Association Between Vaso-Occlusive Crises and Opioid Prescriptions Among Patients with Sickle Cell Disease: A Retrospective Claims-Based Study

Abstract

Background/Objectives: Among sickle cell disease (SCD) patients, vaso-occlusive crises (VOCs) are recurrent and unpredictable attacks of acute pain. These pain crises are often treated with analgesics, including opioids, which have been associated with misuse and overdose. The aim of this study was to examine the association between VOC events and opioid use and assess the association between opioid prescriptions and health care resource utilization among SCD patients. Methods: This was a retrospective cohort study using Texas Medicaid medical and prescription claims between September 2011 and August 2016. The index date was the first SCD diagnosis. Patients (2–63 years) with at least one inpatient or two outpatient SCD diagnoses, who were continuously enrolled during 12 months postindex, were included in the study. The primary outcome was number of opioid prescriptions, while the independent variable was number of VOC events. Covariates included age, gender, nonopioid medication use, nonstudy SCD-related medication (penicillin and folic acid) use, evidence of blood transfusions, number of SCD-related complications, number of SCD-related comorbid conditions, and Charlson Comorbidity Index score. Negative binomial regression analysis was used to address study objectives. Results: Of 3368 included patients, 1978 (58.7%) had at least one opioid prescription with a mean of 4.2 (SD=7.2). Overall, 2071 (61.5%) had at least one VOC event with an average of 2.9 (SD=4.4). The results from the negative binomial regression showed that for every increase in VOC events, the number of opioid prescriptions increased by 9.5% (Incidence rate ratio=1.095, 95% CI: 1.078–1.111; P ≤ 0.0001). Other significant covariates associated with higher opioid use included age (13 and older compared to 2–12) and increase in the number of nonopioid pain medications, nonstudy SCD-related medications, and SCD-related complications. Conclusions: The majority of SCD patients had at least one VOC event and were prescribed opioids during the 12-month study period. We found that each VOC event was associated with a 9.5% increase in the use of opioids. SCD guidelines recommend opioids for the treatment of VOC-related pain. Payers and providers should be aware of opioid use in this population, consider appropriate VOC prevention measures, and provide SCD patients with access to appropriate pain management.

Administrative data identify sickle cell disease: A critical review of approaches in U.S. health services research

“…Numerous peer‐reviewed studies that analyzed public or private claims databases have required either 1 inpatient claim with a diagnosis code for SCD or ≥2 outpatient claims with a diagnosis code for SCD on separate days to identify cases of SCD 2,3,25–45 . One of these studies excluded individuals who also had a claim with a diagnosis code for sickle cell trait, 40 citing a Wisconsin study that reported that individuals who had diagnosis codes for both SCD (282.60) and sickle cell trait were confirmed to have trait 8 …”

Burden of disease, treatment utilization, and the impact on education and employment in patients with sickle cell disease: A comparative analysis of high‐ and low‐ to middle‐income countries for the international Sickle Cell World Assessment Survey

“…This finding was reflected in two recent studies: one that reported that 240 million opioid prescriptions were dispensed in the USA in 2015 (equivalent to almost one prescription for every adult in the general population) 21 and another SCD-based study in the USA that identified that each VOC was associated with an increased use of opioids. 22 The US campaign to identify pain as the fifth vital sign has been a key driver in compelling providers to prescribe opioids for pain. 16 It is important to note that while opioids (both intravenous and oral) remain a valid treatment option for patients with SCD, 23 their availability is country dependent, and particularly limited in many countries across Africa and the Middle East.…”

Opioid Use in Patients With Sickle Cell Disease During a Vaso-Occlusive Crisis: A Systematic Review

“…In addition to this, as morphine is metabolized by liver glucuronidation, dosage adjustment should be considered in patients with liver dysfunction [ 8 ]. One study concluded that with each VOC event, there is an expected 9.5% increase in opioid prescription use [ 4 ]. Long-term opioid use is associated with the risk of abuse potential, leading to physical tolerance, physical and psychological dependence, addiction, and possible opioid hyperalgesia [ 5 ].…”

“…Acute painful crisis (APC) is a consequence of microcirculation occlusion by sickle hemoglobin-containing red blood cells (RBCs), leading to ischemia, inflammation, and subsequent tissue damage [ 3 ]. These pain crises are often recurrent and unpredictable forms of acute pain [ 4 ]. The Cooperative Study of Sickle Cell Disease defines an acute pain crisis as an episode of pain in the extremities, back, abdomen, or head lasting more than two hours that leads to a clinic visit that cannot be explained by any etiology other than SCD.…”