Patterns of opioid use in sickle cell disease

Abstract

Pain, the hallmark complication of sickle cell disease (SCD), is largely managed with opioid analgesics in the United States, but comprehensive data regarding the long-term use of opioids in this patient population is lacking. The pain medication prescription records from a cohort of 203 SCD patients were analyzed. Twenty-five percent were not prescribed opioid medications while 47% took only short-acting opioids, 1% took only long-acting opioids, and 27% took a combination of short-acting and long-acting opioids. The median (interquartile range) daily opioid dose was 6.1 mg (1.7-26.3 mg) of oral morphine equivalents, which is lower than the published opioid use among patients with other pain syndromes. The dose of opioids correlated with the number of admissions due to vaso-occlusive crisis (VOC) (r=0.53, p<0.001). When the patients were grouped into quartiles based on daily dose opioid use, a logistic regression model showed that history of avascular necrosis (AVN) (OR 2.87, 95% CI: 1.37-6.02, p=0.005), 25-OHD levels (OR 0.59, 95% CI: 0.38-0.93, p=0.024) and total bilirubin concentration (OR 0.64, 95% CI: 0.42-0.99, p=0.043) were independently associated with opioid use quartiles. In conclusion, doses and types of opioid medications used by adult SCD patients vary widely. Our findings implicate AVN and lower vitamin D levels as factors associated with higher opioid use. They also suggest an association of higher bilirubin levels, possibly suggesting higher hemolytic rate, with lower opioid use.

Reply to Ruan X et al: “A comment on pattern of opioid use in sickle cell disease”

“…Some SCD patients indeed encounter delayed access to legitimate opioid use based on our own clinical experience. Our results showed that there was a cluster of SCD patients (13%) who used more than 50 mg OME daily, despite a relatively low opioid dose usage in the overall SCD patient population (1), which is also consistent with our unpublished observation from the large cohort of commercially-insured SCD patients. This subset of SCD patients may contribute to the misconception that patients with SCD consume more opioids than other chronic pain syndromes, since they tend to be frequent healthcare utilizers.…”

“…We thank Ruan and colleagues for their comments on our recently published study of opioid use in sickle cell disease (SCD)(1), and share their concern that persons with SCD may be unfairly denied needed pain relief during an acute pain crisis. We would like to emphasize that our study addressed daily opioid use as an outpatient rather than need for opioids in the emergency department or during hospitalization for a vaso-occlusive crisis (VOC).…”

Characterization of opioid use in sickle cell disease

“…Opioid analgesic medications are the main treatment options for acute and chronic pain caused by SCD, although the literature on the patterns of opioid use in this patient population is rather limited . Most studies were based on a self‐reported questionnaire or diary with relatively small numbers of patients, which may be subject to recall or selection bias .…”

“…The evidence on the patterns of opioid use in this patient population is rather limited, and there is still controversy on the dose of opioids that SCD patients use in their daily life . Many believe that patients with SCD tend to use more opioids than many other chronic pain conditions, whereas some studies showed a relatively low opioid dose used in this patient population in their daily life . However, most of the previous studies were based on single institutions with relatively small sample sizes or based on a self‐reported questionnaire or diary, which may limit the generalizability of the results.…”

“…4 Opioid analgesics are a mainstay of pharmacotherapy in treating pain episodes in SCD, 1 although doses and types of opiate medications vary greatly among SCD patients. 5 The evidence on the patterns of opioid use in this patient population is rather limited, and there is still controversy on the dose of opioids that SCD patients use in their daily life. 6,7 Many believe that patients with SCD tend to use more opioids than many other chronic pain conditions, 7 whereas some studies showed a relatively low opioid dose used in this patient population in their daily life.…”