Improved HU access relates to other recommendations in this report, including: 1. Co-Management of Care Between Primary Care Physicians and Hematologists. Frequent monitoring and visiting a hematologist are all associated with improved HU uptake and adherence.232 2. Telehealth. Telehealth can be helpful for monitoring HU use among rural populations.233 3. The Transition from Pediatric to Adult Care. Strategies that improve transition from pediatric to adult care are expected to improve HU adherence.234 4. NC Sickle Cell Syndrome Program Educators. In North Carolina, SCD clinicians suggested having state educators contact patients to explain the benefits of HU and encourage them to continue using the medication. Additional Considerations
PHPs can cover telehealth and other remote services—whether performed by providers or CHWs—to remind patients with SCD to adhere to an HU regimen. PHPs should ensure that patients with SCD are being prescribed and adhering to HU as recommended, and that both providers and patients are aware of HU’s efficacy and safety. For both children and adults, PHPs can do this by facilitating coordination between primary care physicians and hematologists, and NC DHB can reimburse such coordination activity. For pediatric patients transitioning to adulthood, the recommendations outlined in Part II section 1a should increase HU adherence by increasing patient interactions with adult providers. Adjustment of PHP contracts to reimburse pain management would be a shortterm investment because contracts can be changed unilaterally.
50 Part II. Sickle Cell Disease Recommendations
3.2 Pain Management NC Medicaid should require PHPs to take steps to improve pain management approaches within the SCD population. Implementation: • NC Medicaid should require PHPs to offer a variety of opioid and non-opioid pain management techniques. • NC Medicaid should encourage destigmatization of opioid use amongst this patient population. • NC Medicaid should reimburse individualized pain management planning. Background
Pain is the most common SCD morbidity and the leading cause of SCD-related hospitalization.235 Opioids are a mainstay of SCD pain management, but in light of dependency concerns, people living with SCD have difficulty accessing opioids for pain management.236 A significant reason for this difficulty is opioid stigma among providers and suspicions that patients are abusing opioids. Integrative, non-opioid therapies such as cognitive behavioral therapy, yoga, acupuncture and dietary supplements have also demonstrated effectiveness in reducing pain severity in patients with SCD. These therapies can help reduce patient dependence on opioids, which can have harmful long-term effects.237 North Carolina Context
In addition to opioid stigma, a North Carolina SCD clinician noted that provider oversight may also be undermining SCD pain management. Clinicians prescribing opioids for patients with chronic pain fear scrutiny from state medical boards and federal regulators.238 NC Medicaid does not require prior authorization for some short-acting opioids used for SCD pain management for up to five days, but it does require prior authorization for longer use.239 Patients with SCD often remain hospitalized for
