I’m an intern and hoped to hear some thoughts on pain management in sickle cell patients. Even seasoned attendings in both the ED and heme worlds seem frustrated. I don’t want patients to be in pain….but it’s difficult to manage, particularly when home med regimens have patients on such high levels of opioids.
Case in point: a young patient with confirmed SS presented to the ED recently. They had a young child with them (relevant later). This patient presents to the ED once a month when their pain meds that are prescribed by their hematologist run out. I want to believe the patient’s report of their level of pain, but this patient was wandering the department, on their phone…made me a bit hesitant to write for the amount of dilaudid they were requesting. Regardless – we provided the max amount of pain meds we thought safe in a patient refusing admission. We offered admission with a PCA but they refused. We offered 4mg of IV dilaudid then 6mg 2.5hrs later which they said did nothing….which I believe since they’re on such high doses of opiates at baseline. Their hematologist has them on 927 morphine equivalents A DAY. (Confirmed via her opioid registry report) Every 30 DAYS they’re given 360 pills of 30mg oxycodone, 180 pills of 8mg hydromorphone, and 60 pills of 40mg oxymorphone. We even got the doc on the phone at 4am…and all he would say was “I can vouch for her that she is on very high doses of opioids, so she’s going to need more than most.” We were willing to go up on the dosing for this acute session, but the patient wasn’t willing to stay longer that 20min after getting a dose. We thought it was especially important that we monitor them since they had a small child with them. Even though we know the amount of opioids they are prescribed as an outpatient, we had no way of knowing if the patient truly takes that much at home.
1) Is it appropriate for a hematologist to prescribe the levels of pain meds this doc is?
2) In a patient on as much home opioids as this patient, what dosing would you be comfortable discharging them with vs having them admitted?
3) What is the most appropriate way to manage patients with sickle cell pain in the acute vs chronic? (As in what specific dosing/frequency would you offer a patient like this?)
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