| Chronic pain management plan and strategies to reduce pain episodes |
- Take prescribed medications regularly, including long-acting opioid medications and/or methadone if appropriate
- Have short-acting opioids available (and a clear plan for their use) for breakthrough pain
- Maintain hydration
- Avoid extremes of temperature and stress
- Possible use of medications for neuropathic pain
- Discussion of hydroxyurea or other disease-modifying therapies (eg, L-glutamine, regular transfusions) when well as an outpatient, if appropriate
- Address psychosocial issues (eg, depression, social isolation)
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| Acute pain – Prompt assessment and treatment |
- Distinguish between acute vaso-occlusive pain events and non-SCD pain
- Treat minor injuries with rest, heat, elevation, and over-the-counter analgesics (acetaminophen, NSAIDs)
- Treat pain preceded by fever, dehydration, temperature extremes, or other stresses as vaso-occlusive (sickle cell) pain
- Treat with escalating therapy
- Start with nonpharmacologic therapies (eg, relaxation/breathing exercises)
- Add nonopioid therapies (eg, acetaminophen, NSAIDs) if pain is not controlled
- Add short-acting opioids
- Avoid
- Avoid application of ice or cold compresses, which can precipitate sickling
- Avoid ketorolac in hospitalized patients and for prolonged periods, due to concerns about toxicities
- Identify and treat other potential SCD complications
- Pain with fever or cough may indicate respiratory infection or early acute chest syndrome and requires pain management and communication with sickle cell clinic
- Pain with dyspnea, focal neurologic signs, splenic enlargement, and/or signs of severe anemia requires emergency medical attention and evaluation for possible acute chest syndrome, stroke, splenic sequestration, or aplastic crisis
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| Management of opioid side effects |
- Use stimulant laxatives for constipation; osmotic agents are not as effective in opioid-induced constipation
- Use nonsedating (H1-antagonist) antihistamines for pruritus if needed
- Use antiemetics for nausea if needed; a selective 5-HT3 receptor antagonist such as ondansetron should be the first choice because of minimal CNS findings
- Treat insomnia with nonpharmacologic or pharmacologic approaches as needed
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