ORLANDO, Fla. — Recurrent pain episodes are the leading reason for emergency department (ED) visits among patients with sickle cell disease, but adherence to established acute pain management guidelines falls far short.

That’s the conclusion of an analysis of data from across 233 US health systems that showed less than a third of ED visits for acute sickle cell disease pain were guideline-adherent for the timely administration of the first dose of opioid pain medication, and less than 10% were adherent for the second dose.

The findings demonstrate that “timely opioid administration for acute sickle cell disease pain in the emergency department remains suboptimal, with notable disparities according to patient demographics,” said first author Ibrahim Gwarzo, MD, PhD, of Nemours Children’s Health and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware.

“These demographic-related differences in guideline adherence raise questions about equity and potential resource limitations,” added Gwarzo, who reported the findings at the American Society of Hematology (ASH) 2025 Annual Meeting.

Opioid Administration in the ED

Effective treatment of sickle cell disease pain requires prompt administration of opioid-based pain medications, Gwarzo explained.

Guidelines by ASH and the National Heart, Lung, and Blood Institute (NHLBI) recommend administration of the first dose within 60 minutes of ED arrival, and subsequent evaluations and doses should be given at 30-minute intervals (NHLBI) or within 30-60 minutes (ASH). 

However, multiple small studies — mostly involving children — have suggested that guideline adherence is poor, he noted.

Given the paucity of data evaluating the timeliness of opioid administration in pediatric and adult populations, Gwarzo and colleagues analyzed electronic health record data from January 1, 2019, through December 12, 2024, at 233 US centers participating in the Epic Cosmos research platform.

Among 398,895 ED visits by 41,547 unique patients (median age, 31 years; 55% female), guideline adherence was 32.5% for the first opioid dose at 60 minutes. Among 305,846 ED visits involving multiple doses, adherence for the second dose was 9.0% at 30 minutes and 36.2% at 60 minutes.

No significant difference in adherence was observed for oral or parenteral administration of the first dose, but oral administration of the second dose was associated with better guideline adherence (24.3% vs 7.7%), Gwarzo said.

Univariate analysis showed that adherence for the first dose was higher in pediatric vs general EDs (65.4% vs 29.7%; P < .001) and in patients aged 19 or younger versus for those older than 19 years (52.1% vs 29.6%; P < .001), with similar adherence for providing a second dose within 30 minutes. 

Adherence was also better for men than women (36.9% vs 28.9% for the first dose and 10.6% vs 7.7% for the second dose). 

No differences were observed after adjusting for payment method, patient’s historical ED utilization, and acuity levels (odds ratio, 0.28, 0.59, and 1.36 for ED setting, patient age, and patient sex, respectively).

Need for ‘Targeted Interventions’

“The findings underscore the need for targeted interventions to improve guideline adherence and ensure equitable pain management,” Gwarzo concluded.

Payal Desai, MD, director of Sickle Cell Enterprise at Atrium Health Levine Cancer Institute, Charlotte, North Carolina, concurred.

“Timely pain management continues to be the number one issue for patients and families,” she told Medscape Medical News. “I’ve had the opportunity to work in the sickle cell disease pain management space for some time,” and this issue is common, “particularly in the adult setting where the emergency department is constantly facing constraints in terms of beds and staffing.”

Desai noted that “having data that highlights and supports these findings can lead to meaningful conversation and change.” The study showed there are opportunities for the development of specific pathways and novel approaches to help ensure patients with sickle cell disease pain get the care they need, she added.

“Studies such as this really highlight the need for alternative ways to treat pain in large centers, and looking at this in terms of quality allows the system to recognize, track, and hopefully intervene on this issue over time,” she said. 

“There is a lot of work that is being done in this space, but given the magnitude of the problem, there is room for so much more,” Desai concluded.

Gwarzo and Desai have reported no relevant financial relationships. 

Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at sworcester@mdedge.com or on X: @SW_MedReporter.