A Scoping Review on Alternatives to Management of Acute and Chronic Pain in Patients with Sickle Cell Disease

Background:

Recurrent acute pain crises and inadequate control of chronic pain are significant challenges for patients with Sickle Cell Disease (SCD). Although opioids are the primary treatment for vaso-occlusive crises associated with SCD, their use is linked to systemic adverse effects, tolerance, and dependence, which can diminish patients' functionality and quality of life. This cycle of escalating opioid use often exacerbates illness-related anxiety and can lead to the frequent unnecessary need for even higher opioid doses. These concerns underscore the urgent need for safer, more effective treatment alternatives. Buprenorphine, a partial opioid agonist, has recently emerged as a promising alternative to full opioid therapy for managing both acute and chronic pain in various conditions. However, its use in SCD has not been fully studied. To address this gap, we present a scoping review of Buprenorphine's role in the treatment of acute and chronic pain associated with SCD.

Objective:

Describe the applications of Buprenorphine as a possible alternative therapy for pain management in patients with SCD.

Methods:

We conducted a scoping review in accordance with PRISMA guidelines, following a registered protocol on OSF (doi.org/10.17605/OSF.IO/7D4GS). An experienced librarian from our institution performed the initial literature search, and two investigators subsequently screened and filtered the manuscripts. Conflicts were resolved by a senior investigator. The variables analyzed in the review included mean age, ethnicity, gender, acute pain, chronic pain, use of buprenorphine, history of substance use, prior opioid use, complications, acute care utilization (emergency department visits and inpatient admissions), and average length of stay (LOS). This study was exempt from IRB approval as it did not involve using protected patient information.

Results:

Initially, 70 manuscripts were screened, and 55 were excluded due to irrelevant information. Among the 15 articles reviewed in full, 8 were further excluded due to incorrect study design, duplication, or a pediatric population focus. Ultimately, data extraction was performed on 1 case report, 1 case series, 4 retrospective studies, and 1 interview study. The total sample included 473 patients, the majority of whom were African American females (68%), with a mean age of 34.4 years. Sickle Cell Disease (SCD) was the most prevalent condition, though Sickle Cell Trait was reported in 3 of the 7 studies. A history of substance use disorder was noted in 4 manuscripts, while the remaining 3 included patients with chronic opioid use.

The most common approach described by authors included gradually titrating up Buprenorphine while reducing morphine analogs. Acute care utilization was reported in 4 of the 7 manuscripts, showing an average decrease in visits from 14.2 to 2.77. Length of stay (LOS) was documented in 3 manuscripts, with an average reduction from 4.4 days before buprenorphine therapy to 2.1 days afterward.

Patients reported improved mental clarity, increased happiness, and better interpersonal relationships while on Buprenorphine compared to high-dose full opioid agonists. Mild complications, such as opioid withdrawal, were noted in 3 manuscripts, but no mortality was documented.

Conclusion:

This scoping review highlights the potential of Buprenorphine for managing pain in SCD patients undergoing chronic opioid therapy. The transition from full to partial opioid agonists appears to be safe, with only mild, temporary adverse effects and improved patient functionality. These findings underscore the need for further research and the development of formal guidelines to assist clinicians in making informed decisions about alternative pain management strategies for this patient population.

No relevant conflicts of interest to declare.