What business does a pediatric hematologist have pondering opioid pain management, especially as it affects a vulnerable population of adult patients who experience health disparities in medicine?
However, I recall several scenarios where I had to do just that:
Refill of 180 oxycodone pills a month (high MME and opioid risk scores) — what if something goes wrong with this patient if I prescribe this dose?
“Hey Doc, I am not doing well with pain and I need my meds refilled” (five days ahead of the due date) — do I need to put on my sleuthing hat to figure out where five days’ worth of pills went?
“Doc, my pain medicine is not working well at all. I need the dose to be increased ASAP” — how can I evaluate and ensure that the patient is on the right dose of pain medications?
Then the very engaging patient who limps into clinic wincing in pain, and five minutes into the visit seems to forget the discomfort and chats away as if we are long-lost friends (pain score is eight at the time of vital signs measurement) — at least it was easy to figure out that he just needed to talk some.
These scenarios are not limited to hematologists. PCPs nowadays increasingly find themselves in these same situations, as they are often at the forefront of pain management. The CDC reports that primary care doctors prescribe about 37% of all opioid prescriptions, and other clinicians account for considerable proportions of prescriptions — pain medicine doctors prescribe 8.9% and dentists prescribe 8.6%. Previous guidelines by the CDC in prescribing opioids stated that non-opioid treatments were preferred methods to manage chronic pain, and opioids should be used only when the benefits outweigh the risks.
With sickle cell disease (SCD), the burden of treating chronic pain more often falls on the hematologist. Most of our pediatric SCD patients seem to be well managed on a schedule where we write the usual five-day supply or have a maximum number of pills we dispense per month. I ransack my brain and attempt to recall where and when in my three-year fellowship training did I get to rotate with pain medicine or palliative care teams. Did we have fellowship training lectures that spelled out the often-complex scenarios of pain management and interventions that could be employed?
The American Board of Pain Medicine defines the specialty of pain medicine as a discipline that is concerned with the evaluation, treatment, and rehabilitation of persons in pain. Pain medicine specialists use a broad-based approach to treat all pain disorders ranging from pain as a symptom of disease to pain as the primary disease. This expertise is greatly needed in SCD management. However, pain medicine as a specialty is unlikely to take on care for SCD-related pain. The reasons are multifaceted, as I am told, but may be better expressed by the practitioners.
A national poll reported that there was no interest on the part of the hematologist to take on pain medicine practice either. Anecdotal reports state that across multiple clinic settings, SCD physicians spend considerable time discussing pain medications, valuable time that could be spent otherwise focusing on discussing disease-modifying therapies, medication compliance, and other therapeutic interventions. The issue smolders on as there is no easy solution.
To quote Henry Ford, “Coming together is a beginning, staying together is progress, working together is success.” The responsibility to ensure the well-being of SCD patients lies not with a single specialty but with a united front of medical professionals. We, as hematologists, must be prepared to initiate difficult conversations on opioid-related issues while also embracing the expertise of pain medicine physicians. By working together, we can achieve the best possible outcomes for the SCD population, mitigating their pain and enhancing their quality of life.
Should hematologists be responsible for pain management? Share in the comments.
Dr. Grace Onimoe is a pediatric hematologist/oncologist in Cleveland, OH, and is affiliated with MetroHealth Medical Center. She received her medical degree from Nnamdi Azikiwe University College of Health Science and has been in practice 19 years. She is experienced in general pediatric hematology and oncology and aya. She has more than 10 publications and over 50 citings.
Illustration by April Brust