Barbara S. Shapiro

Home management of sickle cell-related pain in children and adolescents : natural history and impact on school attendance

&NA; Some children and adolescents with sickle cell disease experience frequent painful episodes. To gain information about the natural history of the pain and its impact on sleep and school attendance, we developed a home‐based diary system. Eighteen children and adolescents completed 4756 diary days, with an average compliance of 75%. Pain was reported on 30% of days and was managed at home nine‐tenths of the time. Girls reported more days with pain than did boys, and age was positively correlated with the length of the painful episodes. The pain affected school attendance and sleep. Patients were absent from school on 21% of 3186 school days, with half of the absenteeisms on days with reported pain. Of the pain‐associated absenteeisms, two‐thirds occurred when pain was managed at home, and one‐third when patients were hospitalized. The average consecutive number of school days missed was 2.7. These findings have implications for developmentally critical activities.

Sickle cell-related pain: Perceptions of medical practitioners

Pain is the most common problem encountered by patients with sickle cell disease (SCD). We report the results of a survey sent to hematologists and emergency department (ED) physicians regarding their perceptions and practices concerning pain and its management. Hematologists and ED physicians differed considerably in their perceptions about the natural history of the pain, and about the percentage of patients who are addicted to analgesics. Fifty-three percent of the ED physicians and 23% of the hematologists thought that more than 20% of patients are addicted. These beliefs and perceptions about SCD-related pain and the prevalence of addiction must be addressed if clinical care is to be changed substantively.

Patient-controlled analgesia for sickle-cell-related pain.

To delineate dose ranges, utilization patterns, and the frequency and types of problems encountered, we retrospectively reviewed the medical records of 46 patients with sickle hemoglobinopathies who used patient-controlled analgesia (PCA) a total of 92 times for the management of vasooclusive pain. Patients varied widely in the drug administered, use of basal infusion, individual dose, and total amount of drug received. On the day of heaviest use, the average maximum hourly dose was equivalent to 0.09 mg/kg of morphine. In this study, 11 patients and two families disliked PCA, one patient had respiratory compromise, and one patient tampered with the machine. Patient satisfaction with PCA probably reflects interactions among the psychosocial impact of chronic illness and chronic pain, individual psychological and temperamental factors, environmental contingencies, and the expectations and beliefs of the family and the health-care professionals. Based on this experience, recommendations can be proposed for the use of PCA in this condition.

Oral patient-controlled analgesia in adolescents

Adolescence is a time when concerns about independence and self-control are of paramount importance. These developmental issues must be considered when planning treatment for adolescents with acute or chronic pain. Patient-controlled analgesia (PCA) is a method of administering opioids that reinforces patient autonomy. Traditionally, opioids given by PCA are administered via the intravenous or subcutaneous route. Issues of autonomy and control, however, are no less important for patients receiving oral opioids. To augment patient autonomy, we have provided oral medication kept at the bedside (oral bedside PCA) for adolescents with diverse pain problems. We describe our selection criteria and methods for using oral bedside PCA with adolescents and present 4 patients who used this method.

Implications for our definitions of pain

The International Association for the Study of Pain (IASP) definition of pain, by its emphasis on verbal communication, may contribute to the lack of recognition and treatment of pain in certain vulnerable groups of people. Additionally, the definition possesses an inherent Cartesian dualism, which may undermine effective treatment and contribute to stigmatization. Although the definition is valuable in that it addresses the irreducible subjectivity and lack of specificity of the pain experience, certain aspects deserve discussion and revision.

Comment on 'Simultaneous interview technique for patients with persistent pain' by L. Jacobson, A.J. Mariano, C. Chabal and E.F. Chaney in Pain, 45 (1991) 105-106.

We wish to comment on the Ietter from the Clinical Pain Service of the University of Washington [6], discussing the development of a simultaneous interview technique (SIT) for the treatment of persistent pain patients. We were prompted to respond because as members of a pediatric pain management program, we independently evolved a similar interview structure. It too is our view that the biomedical model as applied to chronic pain is flawed, both theoretically and clinically. Therefore, we have moved toward a more integrated evaluation and treatment approach to pain management an approach that is emphasized and reinforced by the stimultaneous interview. We wholeheartedly support the overall direction of the Seattle group’s comments, but we would like to point out some differences in our pediatric experience and discuss their clinical implications. In our pain management program ‘. which began three years ago [S], we instituted an assessment and treatment model in which physicians, mental health clinicians (psychologist or psychiatrist) and clinical nurse specialist as a unit interview all patients and their families, beginning with the initial visit. This is a