A “Narcotics Contract” for a Patient With Sickle Cell Disease and Chronic Pain

For many physicians, the treatment of chronic pain is one of the most difficult clinical and ethical challenges that they encounter. Patients with chronic pain can be demanding, frustrating, and mystifying. In pediatrics, sickle cell disease (SCD) is a common cause of chronic pain. In this issue's “Ethics Rounds,” we present the case of a patient with SCD and ask 2 experts on pain management to discuss the clinical and ethical issues. Carlton Dampier is a professor of pediatrics and assistant dean for clinical research at the Emory University School of Medicine; Carlton Haywood Jr is an assistant professor of medicine and core faculty in bioethics at the Johns Hopkins University.

C.K. is an 18-year-old woman with SCD who has had dozens of hospital admissions and numerous visits to a clinic and the emergency department (ED) for pain crises. Over the previous year she often presented to the ED for treatment of her pain without having first called her hematologists. They have recommended — and stressed — that it would be better to call them first, because they know her and her disease and might be able to manage her pain at home and prevent the need for an ED visit. C.K. has generally listened attentively and promised to call the hematologists before going to the ED, but she then shows up at the ED unannounced.

In the ED, and on the wards when admitted, C.K.'s subjective evaluations of her degree of pain were often at odds with objective parameters such as vital signs and demeanor. Many times she experienced virtually no significant improvement with intravenous ketorolac or hydromorphone dispensed through a patient-controlled analgesia pump. Even an exchange transfusion did not diminish her reported pain despite a postexchange hemoglobin S percentage of zero.

Her doctors recommended psychotherapy. She initially refused …

Address correspondence to John D. Lantos, MD, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu