOC decreased by 52% on inpatient services, and there was a 34% reduction in overall opioid use. Oral opioid use more than doubled during the period (10.2% in 2017 vs 39.1% in 2018, P < .01). LOS between 2017 and 2018 (6 vs 6 days, P = .4774) and total number of ED visits (27 vs 8, P = .276) were similar. There were significantly fewer 30-day readmissions in 2018 versus 2017 (15 vs 28, P = .025). Conclusion: The implementation of IV opioid restrictions resulted in a decrease in IV opioid use in treatment of VOC in patients with SCD without causing increases in length of stay or readmissions. Oral opioids should be considered an option for VOC management in patients with SCD.

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Section: Discussionmentioning

confidence: 59%

“…One case series of 3 patients reported successful transition of patients from PCAs to oral opioids during admissions for VOC pain. 8…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

2022

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“…A three patient case series by Zassman and colleagues evaluated the use of a three-tier oral opioid approach to better prepare patients for discharge. 9 Patients were initially managed on PCA and when their pain was adequately controlled, a three-tier opioid approach was added. This consisted of three oral opioid orders: a scheduled opioid, an as-needed opioid for moderate pain, and another as-needed opioid for severe pain.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a pain management protocol used to deescalate opioid use in adult patients hospitalized with vaso‐occlusive crisis due to sickle cell disease

Ciriello

Cieri‐Hutcherson

Seyse

et al. 2021

J Am Coll Clin Pharm

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Introduction: Limited guidance has been provided for opioid de-escalation when managing pain associated with vaso-occlusive crisis (VOC) in hospitalized patients with sickle cell disease (SCD). Therefore, a pain management protocol was developed for use in this population and piloted at a tertiary academic medical center.Objective: To assess implementation of a newly developed pain management protocol for use in hospitalized patients with a VOC.Methods: This was a retrospective, single-center, pre-post cohort study of SCD patients admitted with a VOC between June 1, 2018 to June 1, 2019 (pre-protocol) and December 31, 2019 to May 12, 2020 (post-protocol). The primary outcome was a reduction in intravenous (IV) short-acting opioid utilization as defined by the proportion of hospitalized days where the route of administration for short-acting opioids was oral rather than IV for ≥75% of doses given. Secondary outcomes included the proportion of hospitalized days where ≥50% and ≥25% of the short-acting opioid doses were administered by mouth. Opioid use (in morphine milligram equivalents [MME]) was also compared between groups.Results: A total of 96 admissions in the pre-protocol group and 29 admissions in the post-protocol group were included in the study. There was a statistically significant increase in the proportion of hospitalized days where ≥75% of the short-acting opioid doses were administered by mouth rather than IV in the post-protocol group compared with the pre-protocol group (0% vs 8.3%, P = .0114). Intravenous opioid use and total opioid use in the post-protocol group was lower compared with the pre-protocol group. Conclusion:Implementation of a pain management protocol for use in hospitalized SCD patients admitted with VOC was associated with an increase in the use of oral short-acting opioids and reduced overall opioid use.

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“…We instituted a new approach to inpatient oral administration of opioids, which we call an “oral tier”, in which a dose of a short acting opioid is scheduled for administration every 3 hours, and additional linked PRN orders allow for administration of additional amounts if the patient reports moderate or severe pain, respectively. (Subsequently, we discovered a literature precedent for this [ 33 – 35 ] and published a description of our approach [ 36 ].) The scheduled dose, which the patient might refuse, assured that the patient experienced regular pain assessments and opportunities to request oral pain medication; thus, it avoided the delays, frustration, and potential conflict associated with PRN dosing.…”

Section: Methodsmentioning

confidence: 99%

Utilization, financial outcomes and stakeholder perspectives of a re-organized adult sickle cell program

et al. 2020

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In 2011 Yale New Haven Hospital, in response to high utilization of acute care services and widespread patient and health care personnel dissatisfaction, set out to improve its care of adults living with sickle cell disease. Reorganization components included recruitment of additional personnel; relocating inpatients to a single nursing unit; reducing the number of involved providers; personalized care plans for pain management; setting limits upon access to parenteral opioids; and an emphasis upon clinic visits focused upon home management of pain as well as specialty and primary care. Outcomes included dramatic reductions in inpatient days (79%), emergency department visits (63%), and hospitalizations (53%); an increase in outpatient visits (31%); and a decrease in costs (49%). Providers and nurses viewed the reorganization and outcomes positively. Most patients reported improvements in pain control and life style; many patients thought the reorganization process was unfair. Their primary complaint was a lack of shared decision-making. We attribute the contrast in these perspectives to the inherent difficulties of managing recurrent acute and chronic pain with opioids, especially within the context of the imbalance in wellness, power, and privilege between persons living with sickle cell disease, predominantly persons of color and poor socioeconomic status, and health care organizations and their personnel.

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Inpatient pain management in sickle cell disease

Cited by 5 publications

References 12 publications

Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

Evaluation of a pain management protocol used to deescalate opioid use in adult patients hospitalized with vaso‐occlusive crisis due to sickle cell disease

Utilization, financial outcomes and stakeholder perspectives of a re-organized adult sickle cell program

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