Sickle Cell Disease: Core Concepts for - PowerPoint Presentation

Slide1

Sickle Cell Disease: Core Concepts for the Emergency Physician and NurseHigh ED Utilization and Perceptions of Opioid Addiction

Hants Williams

, RN, BSN

PhD Student

Duke University School of Nursin

g

Paula Tanabe

, PhD, RN, FAEN, FAAN

Associate Professor

Duke University, Schools of Nursing and Medicine

Objectives

Describe rates

of hospital utilization for persons with

SCD

Discuss opioid addiction in SCD

Present recommendations to assist patients with high ED use & address misconceptions regarding opioid addiction in SCD

Pretest- Question 1

Which reason is

not

related to high utilization of hospital services by persons with SCD?

Renal disease

Lack of primary Care

Between 18 to 24 years of age

Opioid addiction

Pretest- Question 2

What is the estimated rate of addiction to opioids in persons with SCD?

Under 10%

Between 10-30%

Above 30%

100%

Hospital Utilization in SCD

In 2010, SCD had the highest 30-day hospitalization rate

of any disease

-

32%

1

20% of

patients with SCD account for

approximately

54% of emergency department (ED) visits.

2

These patients are often referred

to

as high

utilizers

High utilizers can be defined as patients with

three or more

visits to an ED in one year

3

Characteristics of High Utilizers

When compared to individuals with < 3 hospitalizations per year, high users:

Have a lower 5 year

survival rate

4

Have

higher pain ratings

& decreased quality of life

3

Report

more distrust

toward medical professionals

5

Are more likely to have family members with a

psychiatric illness

6

Factors Associated with Higher Utilization

Age 18-30

9

Provider underuse

of pain medications due to misconceptions of drug addiction

10

Lack of access to primary care

16, 17

Disease severity

Genotypes SS and SB

0

compared to SC, SB

+

Previous diagnoses of aseptic necrosis, renal disease, septicemia, & mood disorders

7

History of Acute Chest Syndrome

8

Misconceptions About Opioid Addiction

M

any clinicians

believe a large proportion of patients with SCD are addicted to

opioids

53% of ED physicians

thought more than 20% of patients with SCD were addicted to pain meds

11

63% of nurses

believed patients with SCD were addicted to pain meds

12

Facts About Opioid Addiction

In SCD, opioid

addiction is uncommon &

similar to that found in other chronic diseases

13

Opioid dependence in SCD has been estimated at

4%

13

Misperceptions by staff

of analgesic addiction has a more important influence on problematic pain management than genuine analgesic

addiction

14

Pseudoaddiction

Attempts

to control pain

can resemble

symptoms of addiction, making patients vulnerable to misperceptions of

addiction, know as

pseudoaddiction

15

Pseudoaddiction

resembles

symptoms of drug dependence

, but occurs in the presence of pain, or attempts to control

pain

Pseudoaddiction in SCD

% displaying

pseudoaddiction : 31%

13

Behaviors Related to Pseudoaddiction

Common behaviors seen in persons with SCD that can be misinterpreted as addiction

More

painful episodes managed at home

14

Greater use of prescription analgesics at home

14

Attempts to give up or cut down opioid use

13

Opioid tolerance

13

Social impairment

13

Greater use than intended

13

Failing role obligations

13

Recommendations – High Utilizers

It

is important to

identify patients without a usual source of care

,

&

provide them with coordinated care

When appropriate,

make referrals to psychologists or social workers

to help address unmet psychosocial needs that may be contributing to high healthcare utilization

Recommendations - Addiction

Because risk of addiction seems

to be no greater in

patients with SCD, clinicians are encouraged

to

treat the pain experienced by the patient

fully

Evidence

suggests that

the undertreatment of pain can

lead to pseudoaddiction, early

readmission,

and increased fear of future crisis

episodes

13,

14

Clinical Scenario

Cut and paste the link below into your browser to view this short

video

https://www.youtube.com/watch?v=9xJ4VwtBtRw

Posttest- Question 1

Which reason is

not

related to high utilization of hospital services by persons with SCD?

Renal disease

Lack of primary Care

Between 18 to 24 years of age

Opioid addiction

Posttest- Question 2

What is the estimated rate of addiction to opioids in SCD?

Under 10%

Between 10-30%

Above 30%

100%

Posttest Answers & Rationale

Question

1

Answer

: d) Opioid

addiction

Rationale:

Common reasons for high utilization include renal disease, lack of primary care, and between the ages of 18-24. There is no evidence to support a relationship between high hospital utilization and opioid addiction in persons with SCD

1,3,6,7, 16, 17

Question

2

Answer:

a) Under 10%

Rationale:

Opioid

addiction is uncommon

and

similar to that found in

other chronic diseases; Opioid dependence

in SCD has been

estimated

at 4

%

13, 14

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