Non-pharmacologic Therapy for Chronic Opioid-dependent Sickle Cell Pain
Sickle cell anemia is an hereditary hemoglobinopathy, chiefly occurring in African-Americans and is often accompanied by chronic and acute bone and joint pain. An acute exacerbation is known as a crisis wherein the pain can become excruciating and require hospitalization and large doses of injectable opioids. Some sickle cell patients take oral opioid medications chronically in an effort to deal with ever-present pain.
Opioid medications can have many undesirable side effects both physical and mental. These might include lethargy, fatigue, constipation and habituation, as well as many others, and are summarized in Table 1.
Pain, often the most disturbing element of the disease, is a subjective phenomenon that has both physical and mental components. The physical bone pathology is, in fact, the cause of the bone pain that patients experience. However, several factors determine how the pain is perceived. Chief among these is the patient’s individual pain threshold. There are both neurological and psychological factors which contribute to this threshold.
Traditionally, pharmacologic agents have been the mainstay in treating sickle cell pain, while other modalities have received much less attention.
|Central Nervous System||Lightheadedness, dizziness, sedation, dysphoria, euphoria, weakness, headache, agitation, tremor, uncoordinated muscle movements, seizure, alterations of mood (nervousness, apprehension, depression, floating feelings), dreams, muscle rigidity, transient hallucinations and disorientation, visual disturbance, insomnia, increased intracranial pressure|
|Gastrointestinal||Constipation, nausea, dry mouth, biliary tract spasm, laryngospasm, anorexia, diarrhea, cramps, taste alteration, constipation, ileus, intestinal obstruction, increases in hepatic enzymes|
|Cardiovascular||Flushing of the face, chills, tachycardia, bradycardia, palpitation, faintness, syncope, hypotension, hypertension|
|Genitourinary||Urine retention or hesitance, reduced libido and/or potency|
|Dermatologic||Pruritus, urticaria, other skin rashes, edema, diaphoresis|
|Other||Sweating, antidiuretic effect, paresthesia, muscle tremor, blurred vision, nystagmus, diplopia, miosis, analphlaxis, dependence, and addiction|
Review of the Literature
Some interesting studies have been published which examine the non-pharmacologic therapy of sickle cell pain.
In Thomas’ study,1 15 sickle cell patients were given training in progressive relaxation, thermal feedback, cognitive strategies, and self-hypnosis to relieve pain. Results from the study show a 38.5% reduction in the number of emergency room visits, and a 31% reduction in the number of hospitalizations. There was also a 50% reduction in inpatient stays during the six months post training, compared to the six months prior to training. Of significant note, there was a 29% reduction in analgesic intake for regular users.
In a study by Gil et al,2 64 patients with sickle cell disease were randomly assigned to either a cognitive coping skills group (three 45 min sessions of training patients to use 6 cognitive coping strategies) or a disease-education control group (three 45 min didactic discussion sessions about sickle cell anemia). Results indicated that brief training in cognitive coping skills resulted in increased coping skills, decreased negative thinking, and a lower tendency to report pain during lab-induced noxious stimulation.
Children, adolescents, and adult patients with sickle cell disease and who reported experiencing seven or more episodes of vaso-occlusive pain the preceding year, were enrolled in a prospective two-period treatment protocol by Dinges et al.3 Patients were taught self hypnosis, and both pain and sleep patterns were studied. Results indicated that self-hypnosis was associated with a significant reduction in pain days. Additionally, both “bad sleep" nights and the use of pain medications decreased significantly during self-hypnosis. Findings suggested that the overall reduction in pain frequency was due to elimination of less severe episodes of pain. The study clearly demonstrated that an adjunctive behavioral treatment for sickle cell pain, involving self-hypnosis and regular contact with a medical self-hypnosis team, can be beneficial in reducing recurrent, unpredictable episodes of pain in patients for whom few safe, cost-effective medical alternatives exist.
This study was an investigation of the effects of the Relaxation Response (R.R) on chronic sickle cell pain in patients requiring chronic opioid analgesics. The R.R. is a term coined by Herbert Benson, M.D. to characterize the body’s response to what is best described as an induced meditative state.5 Table 2 describes the steps Benson used to elicit the R.R.
Adult sickle cell pain patients in an outpatient facility, and who were maintained on chronic oral opioid agents, were invited to participate in the study. The nature of the study was explained and informed consent was obtained. No other criteria, other than the chronic use of opioid agents, were required.
Participating patients filled out a study questionnaire which recorded daily pain levels on a scale of ascending intensity from one to ten along with medication usage over a 30 day period. At the end of 30 days, the patients were taught the R.R. and identical data was collected for the following 30 days. During the second 30 day period, patients performed the R.R. twice daily.