Opioid Utilization in Adults Hospitalized with Sickle Cell Pain Crises: An Understudied Population
Authors: Rodday Angie Mae , Esham Kimberly S , Savidge Nicole S , Mao Daqin , Weidner Ruth Ann , Parsons Susan K 
Published: October 2019

Abstract
Background: Vaso-occlusive crises (VOC), also known as painful crises, are the hallmark of sickle cell disease (SCD) and adults hospitalized with VOC are among the most severe cases. In the midst of the opioid epidemic, appropriate pain management must be available for these patients when they develop VOC. We describe patient, disease, and treatment characteristics at the time of hospitalization for patients with SCD experiencing VOC.
Methods: This retrospective cohort study includes 449 consecutive hospitalizations for VOC among 63 adult patients (≥18 years) with SCD from 2013-2016 at Tufts Medical Center, an academic medical center in Boston, MA. For the current analysis, one hospitalization was randomly selected for each patient (median hospitalizations per patient=4, range=1-45). Demographics, SCD characteristics and complications, pain scores (0-10), and pain medication regimens (pre-admission, inpatient, discharge) were abstracted from electronic medical records (EMR) by trained study staff. History of SCD complications (e.g., acute chest syndrome, avascular necrosis), modeled after the 9-item ASCQ-Me SCD Medical History Checklist (Keller et al. Health and Quality of Life Outcomes, 2017), were obtained from the EMR and subsequently reviewed by two hematologists. Data were described using summary statistics, including means, standard deviations (SD) medians, quartiles (q1, q3), frequencies, and percentages.
Results: Mean age was 27.6 years (SD=8.1), 44.4% were male, 77.8% were black, and 19.1% were Hispanic. The majority of patients (92.1%) were publicly insured (27.0% Medicare; 65.1% Medicaid); only 7.9% were privately insured. Patients had a median of 3 medical complications of SCD. Affective disorders were documented for 33.3%; substance use disorders for 6.4%.
Median pain scores were 9 (8, 10) at admission and 4 (2, 6) at discharge; the median length of stay was 8 days (5, 11). Prior to admission, 87.3% of patients had a home opioid prescription and 20.6% had a neuropathic pain medication prescription (Table). During the hospitalization, 100% received opioids with 36.5% delivered via patient-controlled analgesia (PCA). Neuropathic pain medication was given to 28.6% of hospitalized patients. At discharge, nearly all (98.4%) were prescribed home opioids and 24.6% were discharged with neuropathic pain medication. With regards to treatment combinations across phases of care, approximately half of patients received both short- and long-acting opioids and less than 20% received long-acting opioids and neuropathic pain medication.
Conclusions: All patients with SCD hospitalized with VOC were admitted with significant pain and treated with opioids. Pain decreased during the hospitalization, but did not fully resolve by discharge. Treatment combinations of short- and long-acting opioids and neuropathic pain medication suggest complex acute-on-chronic SCD pain with mixed pain types among this cohort of patients with high-severity SCD. Opioids are an integral component of treatment regimens for patients suffering from debilitating acute-on-chronic pain, such as those with SCD.

Disclosures
Parsons: Seattle Genetics: Research Funding.