Pearls, pitfalls, and updates for pain management

Outcomes of multidisciplinary team interventions in the management of sickle cell disease patients with opioid use disorders. A retrospective cohort study

Objectives:

To identify the magnitude of opioid use disorder (OUD) among sickle cell disease (SCD) patients; emphasize on multidisciplinary team (MDT) role; estimate cost-effectiveness following the proper use of therapeutic guidelines; and facilitate the reduction of emergency room (ER) visits and the length of stay (LOS).

Methods:

This retrospective cohort study included SCD patients aged 14 years and above, who have OUD. Data was collected between January 2016 and December 2018. Data included ER visits, hospital LOS, opioid consumption, and narcotic prescription tracking. The target group was followed with a set of interventions for pain management and healthcare resource utilization.

Results:

Twenty one SCD patients were identified with OUD. Following the interventions, there was a statistically significant decrease in ER visits of these OUD patients (from 8709 visits in 2016 to only 94 in 2018). Morphine consumption decreased by 82% and meperidine by 60%, over the 3-year period. Moreover, there was a huge reduction in both ER and LOS costs for this cohort of patients.

Conclusion:

Establishing an MDT and a series of interventions for SCD patients with OUD, including educational activities for caregivers and patients; establishing a palliative/pain clinic and a SCD addiction clinic; and implementing an adequate opioid prescription tracking system resulted in a significant reduction in both the cost and number of ER visits and hospital LOS and dramatically decreased opioid consumption.

Differences in Sensory Pain, Expectation, and Satisfaction Reported by Outpatients with Cancer or Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) report pain scores that appear greater than those reported in a meta-analysis for patients with cancer, but statistical comparisons of the pain scores from both populations have not been published.

AIMS

The goal of the study described here was to compare pain outcomes reported by outpatients with cancer or SCD.

DESIGN

Descriptive comparative study.

SETTING

Outpatient oncology or sickle cell clinics.

SUBJECTS

The participants were outpatients (N = 415) from three studies: (1) 106 patients with SCD, 93% African-American (referent group); (2) 140 patients with cancer, 90% Caucasian (race discordant); (3) 169 patients with cancer, 20% Caucasian, 65% African-American (race concordant).

METHODS

Patients completed the PAINReportIt including pain location, quality, pattern, intensity, expectation, satisfaction, and demographic questions. Analyses included the χ² test, analysis of variance, and regression.

RESULTS

Outpatients with SCD reported more pain location sites than the race-discordant (p < .001) and race-concordant (p < .001) cancer groups; higher pain quality than the race-discordant (p < .001) and race-concordant (p < .001) groups; and greater pain pattern scores than the race-discordant (p < .001) and race-concordant (p < .001) groups. The race-concordant group reported higher worst pain intensity than the SCD (p < .001) and race-discordant (p = .002) groups. The three groups did not differ significantly on pain expectation (p = .06). Regarding satisfaction with pain level, there was a significant difference between the race-concordant and SCD (p = .006) groups, but not between the race-discordant and SCD (p = .12) groups or between the race-discordant and race-concordant (p = .49) groups.

CONCLUSIONS

Outpatients with SCD reported three of four sensory pain parameters that were greater than those reported by outpatients with cancer. A better understanding of these differences is pertinent to improving pain outcomes.

Sickle cell disease patients' perceptions of emergency department pain management

Patients with sickle cell disease (SCD) experience painful crises that often require admission to the emergency department (ED) for pain management. Factors such as ED overcrowding and negative perception and stigmatization of SCD may impact patients' perceptions of the quality of pain management in the ED. Data from a multisite prospective cohort study was assessed to determine whether demographic (age and sex), clinical (time to administration of initial analgesia, number of analgesic doses, discharge disposition, and clinical site), or interpersonal factors (separately measured perceptions of being treated with trust and respect by ED triage nurses, nurses, and physicians) were associated with patient ratings of their pain management in the ED. Patients were adults with SCD seen at 3 EDs (2 urban and 1 rural). Demographic and clinical information was derived from medical record review; interpersonal and ED pain management ratings were derived from interviews conducted 1 week post ED visit. A total of 209 interviews by 98 patients were analyzed. Results indicated significant differences among the ED sites on the demographic, clinical, and interpersonal factors. Overall, patients reported being treated with trust and respect by ED clinicians. Adjusted logistic regression analyses indicated that ED clinical site 1 (odds ratio [OR], 10.42; 95% confidence interval [Cl], 1.44-7.36) and being treated with trust and respect by the ED physician (OR, 25.53; 95% CI, 2.07-314.96) predicted good ED pain management ratings. Interpersonal health care experiences may be an important indicator of patient satisfaction and quality of care received by patients with SCD in the ED.

Urgency of emergency department visits by children with sickle cell disease: a comparison of 3 chronic conditions

OBJECTIVE

Children with sickle cell disease (SCD) often receive care in the emergency department (ED), but the urgency of these frequent visits is not well understood. This study examined ED use by children with SCD by comparing the urgency of ED visits among children with SCD, asthma, and diabetes mellitus.

METHODS

We conducted a retrospective cohort study of Maryland ED visits for SCD, diabetes, or asthma from 2000 to 2004. ED visits resulting in hospital admission were deemed urgent. The urgency of ED visits not resulting in admission was determined using 2 methodologies: evaluation and management (E/M) coding and resource utilization. Multivariable logistic regression models were used to compare the likelihood of admission or urgent, treat-and-release ED visits across the 3 chronic conditions.

RESULTS

Nearly half (45%) of ED visits with a primary diagnosis of SCD resulted in admission, which was substantially higher than the 12% seen for asthma (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI], 6.4-7.4) and comparable to that seen for diabetes (41%). ED visits associated with primary diagnoses of SCD (AOR 5.9, 95% CI, 5.3-6.5) and diabetes (AOR 6.6, 95% CI, 6.0-7.3) were more likely than those associated with asthma to result in either admission or a discharge of higher urgency, as measured by E/M coding. These relationships persisted among repeat ED visitors, for visits with any diagnosis (ie, primary or nonprimary) of SCD, diabetes, and asthma, and when evaluated using the resource utilization method.

CONCLUSIONS

Similar to visits by children with diabetes, ED visits by children with SCD are substantially more likely than those by children with asthma to be of high urgency.

Sickle cell disease: an opportunity for palliative care across the life span

Sickle cell disease is a chronic illness that affects patients physically and emotionally and can do so at an early age. An ecological model of palliative care that involves improved communication among the health care team, patients, and their families can be beneficial. Open and honest communication regarding advance care planning, disease management, relief of pain and other symptoms, and bereavement and grief are all important for the patient, family, and health care team. Given the multiple acute and chronic complications of sickle cell disease, an approach to care that is holistic and comprehensive may help to improve a patient's biologic function and the perceived health, functional status, and quality of life of the patient and family.

Patient-reported outcomes: descriptors of nociceptive and neuropathic pain and barriers to effective pain management in adult outpatients with sickle cell disease

Despite frequent episodes of severe recurrent pain in sickle cell disease (SCD), sensory pain in outpatient adults with SCD lacks sufficient characterization. Furthermore, pivotal barriers may interfere with these patients' adherence to prescribed analgesic therapies but have not been studied systematically. We describe sensory pain characteristics, barriers, and analgesic use reported by adults with SCD during routine clinic visits. Patients (N = 145; 67% female, 94% African American) completed measures on a pen-tablet computer. Patients reported an average of 3.6 +/- 2.3 pain sites; mean current pain intensity (3.3 +/- 3.2), least (3.0 +/- 2.7) and worst (4.9 +/- 3.5) pain intensity in 24 hours on a 0 to 10 scale, multiple neuropathic (4.5 +/- 3.4, 8.3% selected none) and nociceptive (6.8 +/- 4.0) pain descriptors, and continuous pain pattern (59%). Their mean pain barriers score was 2.2 +/- 0.9, and 33% were dissatisfied with their pain levels. Only 14% reported taking at least 1 adjuvant drug, 82% were taking nonopioids, 85% step 2 opioids, and 65% step 3 opioids. Patients reported using, on average, 4.9 +/- 2.7 analgesics. Their pain barriers scores were similar to or greater than people with cancer. Importantly, their pain may be both nociceptive and neuropathic, contrary to common expectations that SCD pain is only nociceptive. Few patients, however, took drugs effective for neuropathic pain.

Intravenous Morphine Plus Ketorolac Is Superior to Either Drug Alone for Treatment of Acute Renal Colic

STUDY OBJECTIVE

To study the efficacy of intravenous ketorolac, morphine, and both drugs in combination in reducing pain in acute renal colic.

METHODS

We conducted a prospective, double-blinded, randomized controlled trial in an urban, teaching emergency department. Patients aged 18 to 55 years and with a clinical diagnosis of acute renal colic and a pain rating greater than 5 on a 10-cm visual analogue scale or at least "moderate pain" on a 4-category verbal pain scale were eligible for inclusion. Exclusion criteria were contraindication to nonsteroidal anti-inflammatory drugs or opiates, a history of drug dependence, presence of peritonitis, or analgesics within 6 hours of presentation. Patients received either morphine 5 mg at time zero and 5 mg at 20 minutes, ketorolac 15 mg at time zero and 15 mg at 20 minutes, or a combination of both. Primary outcomes were pain reduction and the need for rescue analgesia at 40 minutes.

RESULTS

Of the 555 consecutive patients screened, 158 patients met inclusion criteria and 130 patients were randomized during 6 months. Mean difference in change in pain score (visual analog scale 40 minutes minus visual analog scale 0 minutes) between combination group and morphine group was 1.8 cm (95% confidence interval [CI] -3.3 to -0.1) and, compared to the ketorolac group, was 2.2 cm (95% CI -3.7 to -0.5); P<.003. Patients with combination therapy were less likely to require rescue morphine compared to the morphine group (odds ratio 0.2; 95% CI 0.1 to 0.7; P=.007).

CONCLUSION

A combination of morphine and ketorolac offered pain relief superior to either drug alone and was associated with a decreased requirement for rescue analgesia.

Opioid analgesia and assessment of the sonographic Murphy sign

Administration of intravenous opioid analgesia to patients with undifferentiated abdominal pain remains a controversial topic in many emergency departments. To determine whether opioid analgesia impacts assessment of the sonographic Murphy sign (SM) in evaluating acute gallbladder disease (GBD), a retrospective chart review was undertaken. The chart review encompassed 119 patients, 21% of whom, having received opioid analgesia before ultrasound, constituted the opioid group. Between the opioid and control (i.e., no opioid analgesia) groups, there were no significant differences in SM sensitivity (48.2%; CI 28.7-68.1% vs. 68.8%; CI 41.3-89%, respectively) or specificity (92.5%; CI 83.4-97.5% vs. 88.9%; CI 51.8-99.7%, respectively) for GBD. There was no association between opioid analgesia and false-positive SM (OR 0.74, CI 0.08-6.65), or false-negative SM (OR 1.42, CI 0.46-4.43). We conclude that the test characteristics of SM are unaffected by opioid analgesia.

Mandated pain scales improve frequency of ED analgesic administration

A retrospective study design was used to determine the effect of introducing a mandated verbal numeric pain scale on the incidence and timing of analgesic administration in the ED. Consecutive patients presenting with renal colic, extremity trauma, headache, ophthalmologic trauma, and soft tissue injury were included. 521 encounters were reviewed before and 479 encounters after the introduction of the pain scale. Groups were similar in baseline characteristics. Analgesic use increased from 25% to 36% (p < 0.001), and analgesics were administered more rapidly after the scale was introduced (113 minutes vs. 152 minutes, p = 0.09). Analgesic use correlated with pain severity. Patients undergoing diagnostic testing were less likely to receive analgesics, especially when presenting with a headache (p < 0.001). We conclude that use of a pain scale at triage significantly increases use of analgesia, and shortens the time till its administration. Patients undergoing diagnostic workups were less likely to receive analgesia.

Structure and function of the emergency department: matching emergency department choices to the emergency department mission

Emergency caregivers experience considerable new challenges to the provision of competent, compassionate care. The good news is there are ample new approaches and new technologies to meet those new challenges.ED leaders who understand the ED mission and the resources available today and who engage vigorously in the change process will turn that mission into immensely beneficial action.

Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication

OBJECTIVE

To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine.

METHODS

Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported.

RESULTS

Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, increased from 62.7% before the protocol change to 69.5% after, an increase of 6.8% (95% CI 2.7, 11.0). Transports before and after implementation of the new protocol did not differ with respect to patient sex, age, or chief complaint; number of morphine doses or total morphine administered per patient; or proportion of prehospital patients receiving morphine.

CONCLUSIONS

A change in protocol that permits trained paramedics to administer morphine without physician approval reduces time to analgesia administration without influencing the amount of morphine delivered per patient or the rate of prehospital morphine use. Further study should measure the effect on base hospital physician interruptions and patient outcome.

Emergency physicians' role in end-of-life care

End-of-life care, as it merges with emergency medicine, raises as many ethical issues as it does clinical judgments. The role of the ED physician as it pertains to end-of-life treatment options encompasses a vast array of variables that should nevertheless center on patient welfare. The choice between ethical responses and trained reactions is an ever-present reality in emergency medicine, and the instinct to perform aggressive procedures may overshadow the professional purpose to inform, comfort, counsel, and treat. The exercise of clinical judgment should be balanced by previously reasoned ethical conduct codes when it comes to end-of-life emergent care.