Breaking the Cycle: Complex Persistent Opioid Dependence and Buprenorphine in Chronic Sickle Cell Pain

Key Message: Chronic daily pain in people with sickle cell disease is distinct from acute vaso-occlusive episodic pain and requires a different management strategy. Using buprenorphine to limit the risks associated with pure mu-agonist therapy is strongly recommended to minimize the numerous risks associated with long term opioid therapy.

Abstract: The mainstay of treatment for pain in people with sickle cell disease (SCD) has long been opioid therapy, which inherently carries serious risks. Recent studies demonstrate that opioid use disorder (OUD) is not highly prevalent in individuals with SCD, but a subset of patients on high-dose, long-term opioids develop complex persistent opioid dependence (CPOD), leading to inadequate pain control and high healthcare utilization. (1,2) CPOD is characterized by central sensitization driven by the progression of opioid dependence and tolerance. (2) While opioids remain essential for acute vaso-occlusive episodes, chronic opioid therapy for SCD pain is suboptimal, with limited evidence for long-term benefit and significant risk for CPOD, opioid-induced hyperalgesia, and mood disorders. (1,2)
 
An emerging body of evidence supports buprenorphine as a harm-reduction strategy for patients with CPOD and chronic SCD pain. Both qualitative and quantitative studies demonstrate that buprenorphine is safe, feasible, and associated with reduced acute care utilization and improved social functioning for adults with SCD. (3,4) The experience of patients on buprenorphine is qualitatively different from those on full agonists, with many reporting improved function and satisfaction. Nevertheless, restrictive opioid prescribing policies have created barriers to appropriate pain management and contributed to stigmatization and undertreatment in SCD. (5)
 
This session will highlight the need for a multimodal, patient-centered, and harm-reducing approach to support the symptomatic needs of patients with SCD and will explore the complexities of chronic opioid therapy in SCD. The panelists will discuss their extensive experience in caring for patients with SCD and propose solutions for managing chronic pain for these patients using a harm-reducing, anti-racist approach that aims to be safe, effective, and patient-centered.

References: 1.
Optimizing the Management of Chronic Pain in Sickle Cell Disease. Osunkwo I, O'Connor HF, Saah E. Hematology. American Society of Hematology. Education Program. 2020;2020(1):562-569. doi:10.1182/hematology.2020000143.

2.
Complex persistent Opioid Dependence - an Opioid-induced Chronic Pain Syndrome. Manhapra A. Current treatment options in oncology, 23(7), 921–935. https://doi.org/10.1007/s11864-022-00985-x

3.
Converting Adults With Sickle Cell Disease From Full Agonist Opioids to Buprenorphine: A Reliable Method With Safety and Early Evidence of Reduced Acute Care Utilization. David MS, Jones J, Lauriello A, et al. American Journal of Hematology. 2022;97(11):1435-1442. doi:10.1002/ajh.26699.

4.
"Buprenorphine, It Works So Differently": Adults With Sickle Cell Disease Describe Transitioning to Buprenorphine for Treatment of Chronic Pain. Prince E, Loeser P, Early M, et al. The Journal of Pain. 2024;25(3):632-641. doi:10.1016/j.jpain.2023.09.014.

5.
Opioid Prescribing and Outcomes in Patients With Sickle Cell Disease Post–2016 CDC Guideline. Kang HA, Wang B, Barner JC, et al. JAMA Internal Medicine. 2024;184(5):510-518. doi:10.1001/jamainternmed.2023.8538.