1. Sickle Cell Disease: Core Concepts for
the Emergency Physician and Nurse
High ED Utilization and
Perceptions of Opioid Addiction
Hants Williams, RN, BSN
PhD Student
Duke University School of Nursing
Paula Tanabe, PhD, RN, FAEN, FAAN
Associate Professor
Duke University, Schools of Nursing and Medicine

2. 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

3. Pretest- Question 1
Which reason is not related to high utilization of hospital services
by persons with SCD?
a. Renal disease
b. Lack of primary Care
c. Between 18 to 24 years of age
d. Opioid addiction

4. Pretest- Question 2
What is the estimated rate of addiction to opioids in persons with
SCD?
a. Under 10%
b. Between 10-30%
c. Above 30%
d. 100%

5. 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

6. 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

7. 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 care16, 17
• Disease severity
– Genotypes SS and SB0 compared to SC, SB+
– Previous diagnoses of aseptic necrosis, renal disease, septicemia,
& mood disorders 7
– History of Acute Chest Syndrome 8

8. Misconceptions About
Opioid Addiction
• Many 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

9. Facts About Opioid Addiction
• In SCD, opioid addiction is uncommon & similar to that found
in other chronic diseases13
• 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

10. 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

11. 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

12. 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

13. 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

14. Clinical Scenario
• Cut and paste the link below into your browser
to view this short video
• https://www.youtube.com/watch?v=9xJ4VwtB
tRw

15. Posttest- Question 1
Which reason is not related to high utilization of hospital services
by persons with SCD?
a. Renal disease
b. Lack of primary Care
c. Between 18 to 24 years of age
d. Opioid addiction

16. Posttest- Question 2
What is the estimated rate of addiction to opioids in SCD?
a. Under 10%
b. Between 10-30%
c. Above 30%
d. 100%

17. 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

18. References
1. Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for
Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf.
2. Elander, J., Marczewska, M., Amos, R., Thomas, A., & Tangayi, S. (2006). Factors Affecting Hospital Staff Judgments About Sickle Cell Disease Pain.
J Behav Med, 29(2), 203-214.
3. Aisiku, I. P., Smith, W. R., McClish, D. K., Levenson, J. L., Penberthy, L. T., Roseff, S. D., . . . Roberts, J. D. (2009). Comparisons of high versus low
emergency department utilizers in sickle cell disease. Ann Emerg Med, 53(5), 587-593. doi: 10.1016/j.annemergmed.2008.07.050
4. Platt, O. S., Thorington, B. D., Brambilla, D. J., Milner, P. F., Rosse, W. F., Vichinsky, E., & Kinney, T. R. (1991). Pain in sickle cell disease. Rates and
risk factors. N Engl J Med, 325(1), 11-16. doi: 10.1056/nejm199107043250103
5. Haywood, C., Lanzkron, S., Ratanawongsa, N., Bediako, S. M., Lattimer, L., Powe, N. R., & Beach, M. C. (2010). The association of provider
communication with trust among adults with sickle cell disease. J Gen Intern Med, 25(6), 543-548.
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11. Shapiro, B. S., Benjamin, L. J., Payne, R., & Heidrich, G. (1997). Sickle cell-related pain: Perceptions of medical practitioners. Dulwich Centre Review,
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