Specific Pain Condition

The sickle cell anemia patient is a particularly good example of the potential complicating effects of unstable opioid levels in the often physically dependent patient. In this case, chronic, episodic use of opioids can lead to a state of physical dependency. When the opioids used are unable to provide pharmacologic stability, withdrawal symptoms including arthralgia and abdominal pain may be misinterpreted as acute, vaso-occlusive disease.

Not uncommonly, infrequent, discrete vaso-occlusive episodes are treated with paren-teral opioids, particularly meperidine. This choice of drug is problematic for several reasons. The first is that meperidine is metabolized to normeperidine, which is a neurotoxic metabolite that at low levels can cause subtle personality changes while at higher levels can lead to frank seizure activity. This becomes particularly problematic in those sickle cell anemia patients who have compromised renal function secondary to vaso-occlusive illness. Unfortunately, sickle cell disease can lead to frequent crises episodes resulting in continuous use of potent opioids. Due to the relatively short duration of action of short-acting opioids such as meperidine, physically dependent patients may cycle through periods of opioid withdrawal that may be indistinguishable from their underlying vaso-occlusive disease.

By stabilizing the physically dependent opioid user with a truly long-acting agent such as methadone, true vaso-occlusive episodes of sickle cell crisis-driven arthralgia and abdominal pain can be identified and appropriately treated.

Patients with sickle cell disease, who have recurrent ER visits, have been called "frequent flyers.'' These patients usually have been treated in the hospital or ER with opioids. If upon discharge, the now physically dependent patient is sent out without opioid medication, approximately 24 to 48 hours later, the patient may develop abdominal and joint pain. Is this a manifestation of physical dependence with withdrawal or a recurrent crisis? Physical dependence can occur within hours or days with the use of certain medications such as opioids (50,51). By compassionate treatment of the patient with sickle cell anemia, the demeaning term "frequent flyers'' can be eliminated from the medical terminology.

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