Pain management in sickle cell disease

The sound of blood: photoacoustic imaging in blood analysis

Blood analysis is a ubiquitous and critical aspect of modern medicine. Analyzing blood samples requires invasive techniques, various testing systems, and samples are limited to relatively small volumes. Photoacoustic imaging (PAI) is a novel imaging modality that utilizes non-ionizing energy that shows promise as an alternative to current methods. This paper seeks to review current applications of PAI in blood analysis for clinical use. Furthermore, we discuss obstacles to implementation and future directions to overcome these challenges. Firstly, we discuss three applications to cellular analysis of blood: sickle cell, bacteria, and circulating tumor cell detection. We then discuss applications to the analysis of blood plasma, including glucose detection and anticoagulation quantification. As such, we hope this article will serve as inspiration for PAI's potential application in blood analysis and prompt further studies to ultimately implement PAI into clinical practice.

Communicating and understanding pain: Limitations of pain scales for patients with sickle cell disorder and other painful conditions

Pain communication in healthcare is challenging. We examine use of pain scales to communicate pain severity via a case study of people with sickle cell disorder (SCD). We show how pain communication involves complex social interactions between patients, healthcare professionals and significant others - none of which are included in pain ratings. Failure to account for relational aspects of pain may cause problems for any patient. For SCD, mutual distrust shapes pain communication, further complicating clinical assessments. Moreover, SCD pain is particularly severe, making ratings hard to interpret compared with ratings from non-SCD patients, potentially exacerbating problems in managing pain relief.

Opioid Use in Adults With Sickle Cell Disease Hospitalized During Vaso-Occlusive Crisis: A Systematic Review

Background

While pain is the hallmark of sickle cell disease (SCD), healthcare personnel are often ill-equipped to adequately treat patients who present in vaso-occlusive crisis (VOC). Although symptom severity varies from individual to individual, SCD is characterized by intervallic pain as a result of oxygen deprivation in tissues and organs. Regardless of pain severity, SCD patients are often viewed as drug seekers by healthcare personnel who have concerns regarding patients’ dependence on opioids which may lead to addiction. The objective was to assess the types and amount of opioids used to treat VOC in comparison to Centers for Disease Control opioid prescription guidelines.

Methods

Literature search was conducted using CINAHL, PubMed, the Cochrane Library, Web of Science and hand search. Data were analyzed from 1999 to 2018. Randomized trials, observational, and case studies involved hospitalized adults with SCD who were prescribed opioids to treat VOC. Quality assessment was conducted using Downs and Black checklist. Meta-analysis was not conducted.

Results

Five studies were conducted in the USA, Arabia and the Netherlands, and the USA and Canada were included. Participants were treated with either morphine or morphine milligram equivalent (MME). No study used the same method of opioid administration.

Conclusions

Patients with SCD who are hospitalized secondary to VOC mostly received opioids for pain well within the Centers for Disease Control and Prevention prescription guidelines. No uniform method exists. Additional research is warranted.

Transcutaneous electrical nerve stimulation (TENS) for pain management in sickle cell disease

BACKGROUND

Sickle cell disease (SCD), one of the most common inherited disorders, is associated with vaso-occlusive pain episodes and haemolysis leading to recurrent morbidity, hospital admissions and work or school absenteeism. The crises are conventionally treated with opioids, non-opioids and other adjuvants with the risk of developing complications, addictions and drug-seeking behaviour. Different non-pharmacological treatments, such as transcutaneous electrical nerve stimulation (TENS) have been used for managing pain in other painful conditions. Hence, the efficacy of TENS for managing pain in SCD needs to be reviewed.

OBJECTIVES

To assess the benefits and harms of TENS for managing pain in people with SCD who experience pain crises or chronic pain (or both).

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Register, comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries and the reference lists of relevant articles and reviews. Date of the last search: 26 Febraury 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs, where TENS was evaluated for managing pain in people with SCD.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the trials identified by the literature searches according to the inclusion criteria. Two review authors then independently extracted data, assessed for risk of bias using the Cochrane standard tool and rated the quality of evidence using the GRADE guidelines.

MAIN RESULTS

One double-blind cross-over RCT with 22 participants with SCD (aged 12 to 27 years) was eligible for inclusion. Following stratification into four pain crises severity grades, participants were then randomised to receive TENS or placebo (sham TENS). The trial was concluded after 60 treatment episodes (30 treatment episodes of each treatment group). There is a lack of clarity regarding the trial design and the analysis of the cross-over data. If a participant was allocated to TENS treatment for an episode of pain and subsequently returned with a further episode of a similar degree of pain, they would then receive the sham TENS treatment (cross-over design). For those experiencing a pain episode of a different severity, it is not clear whether they were re-randomised or given the alternate treatment. Reporting and analysis was based on the total number pain events and not on the number of participants. It is unclear how many participants were crossed over from the TENS group to the sham TENS group and vice versa. The trial had a high risk of bias regarding random sequence generation and allocation concealment; an unclear risk regarding the blinding of participants and personnel; and a low risk regarding the blinding of the outcome assessors and selective outcome reporting. The trial was small and of very low quality; furthermore, given the issue with trial design we were unable to quantitatively analyse the data. Therefore, we present only a narrative summary and caution is advised in interpreting the results. In relation to our pre-defined primary outcomes, the included trial did not report pain relief at two to four weeks post intervention. The trial authors reported that no difference was found in the changes in pain ratings (recorded at one hour and four hours post intervention) between the TENS and the placebo groups. In relation to our secondary outcomes, the analgesic usage during the trial also did not show any difference between groups. Given the quality of the evidence, we are uncertain whether TENS improves overall satisfaction as compared to sham TENS. The ability to cope with activities of daily living was not evaluated. Regarding adverse events, although one case of itching was reported in the TENS group, the site and nature of itching was not clearly stated; hence it cannot be clearly attributed to TENS. Also, two participants receiving 'sham' TENS reported a worsening of pain with the intervention.

AUTHORS' CONCLUSIONS

Since we have only included one small and very low-quality trial, with a high risk of bias across several domains, we are unable to conclude whether TENS is harmful or beneficial for managing pain in people with SCD. There is a need for a well-designed, adequately-powered, RCT to evaluate the role of TENS in managing pain in people with SCD.

Randomized clinical trial of computerized PAINRelieveIt® for patients with sickle cell disease: PAINReportIt® and PAINUCope®

OBJECTIVE

To compare effects of a tailored multimedia education program versus usual-care on barriers to pain management of adult patients with SCD.

METHODS

Pretest/posttest randomized controlled trial (RCT) of 228 outpatients with SCD randomized to the tablet-based PAINUCope intervention focused on barriers to pain management, pain, and analgesic adherence or selection of games (control). Outcomes were barriers to pain management, pain, and analgesic adherence.

RESULTS

The barriers to pain management and pain scores did not change significantly from pretest to posttest for either condition. Changes in analgesic adherence rates from pretest to posttest were statistically significant for the intervention group (p = .046) but not for the usual care group (p = .419). The group difference was not statistically significant.

CONCLUSIONS

This first RCT of a tailored multimedia education intervention with adult patients with SCD did not significantly reduce the outcomes of interest compared to the control group. Findings provide insights for improving intervention delivery and reinforcement of patient behaviors.

PRACTICE IMPLICATIONS

Study redesign is warranted with modifications that include theoretical and methodological approaches and patient-centered delivery of the intervention that take advantage of recent technology developments.

Prescription audit in a paediatric sickle cell clinic in South-West Nigeria: A cross-sectional retrospective study

Background

Sickle cell disease (SCD) is a genetic haematological disorder that affects millions of people around the world especially people of African heritage. The treatment of the symptoms of SCD includes the use of analgesics, antibiotics, and anti-malarial drugs. Studying the pattern of drug prescription is a veritable tool for establishing the current practice and how it conforms to existing guidelines.

Objectives

The main objective of this study was to assess the pattern of drug prescription in children with sickle cell disease (SCD) attending the paediatric outpatients' clinic of a tertiary care centre in Ado-Ekiti, South-West Nigeria.

Methods

This was a cross-sectional retrospective study carried out using the medical records of all patients with SCD who attended the paediatric outpatient clinic of the teaching hospital between January 1 and December 31, 2014. The information retrieved from the case notes included the bio-demographic data, associated co-morbid conditions and the list of prescribed drugs.

Results

A total of 202 SCD patients aged below 18 years were seen in the clinic during the study period with males accounting for 61.9% of them. The mean age of all patients was 6.9 ±3.8 yrs. A total of 1015 medications were prescribed during the study period giving a mean of 5.02 ± 1.9. Vitamins/micronutrients, anti-malarial drugs, antibiotics and analgesics accounted for 41.4%, 29.0%, 15.7% and 13.9% of all prescribed drugs respectively. Antibiotics from the penicillin group were the most commonly prescribed followed by macrolides and cephalosporins while Ibuprofen (60.3%) and Acetaminophen (32.6%) were the commonly prescribed analgesics.

Conclusion

High rate of antibiotic prescription, low use of opioid analgesics and non-prescription of prophylactic penicillin/pneumococcal vaccination were the main findings in this study. There is need for the introduction of standard treatment protocols for this group of patients.

Nurses' attitudes toward patients with sickle cell disease: a worksite comparison

Individuals with sickle cell disease (SCD) have reported being stigmatized when they seek care for pain. Nurse attitudes contribute to stigmatization and may affect patients' response to sickle cell cues, care-seeking, and ultimately patient outcomes. The purpose of this cross-sectional, descriptive, comparative design study was to determine whether there are significant differences in nurse attitudes toward patients with SCD by worksite-medical-surgical units compared with emergency departments/intensive care units (ED/ICU). The sample consisted of 77 nurses (36 nurses from the ED/ICU and 41 from medical-surgical units) who completed an anonymous online survey. No significant differences were noted in attitudes by worksite, with nurses from both sites demonstrating high levels of negative attitudes toward patients with SCD. Findings suggest that nurses from both worksites need additional education about SCD and care of this vulnerable, patient population.

Acute Pain Management

Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.

Traumatic Exposure History as a Risk Factor for Chronic Pain in Adult Patients with Sickle Cell Disease

This article describes the impact of the integration of a licensed clinical social worker (LCSW) with expertise in behavioral health on identification of risk factors for chronic pain in a cohort of adults with sickle cell disease. Authors conducted a retrospective chart review of all visits to the adult sickle cell center during the first six months of LCSW integration. Demographics, clinical history, and LCSW notes were reviewed. Overall, 71 patients were introduced to the LCSW; 55 percent of them had chronic pain. Patients with chronic pain were older, used opioids daily, took hydroxyurea, reported higher daily pain scores, and underwent more acute care visits and hospitalizations for pain with longer stays. Fifty-eight (81 percent) patients requested concrete social work services such as transportation and housing. Thirty-two patients (55 percent) expressed a desire for mental health counseling while receiving concrete services. Twenty-two (69 percent) of these patients self-disclosed at least one traumatic experience. In fact, a statistically significant relationship between chronic pain and a history of trauma was identified (p = 0.001). Results suggest that sickle cell patients should receive clinical social work services to assess for traumatic exposures that may influence chronic pain.

Attitudes toward Management of Sickle Cell Disease and Its Complications: A National Survey of Academic Family Physicians

Objective. Sickle cell disease (SCD) is a disease that requires a significant degree of medical intervention, and family physicians are one potential provider of care for patients who do not have access to specialists. The extent to which family physicians are comfortable with the treatment of and concerned about potential complications of SCD among their patients is unclear. Our purpose was to examine family physician's attitudes toward SCD management. Methods. Data was collected as part of the Council of Academic Family Medicine Educational Research Alliance (CERA) survey in the United States and Canada that targeted family physicians who were members of CERA-affiliated organizations. We examined attitudes regarding management of SCD. Results. Overall, 20.4% of respondents felt comfortable with treatment of SCD. There were significant differences in comfort level for treatment of SCD patients depending on whether or not physicians had patients who had SCD, as well as physicians who had more than 10% African American patients. Physicians also felt that clinical decision support (CDS) tools would be useful for treatment (69.4%) and avoiding complications (72.6%) in managing SCD patients. Conclusions. Family physicians are generally uncomfortable with managing SCD patients and recognize the utility of CDS tools in managing patients.

Challenges and resilience in the lives of adults with sickle cell disease

This qualitative study focused on the experiences of adults living with sickle cell disease (SCD) in the New York City area. Twenty-three individuals participated in one of three focus groups. The purpose of this study was to learn if appropriate health care for individuals with sickle cell disease, based on years of research, has been implemented. The findings indicate that best practices in the treatment of SCD are often not followed by medical personnel. Critical race theory provides a framework to understand the 10 emergent themes. The participants' responses illustrate resilience in facing adversity. Implications for social work practice are presented.

An Intervention to Decrease Stigma in Young Adults With Sickle Cell Disease

Young adults with sickle cell disease (SCD) are often stigmatized when they seek care for pain. The purpose of this pilot study was to test an intervention to decrease health-related stigma during care-seeking. Young adults with SCD ages 18 to 35 years ( n = 90) were randomized to either the care-seeking intervention (CSI) or an attention control group that participated in life review interviews. The two groups were compared by t tests and longitudinal data analyses on the change from baseline to the last time point in total health-related stigma and health-related stigma by doctors. Findings suggest that the CSI was associated with significant increased awareness of perceived total stigma and stigma by doctors compared with the attention control group. These findings are promising in terms of lessons learned from a pilot intervention that focused on the role communication skills play in decreasing health-related stigma in young adults with SCD.

A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease

Chronic pain in adults with sickle cell disease (SCD) is a complex multidimensional experience that includes biologic, psychologic, sociologic, and spiritual factors. To date, three models of pain associated with SCD (i.e., biomedical model, biopsychosocial model for SCD pain, and Health Beliefs Model) have been published. The biopsychosocial multidimensional approach to chronic pain developed by Turk and Gatchel is a widely used model of chronic pain. However, this model has not been applied to chronic pain associated with SCD. In addition, a spiritual/religious dimension is not included in this model. Because spirituality/religion is central to persons affected by SCD, that dimension needs to be added to any model of chronic pain in adults with SCD. In fact, data from one study suggest that spirituality/religiosity is associated with decreased pain intensity in adults with chronic pain from SCD. A biopsychosocial-spiritual model is proposed for adults with chronic pain from SCD, because it embraces the whole person. This model includes the biologic, psychologic, sociologic, and spiritual factors relevant to adults with SCD based on past and current research. The purpose of this paper is to describe an adaptation of Turk and Gatchel's model of chronic pain for adults with SCD and to summarize research findings that support each component of the revised model (i.e., biologic, psychologic, sociologic, spiritual). The paper concludes with a discussion of implications for the use of this model in research.

Care seeking for pain in young adults with sickle cell disease

In individuals with sickle cell disease (SCD), recognizing the cues to an acute pain episode and responding appropriately are important. The purpose of this mixed-methods pilot study is to identify preliminary factors that influence care seeking for pain in young adults with SCD. Responses were received from 69 young adults with SCD, age 18-35 years. The majority of respondents (88%) wait until the pain intensity is an average of 8.7 (± 1.2) on a scale of 1 to 10 before seeking care. Prominent themes influencing care seeking for pain include: trying to treat pain at home, avoiding the emergency department because of past treatment experiences, the desire to avoid admission to the hospital, and the importance of time in the lives of the young adults with SCD. Young adults with SCD need additional support from family and healthcare providers in order to make timely, appropriate decisions regarding care seeking.

Sickle cell disease and the "difficult patient" conundrum

The convergence of sickle cell disease's unique political, historical, cultural, medical, and psychological dimensions begets an especially distressing plight for sufferers of the disease. Too often, this convergence results in sickle cell patients being classified as "difficult." As Autumn Fiester recently argued, traditional understanding of the "difficult" patient warrants reevaluation. By acknowledging the nuanced dimensions of sickle cell disease, we identify barriers to care particular to the disease, which further substantiate the need to redefine orthodox notions of the "difficult" patient. We support development of mechanisms in both health care provider education and third-party consultation support by the Ethics Consultation Service, or by other appropriately designated specialists, to respect the manifold dimensions of sickle cell disease as a necessary step toward the enhancement of clinical care for sickle cell patients.

Preliminary validity and reliability of the Sickle Cell Disease Health-Related Stigma Scale

There have been no published studies that measure health-related stigma in individuals with sickle cell disease (SCD). This study provides preliminary validity and reliability of the Sickle Cell Disease Health-Related Stigma Scale (SCD-HRSS). Using a sample of 77 young adults with SCD, ages 18-35 years, the results support the reliability of the SCD-HRSS with an overall Cronbach's alpha reliability of 0.84 and construct validity with a positive correlation between SCD-HRSS and a measure of depressive symptoms. Participants reported the highest levels of perceived stigma from the general public, then doctors, and lastly family. Limitations and directions for future research are discussed.

A video-intervention to improve clinician attitudes toward patients with sickle cell disease: the results of a randomized experiment

BACKGROUND

Clinician attitudes toward patients are associated with variability in the quality of health care. Attitudes are typically considered difficult to change, and few interventions have attempted to do so. Negative attitudes toward adults with sickle cell disease have been identified as an important barrier to the receipt of appropriate pain management for this patient population.

OBJECTIVE

To test the effect of a video-intervention designed to improve clinician attitudes toward adults with sickle cell disease.

INTERVENTIONS

An 8-minute video depicting a clinician expert and patients discussing challenges in seeking treatment for sickle cell pain.

DESIGN AND PARTICIPANTS

A randomized post-test only control group design was used to assess the impact of the intervention on the attitudes of 276 nurses and housestaff working at a large, urban, academic medical center.

MAIN MEASURES

Attitudes toward adult sickle cell patients assessed using 5- and 6-point Likert-scale items. Exploratory factor analysis was used to identify underlying attitudinal domains and develop scales. Examples of the negative and positive attitudes assessed include clinician estimates of the percentage of SCD patients that exaggerate pain (negative) or make clinicians glad they went into medicine (positive).

KEY RESULTS

Compared to the control group, the intervention group exhibited decreased negative attitudes (Difference in means = -8.9, 95%CI [-14.2, -3.6]; Cohen's d = 0.41), decreased endorsement of certain patient behaviors as "concern-raising" (Difference in means = -7.8, 95%CI [-13.1, -2.5]; Cohen's d = 0.36), and increased positive attitudes toward sickle cell patients (Difference in means = 6.6, 95% CI [0.6, 12.6]; Cohen's d = 0.27).

CONCLUSIONS

Our results suggest that the attitudes of clinicians toward sickle cell patients may be improved through a short and relatively easy to implement intervention. Whether the attitudinal differences associated with our intervention are sustainable or are linked to clinical outcomes remains to be seen.

Problematic hospital experiences among adult patients with sickle cell disease

BACKGROUND

Adults with sickle cell disease (SCD) have often reported difficulties obtaining care during vaso-occlusive crisis (VOC) in qualitative studies.

METHODS

We measured the experiences of 45 SCD patients who received in-hospital care for VOC using the Picker Patient Experience Questionnaire (PPE-15), and used the one sample binomial test to compare with national norms.

RESULTS

Most SCD patients reported that they were insufficiently involved in decisions (86%), staff gave conflicting information (64%), it wasn't easy to find someone to discuss concerns (61%), doctors' answers to questions were not clear (58%), nurses' answers to questions were not clear (56%), doctors did not always discuss fears and anxieties (53%), and nurses did not always discuss fears and anxieties (52%). A greater percentage of SCD patients than the U.S. sample in 9 of 12 areas reported problems.

CONCLUSIONS

Further research is needed to determine the consequences of and potential interventions to improve these poor experiences.

Chart Card: feasibility of a tool for improving emergency department care in sickle cell disease

BACKGROUND

Patients with sickle cell disease (SCD) are concerned with emergency department care, including time to treatment and staff attitudes and knowledge. Providers are concerned about rapid access to patient information and SCD treatment protocols. A software application that stores and retrieves encrypted personal medical information on a plastic credit card-sized Chart Card was designed.

OBJECTIVE

To determine the applicability and feasibility of the Chart Card on patient satisfaction with emergency department care and provider accessibility to patient information and care protocols.

METHODS

One-half of 44 adults (aged -18 years) and 50 children with SCD were randomized to either the Chart Card or usual care. Patient satisfaction was surveyed pre and post implementation of the Chart Card program, and emergency department staff was surveyed about familiarity with SCD treatment protocols.

CONCLUSION

Patient satisfaction with emergency department care and efficacy in health care increased post Chart Card implementation. Providers valued immediate access to patient information and SCD treatment guidelines. The technology has potential for application in the treatment of other illnesses in other settings.

Health-related stigma in young adults with sickle cell disease

Health-related stigma is increasingly becoming a major public health issue that is receiving more attention. Young adults with sickle cell disease (SCD) are at risk for health-related stigmatization due to the many challenges of the disease. SCD includes the lifelong challenges of managing the chronic illness while accessing and navigating the health care system. The burdens of the disease can affect all aspects of the lives of individuals with SCD to include physiological, psychological, and social well-being. Although others may be involved in the process of stigmatization, the purpose of this paper was to support the need to develop patient-oriented interventions to prevent and treat health-related stigma in young adults with SCD, as these individuals may face health-related stigma throughout their lives, but especially immediately after transitioning from pediatric to adult care. Additionally, the Revised Theory of Self-Care Management for Sickle Cell Disease is offered as a framework from which theory-based interventions can be derived.

Impact of clinical pathway on quality of care in sickle cell patients

Clinical pathways are disease specific and are designed to standardize care. They are intended to serve the purpose of improving quality of care and decreasing healthcare and societal costs. A retrospective cross-sectional study was conducted comparing sickle cell patients admitted to Mercy Children's Hospital (MCH) from June 1999 to November 2001 before the implementation of the clinical care pathway (n=66), to a similar group of patients admitted from December 2001 to July 2004 after pathway (n=121) implementation. The χ2 tests were used to compare categoric variables and independent t-tests for continuous variables. The results indicate improvement in compliance postpathway with specific care elements: incentive spirometry, pulse oximetry, ordering comfort measures, right dosage of pain medications, and achieving excellent nursing compliance in documenting pain scores. There was a significant decrease in the number of blood transfusions in postpathway patients. Though limited by sample size, the results suggest that clinical pathways are good tools for standardization of care in certain care elements and help to improve quality of care in sickle cell patients.

Developing a short form of the simple Rathus assertiveness schedule using a sample of adults with sickle cell disease

PURPOSE

Ethnic and cultural norms influence an individual's assertiveness. In health care, assertiveness may play an important role in health outcomes, especially for predominantly minority populations, such as adults with sickle cell disease. Therefore, it is important to develop measures to accurately assess assertiveness. It is also important to reduce response burden of lengthy instruments while retaining instrument reliability and validity. The purpose of this article is to describe development of a shorter version of the Simple Rathus Assertiveness Schedule (SRAS).

DESIGN

Data from a cross-sectional descriptive study of adults with sickle cell disease were used to construct a short form of the SRAS, guided by stepwise regression analysis.

RESULTS

The 19-item Simple Rathus Assertiveness Scale-Short Form (SRAS-SF) had acceptable reliability (α = .81) and construct validity and was highly correlated with the SRAS (r = .98, p = .01).

CONCLUSIONS

The SRAS-SF reduces response burden, while maintaining reliability and validity.

Efficacy of tramadol vs meperidine in vasoocclusive sickle cell crisis

Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned.

Can Heterogeneity of Chronic Sickle-Cell Disease Pain Be Explained by Genomics? A Literature Review

This literature review explores the potential of genomics to explain, or at least contribute to the discussion about, heterogeneity in chronic pain in sickle-cell disease (SCD). Background: Adults with SCD, a single-gene disorder, are living longer than in years past, yet report being burdened by chronic pain. With only a few studies on chronic pain in this population, the epidemiology is unclear. However, research in the area of pain genetics continues to advance since the conclusion of the Human Genome Project. Two pain susceptibility genes, catechol-O-methyltransferase (COMT) and cytochrome P450, have, to date, been discovered that can increase individual susceptibility to the development of chronic pain. Method: A search was conducted in PubMed, CINAHL, and EBSCO using the terms ``sickle cell,'' ``chronic pain,'' ``polymorphism,'' ``genetics,'' ``pain genetics,'' ``human,'' ``adult,'' ``association studies,'' and ``pain susceptibility genes'' to search for articles published between 1970 and 2008. Findings: Chronic pain generally is more prevalent and severe than previously reported, and individuals with SCD report daily pain. The genomic era has made it possible for scientists to identify pain susceptibility genes that contribute to variability in the interindividual experience of chronic pain. Conclusion: Nurses are well positioned to generate and translate genomic research, thus improving care delivery. Such research may lead to the identification of polymorphisms associated with pain sensitivity in individuals with SCD.

Hematologic problems in psychosomatic medicine

Vitamin B12 deficiency is associated with problems in cognition, mood, psychosis, and less commonly, anxiety. Folate deficiency primarily is associated with problems in mood. Patients who have sickle cell disease, a disease of chronic pain, experience difficulties with depression, anxiety, stigma, and are at risk for substance abuse and dependence. Patients with hemophilia have benefited from advances in treatment; however, their morbidity and mortality were compounded in those who received blood products contaminated with HIV, or hepatitis B and C. Psychiatrists who practice psychosomatic medicine should expect to encounter patients with the above problems, as they are frequently seen in medical settings. Finally, most of the commonly used psychotropic medications have uncommon but potentially important hematologic side effects or may interact with the anticoagulants used in medically ill patients.

Optimism predicting daily pain medication use in adolescents with sickle cell disease

This study examined the influence of optimism on pain medication use in adolescents with sickle cell disease (n=27; 18 females, 9 males). Participants completed a baseline measure of optimism and an average of 100 daily-diary assessments of pain severity and medication use. Results indicated that adolescents who experienced more severe pain used more analgesic and opioid medications. Optimism was a significant moderator of the relation between pain and opioid-medication use. At medium and high levels of optimism, pain was positively related to opioid use, but at low levels of optimism, the same relation was not present, suggesting that more optimistic adolescents are better able to match their medication use to their pain severity. Future research should examine how other psychosocial factors might influence pain medication use in adolescents and adults who experience pain, and clinicians should take into account psychosocial factors when working with pain populations.

Sickle cell disease: a stigmatizing condition that may lead to depression

Individuals with a chronic illness such as sickle cell disease are at risk for depression. Moreover, they are at risk for untreated depression. Depression may go untreated because of the stigma and high rates of disability associated with this chronic illness that most often affects African Americans in the United States. The purpose of this cross-sectional study was to describe depressive symptoms using the Beck Depression Inventory Fast Screen in a sample of 232 African American adults with sickle cell disease. Respondents reported higher levels of depression (26%) and depressive symptoms (32%) than did the overall United States population (9.5%). All adults with chronic illnesses need to be screened for depression in primary care practice sites where the diagnosis and treatment of depression needs to be coordinated.

A brief review of the pathophysiology, associated pain, and psychosocial issues in sickle cell disease

Sickle cell disease (SCD) is the most common genetic disorder of the blood. The disease produces significantly abnormal hemoglobin (Hgb) molecules in red blood cells (RBCs). The sickling of RBCs occurs when partially or totally deoxygenated Hgb molecules distort their normal disk shape, producing stiff, sticky, sickle-shaped cells that obstruct small blood vessels and produce vasoocclusion as well as the disruption of oxygen to body tissues. Because tissue damage can occur at multiple foci, patients with SCD are at risk for other medical complications including, but not limited to, delayed growth and sexual maturation; acute and chronic pulmonary dysfunction; stroke; aseptic necrosis of the hip, shoulders, or both; sickle cell retinopathy; dermal ulcers; and severe chronic pain. The chronicity of the illness combined with frequent hospitalizations for pain and other medical management can contribute significantly to impaired psychosocial functioning, altered intra- and interpersonal relationships, and reduced quality of life. Unlike previous qualitative reviews of SCD, this article describes the relevant clinical and research data on the relation between psychosocial functioning and SCD in adult and child populations. The authors discuss the significant role of psychosocial issues in the trajectory and management of the disease and conclude that understanding the pathophysiology of SCD without thoroughly understanding the equally important psychosocial influences is misunderstanding SCD.

Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study

The assessment of addiction-related outcomes is crucial to the management of chronic pain with opioid drugs in all patients. Pain management for patients who have concomitant drug abuse or addiction issues is a particularly complex task involving a need for a common nomenclature as well as empirically derived data to support management strategies during treatment regimens. Complicating the issue is the notion of pseudoaddiction, which is an abuse of medications driven by unrelieved pain that appears on the surface to be very similar to the behavior patterns of addicts. For proper adherence to medical therapy and safety during treatment, it is necessary to address and manage substance abuse-related behaviors. Aberrant drug-taking behavior presents many threats to the integrity of pain treatment. Unfortunately, the current state of the art still has a long way to go before clear guidelines for treatment and management can emerge. What is ultimately needed is a broad-based spectrum of research that highlights the epidemiology of drug-taking behaviors for different medical illnesses ranging from cancer to back pain. This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain.