Acute pain in adolescents and young adults with sickle cell disease: Delayed and increased opioid dosing following transition to adult care
Authors: Nathan Stehouwer, Preston Edge, Bohyung Katie Park, Connie Piccone, Jane Little
Journal: American Journal of Hematology (2017)

The transition from pediatric to adult care is a high risk time for adolescent and young adult (AYA) patients with sickle cell disease (SCD). Management of acute pain is a major point of contact between patients and the healthcare system,1 and inconsistent care delivery in the ED and inpatient settings may be one important barrier to successful transition from pediatric to adult care. At our institution we reviewed all adult and pediatric ED visits for pain by AYA patients with SCD (defined as ages 13–22) over a three year period, examining the time to first analgesic administration, the equianalgesic dose of the first opioid given, calculated using standard opioid conversion tables,2 and the total daily equianalgesic opioid dose administered in patients who were hospitalized. To adjust for patients' unequal numbers of ED visits during the study period, correlation between visits by the same patient were controlled in all analyses using a generalized linear mixed model and the least squares mean (LS-mean) time from ED registration to first analgesic administration and the equianalgesic dose of the first opioid given were compared. Results were adjusted for age, baseline hemoglobin, and presenting pain score. One hundred ninety-three ED visits by 45 patients, half of whom were male and most of whom had either HbSS or HbSβ0, were examined. AYA patients with SCD received parenteral hydromorphone as their first opioid in 7% of visits to the pediatric ED and 71% of visits to the adult ED (P < .05). In distinction, parenteral morphine was the first opioid given in 77% of visits to the pediatric ED but only 19% of visits to the adult ED (P < .05). Mean time to medication administration was significantly longer in the adult ED than in the pediatric ED (Figure 1). The odds ratio for waiting longer than 60 min was 1.46 (95% CI 1.25-14.87, P = .008) in the adult ED compared with the pediatric ED. The dose of first opioid medication administered in the adult ED was nearly double that given in the pediatric ED (Figure 1). Among patients who were subsequently admitted to the hospital, total daily opioid doses given were higher in the adult hospital (97.3 ± 9.6, 84.5 ± 9.6, and 90.6 ± 9.6 mg IV morphine equivalents on days 1, 2, and 3 of admission) than in the pediatric hospital (62.4 ± 11.8, 47.6 ± 11.8, and 31.2 ± 11.8 mg IV morphine equivalents on days 1, 2, and 3 of admission, P < .05 for all 3 days) (Supporting Information Figure 1). Acute pain management in the ED for AYA with SCD. (A) Time from registration to administration of first analgesia. Time to first analgesia was 64.0 ± 11.5 min in the pediatric ED and 136.9 ± 9.7 min in the adult ED (P < .0001). (B) Equianalgesic dose of first opioid. The first opioid dose, expressed in mg of equivalent IV morphine, was 5.5 ± 0.7 mg in the pediatric ED and 9.6 ± 0.6 mg in the adult ED (P < .0001). Results are given as LS-mean ± the standard error of the mean (SEM). All data shown were adjusted for pain score, baseline hemoglobin, and genotype Our data suggest a significant unplanned change in management of acute pain as AYA patients with SCD leave pediatric care, including delayed treatment and increasing doses of a more potent opioid. There are several possible explanations for these shifts in care. Increased wait times may reflect an overall increased patient volume in the adult ED as well as assignment to lower triage scores as adults. While we adjusted our results for genotype, it is possible that the higher proportion of adults in our population with HbSS may have influenced the results. Disease severity, chronic pain burden, opioid tolerance, and difficulty of vascular access may have increased over the AYA interval and contributed to observed differences. Provider perception of adult patients as "drug seeking" may contribute to delays; surveys have shown that providers are concerned that SCD patients are "drug-seeking" or are at risk for developing addiction if treated with parenteral opioids.3 Finally, adult medical providers exhibited a preference for hydromorphone, which has higher potency than morphine which was the opioid of choice in the pediatric ED. The association of higher potency opioids with greater total equianalgesic drug doses was also seen in data from the PROACTIVE study, in which patients aged 18-35 who received hydromorphone received higher equianalgesic doses than did adolescents aged 10-17, who primarily received morphine; increased doses were not seen in patients aged 18-35 who were given morphine.4 The significant differences in care delivery between pediatric and adult settings for AYA patients with SCD reflect inadequate preparation of patients, providers, and healthcare systems for the pediatric to adult transition. At our center, a comprehensive sickle cell transition program has been implemented since 2013, and as part of this program we are working to standardize and coordinate care for acute pain management of AYA SCD patients in the ED and in a dedicated acute care clinic. While from a single center, our data identify significant differences in pain management between pediatric and adult acute care settings, and point to several opportunities to improve the consistency of care of patients with SCD in the AYA period. Successful initiatives to decrease wait times5 and improve pain score reduction6 have been published, demonstrating the feasibility of such efforts. Implementation of comprehensive transition programs for adolescents and young adults with SCD should include assessments of local ED and inpatient management practices in order to ensure an optimal transition of care. This research was supported by the Case CAN (Case Children's Access Now) program. This program is partially funded by the MEDTAPP Healthcare Access (HCA) Initiative and utilizes federal financial participation funds through the Ohio Department of Medicaid. MEDTAPP HCA Initiative funding supports teaching and training activities associated with this program, and does not support the delivery of Medicaid eligible services. The MEDTAPP HCA Initiative partners with Ohio's colleges and universities to support the development and retention of additional healthcare providers to better serve the Ohio Medicaid population using emerging, interdisciplinary, and evidence-based care models. Views stated in this presentation are those of the researchers only and are not attributed to the study sponsors, the Ohio Department of Medicaid or to the Federal Medicaid Program. Additional Supporting Information may be found in the online version of this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.