A comment on pattern of opioid use in sickle cell disease
Authors: Xiulu Ruan, Hong Wu, Dian Wang
Journal: American Journal of Hematology (2017)

We read with interest the article by Han et al., titled "Patterns of opioid use in sickle cell disease," published in the American Journal of Hematology.1 The authors analyzed pain medication prescription records from a cohort of 203 patients with sickle cell disease (SCD), and found that the median (interquartile range) daily opioid dosage was 6.1 mg (1.7–26.3 mg) oral morphine equivalent (OMEQ), which is significantly lower than published opioid use among patients with other pain syndromes. The dose of opioids was found to be correlated with the number of admissions due to vasoocclusive crisis (VOC).1 We would like to commend the insightful work of Han et al., but we are very surprised by their finding that the median daily dose of only 6.1 mg oral morphine equivalent (OMEQ), considering the smallest dose of commercially available morphine pill is 15 mg, and patients with SCD tend to consume more opioids than many other chronic diseases. We wonder whether the results of their investigation truly reflect the "pattern" of chronic opioid in patients with SCD. Ballas et al.2 investigated the consumption of opioids at home, during acute care, and in the hospital, and found the opioids most commonly used at home were Oxycodone and Codeine followed by Meperidine and others. The mean oral daily dose for use at home was 15.5 mg (31 mg Morphine OMEQ) for Oxycodone, 79.8 mg (12 mg OMEQ) for Codeine, and 186.7 mg (18.7 mg OMEQ) for Meperidine. The mean parenteral daily dose during hospitalization was 523.4 mg (69.8 mg Morphine mEq) for Meperidine, 53.3 mg for Morphine, and 30.2 mg (201.3 mg Morphine mEq) for Hydromorphone,2 which would translate into 209.4 mg OMEQ (Meperidine), 159.9 mg OMEQ (morphine), and 603.9 mg OMEQ (hydromorphone), based on the routine conversion ratio of 1:3 from parental to oral administration. It is commonly accepted that SCD patients consume much more opioids during their VOC, when they receive treatment at Emergency Department (ED), especially when they are admitted to the hospital floor for the treatment of pain crisis. In the study of pattern of opioid usage in patients with SCD, Han et al. analyzed the results based on the prescribing records of adult SCD patients in its sickle cell care center at University of Illinois Hospital (UIH) only.1 In the Discussion section, authors did acknowledge some patients might obtain pain medication prescriptions upon hospital/ER discharge or from other institutions, and the UIH prescription records generally under-estimated use by approximately 40% in comparison with the dispensing records of the Illinois Prescription Monitoring Program. However, Han et al did not take into account the opioids consumed in ED or while inside the hospital, which, we believe, should be included for completeness to avoid any confusion by the healthcare providers and insurance carrier. We are concerned that if the median daily 6.1 mg opioid OMEQ gets misinterpreted or used as a norm in guiding pain management in patients with SCD, many patients who require higher amount of opioids may unfairly be deemed outliers. Ruta and Ballas3 recently expressed their concern that the current national opioid phobia may, unwittingly, deny opioids to patients who truly need them, especially those who experience recurrent exacerbations of acute pain such as patients with SCD. Suspicion and guilt, although rooted in concern and respect for the law, do not provide any solution to the complex problem.3 Drs. Fleegler and Schechter4 opined, "These are challenging times for clinicians who care for children and adults in pain. The general philosophy regarding the level of attention that should be paid to pain, as well as its treatment, has changed dramatically during the past 30 years, swinging wildly between extremes, and remains a moving target. Currently, most articles in the lay and even professional press highlight the problems associated with these drugs, as opposed to the significant benefits that may accrue from their appropriate use. As a result, at this time, we run the genuine risk of returning to a state of opiophobia and denying individuals in severe pain the mercy of access to these incredibly valuable drugs." None.