Hello all!
Just wondering about your experiences with this difficult issue.
When your palliative service is consulted for a sickle cell crisis, how do you typically handle it? In my fellowship (pain) we would be consulted for this occasionally, and there were some very challenging cases, with extremely high PCA doses, tricky historians, etc.
In your training or in your current practice in palliative care, did/do you:
1. Take over care of pain or make recommendations and sign off?
2. Titrate IV opioids to effect? Do you have a ceiling? What if the primary team has already titrated to extremely high doses?
3. How did/do you manage or recommend transition to outpatient?
Thank you very much!
Given the nature of the chronic condition, I would argue that it is in the wheelhouse for palliative medicine.
Having come from EM, I had the familiar bias in clinicians about patients presenting for sickle cell pain crisis. That said, as you allude, it can be a very complex situation for these patients and the nature of their relationship with their doctors. For example, there would be a patient in my old ED which would come by often requesting right off the bat high dose IV dilaudid and being aggressive when offered a plan that deviates from that. Sure enough, as it turned out, he had sickle cell trait and whatever we were medicating-- it wasnt SCD pain crisis. Cases like that carry over with countertransference since there are usually many similarities to the next patient coming in stating their are in a "SCD pain crisis".
Pseudoaddiction is likely a larger issue with these patients than given mind to... many of those same behaviors that nurses/docs consider as red flags (asking for a specific opioid by name, insisting on IV route, wanting a PCA, asking for increased dosage or frequency) are just as likely being mislabeled as "drug seeking behavior" when it is really just their pain being undertreated and from their experience with there disease they know "what works" and want to feel better ASAP.
The textbook correct answer for HPM is to trust the patient, start an opioid PCA and titrate to effect... you might be using 2mg, 4mg, 6mg boluses of hydromorphone... dosages that would make most hospital specialties blush... but as long as the patient isn't demonstrating pain-sedation mismatch, adverse effect, or toxicity, proceed in aggressive escalation without ceiling until the crisis is controlled. Of course opioid rotation as needed and adjuvants as possible can be implemented.
I can't comment much on how the outpatient management would look as the current region I live has essentially no patients with this condition. My prior institutions had a dedicated SCD heme service that essentially owned them entirely.
The management of chronic pain in these patients get even more murky and I imagine my current practice would be to follow them for GOC but we wouldnt manage regular chronic nonspecific pain. Acute inpatient pain crisis being a different story -- follow with reccs until resolved. Sign off -- or continue for GOC.
Regardless of setting, they are best served with a robust IDT. The lone doc that just writes an opioid prescription blindly every 30 days isnt the best care for these patients.
