International Differences in Outpatient Pain Management: A Survey of Sickle Cell Disease

Abstract

Vaso-occlusive pain crises are the hallmark of sickle cell disease (SCD) and the primary reason for health care utilization. Both national and international guidelines recommend aggressive intravenous opioids, intravenous fluids and anti-inflammatory therapy as the mainstay of treatment for acute SCD pain. However, many vaso-occlusive crises are managed at home with oral medication and supportive care. There are no guidelines on home medication management of SCD-related pain, likely due to the lack of well-defined endpoints for acute events and the lack of funding for already approved pain medications. Amplifying this issue is the growing concern for opioid abuse and misuse in the United States (US) and internationally. This study aimed to evaluate differences in opioid prescribing practices among providers treating SCD in the US and internationally. A survey was disseminated electronically to known providers using a combination of purposive and snowball sampling strategy. There were 127 responses and 17 countries represented. US providers were more likely to prescribe opioids (p < 0.001) and were more likely to be “very comfortable” prescribing opioids than non-US prescribers (p < 0.001). US providers also tended to prescribe more tablets per patient of stronger opioids than non-US physicians. US physicians were more likely to be concerned that patients were abusing opioids than non-US physicians (32% vs. 27%, p < 0.05). There are significant variations in how different parts of the world manage pain in the outpatient setting for SCD. Identifying optimal home pain management strategies is necessary to improve care and long-term outcomes in SCD.

Rates of Opioid Misuse Amongst Patients Receiving Pain Management for Sickle Cell Disease in An Urban Setting

“…Outpatient treatment of chronic pain is adequately treated with oral analgesics. 9 It is important to determine the incidence of opioid misuse amongst patients with SCD since the United States is currently experiencing an opioid epidemic. 10,11 In a study investigating pain management in adults with SCD, patients were asked to self-report on the pain medications they were using at home.…”

“…9 Still, data show the results of these urine drug screens are hard to come by or inconsistently reported. 9 The information elucidated from these databases include urine drug screens which can be very useful in highlighting patient characteristics associated with prescription misuse. Additionally, it can help identify patients who need treatment modification if prescriptions are consistently being used inappropriately.…”

“…10,11 This is quite a concern as chronic pain medications are a necessary way of life for those living with SCD. 9 There are some studies that show that patients with SCD require opioid dose escalation for chronic pain due to tolerance and continuous pain potentially equating to high morphine milligram equivalent (MME) doses. [13][14][15] A study by Karafin and colleagues 15 showed that patients on 90 MMEs or higher had worse mental health, higher somatic symptom burden and worse health related quality of life (HRQOL).…”

“…A study by the Medical University of South Carolina showed that in the United States, providers are more likely to prescribe stronger, longer-acting opioids for chronic pain management than non-US providers. 9 However, US prescribers are also more inclined to perform urine drug tests and to utilize databases that track prescriptions. 9 Still, data show the results of these urine drug screens are hard to come by or inconsistently reported.…”

“…9 However, US prescribers are also more inclined to perform urine drug tests and to utilize databases that track prescriptions. 9 Still, data show the results of these urine drug screens are hard to come by or inconsistently reported. 9 The information elucidated from these databases include urine drug screens which can be very useful in highlighting patient characteristics associated with prescription misuse.…”