Page 258 Guide to Pain Management in Low-Resource Settings

246 Paula Tanabe and Knox H. Todd

How can pain be managed suspicious for addiction are frequently an indication of
pharmacologically? undertreatment of pain or disease progression (called
“pseudo-addiction”).
Th erapists must consider the need for chronic pain
management as well as rescue medication for acute Are there any nonpharmacological
painful crises. Persons with more than three painful
therapies for chronic and acute
crises per year are candidates for hydroxyurea thera-
py, which has been shown to signifi cantly decrease the pain episodes?
number of painful crises, as well as the incidence of
Many therapies have been reported by persons with
acute chest syndrome.
SCD as helping either avoid painful crises or treat
General recommendations include:
chronic pain. Th ese are listed below:
• Treat pain as an emergency
• Maintaining adequate hydration
• Assess pain levels frequently
• “Journaling” or keeping a diary of diet, activities,
• Assess hydration status and maintain adequate
and stressors, which helps to identify triggers of
hydration
painful crises
• Investigate other possible causes of pain/compli-
• Heat and massage
cations of the disease (acute chest syndrome, pri-
• Use of a variety of herbs and vitamins (in particu-
apism, splenic sequestration, cholelithiasis)
lar, folic acid)
• Do not withhold opioids when pain is severe
• Careful attention to a healthy diet (high quanti-
Analgesics for mild to moderate pain include
ties of fruits and vegetables, low amounts of pro-
acetaminophen (avoid if liver disease is present) and
tein).
nonsteroidal anti-infl ammatory drugs (NSAIDs) such as
ibuprofen or ketorolac (contraindicated in patients with
gastritis/ulcers and renal failure: monitor renal function What complications may be
if used chronically). important to recognize other than a
Moderate to severe pain should be treated with pain crisis?
opioids such as morphine sulfate or hydromorphone.
Many patients with SCD-associated chronic pain may Sickle cell disease is associated with early mortality in
require daily doses of opioids to maintain optimal func- many countries, although accurate life expectancy esti-
tion. High doses of opioids are often necessary to treat mation is not available. Historically, children with SCD
painful crises. Meperidine is NOT recommended, since would not survive into adulthood. However, due to the
it may be associated with seizures and renal toxicity. Ac- use of prophylactic penicillin until age fi ve to prevent
etaminophen or NSAIDs in combination with opioids sepsis, children are surviving, and many adults in the
may be helpful in treating severe pain crises. United States are living well into their 60s. Th e follow-
ing is a list of serious complications that should always
Should I be concerned be considered when treating a person with SCD. Th ese
about the risk of addiction complications are more common in childhood; howev-
if prescribing opioids? er, they can also occur in adults:
• Chronic anemia
Opiophobia, the fear of prescribing opioids, is a world- • Acute splenic sequestration
wide phenomenon. And certain pain syndromes remain • Sepsis
poor indications for opioids (e.g., chronic back pain, • Aplastic crisis
headache). But SCD seems to have a good indication for • Acute chest syndrome
opioids, and there are no data to suggest persons with • Stroke
SCD are at an increased risk of becoming addicted to Chronic complications common in adults include:
opioids. Th e unjustifi ed fear of causing addiction results • Pulmonary hypertension
in undertreatment of the severe and debilitating eff ect • Progressive renal disease
of SCD pain. Pain in SCD should, therefore, always be • Chronic anemia
aggressively treated. Behaviors often thought of as being • Retinopathy