Sickle Cell Crisis and pain management? - Page 2

An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...

[color=#315a66]the vaso-occlusive crisis, or sickle cell crisis, is initiated and sustained by interactions among sickle cells, endothelial cells and plasma constituents.1 vaso-occlusion is responsible for a wide variety of clinical complications of sickle cell disease, including pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.
[color=#315a66]a vaso-occlusive crisis is initiated and sustained by the interaction among sickle cells, endothelial cells and plasma constituents. clinical complications include pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.
[color=#315a66]acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of microvascular beds by sickled erythrocytes during an acute crisis. chronic pain occurs because of the destruction of bones, joints and visceral organs as a result of recurrent crises. the effect of unpredictable recurrences of acute crises on chronic pain creates a unique pain syndrome.2,3
[color=#315a66]acute bone pain from microvascular occlusion is a common reason for emergency department visits and hospitalizations in patients with sickle cell disease.4 obstruction of blood flow results in regional hypoxemia and acidosis, creating a recurrent pattern of further sickling, tissue injury and pain. the severe pain is believed to be caused by increased intramedullary pressure, especially within the juxta-articular areas of long bones, secondary to an acute inflammatory response to vascular necrosis of the bone marrow by sickled eythrocytes.5 the pain may also occur because of involvement of the periosteum or periarticular soft tissue of the joints.

[color=#315a66]the approach to pain control must include measures to treat acute pain crises, prevent future vaso-occlusive crises and manage the long-term sequelae of chronic pain that can result from multiple recurrent bony infarction.

tolerance, physical
dependence, addiction,
and pseudoaddiction
a major barrier to effective management of
sickle cell pain is a lack of understanding of
opioid tolerance, physical dependence, and
addiction. tolerance and physical dependence
are expected pharmacologic consequences of
long-term opioid use and should not be confused
with addiction.

■ tolerance is a physiologic response to the
exogenous administration of opioids, and
the first sign is decreased duration of medication
action. when tolerance develops,
larger doses or shorter intervals between
doses may be needed to achieve the same
analgesic effect.

■ physical dependence also is a physiologic
response to the exogenous administration
of opioids. it requires no treatment unless
withdrawal symptoms—such as dysphoria,
nasal congestion, diarrhea, nausea, vomiting,
sweating, and seizures—occur or are
anticipated. the risk varies among individuals,
but when opioids are given for more
than 5 to 7 days, doses definitely should
be tapered to avoid physiologic symptoms
of withdrawal.
genetic, psychologic, and social roots. the
use of opioids for acute pain relief is not
addiction, regardless of the dose or duration
of time opioids are taken. patients
with scd do not appear to be more likely
than others to develop addiction. the
denial of opioids to patients with scd
due to fear of addiction is unwarranted
and can lead to inadequate treatment,

pseudoaddiction (16) applies to patients
who receive inadequate doses of opioids
whose doses are not tapered, and therefore
they develop characteristics that resemble
opioid addiction.
understandably, some patients whose pain is
managed poorly will try to persuade medical
staff to give them more analgesic, engage in
clock-watching, and request specific medications
or dosages. staff often regard this as
manipulative or demanding behavior. patients
with scd often are quite knowledgeable
about the medications they take for their condition
and the doses that have worked in the
past. requests for these specific medications
and doses should not be interpreted as indications
of drug-seeking behavior. in addition,
patients who have had frequent painful
episodes often behave in ways learned from
prior experiences. a patient, for example, who
believes that a medication will not be given
unless he or she appears to be in severe pain
may lie quietly when alone but begin to
writhe and moan when a nurse or physician
enters the room. pseudoaddiction or clockwatching
behavior usually can be resolved by
effective communication with the patient to
ensure accurate assessment and by adequate
opioid doses.
as in the general population, some persons
with scd will use illicit drugs, such as
cocaine. patients who have problems with
substance abuse require individual treatment
to provide competent and humane management
of their pain.
http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf