Opioid Prescription for Sickle Cell Disease Misses Guideline Recommendation, With Ibrahim Gwarzo, MPH

Patients hospitalized for acute sickle cell disease (SCD) pain do not receive guideline-adherent opioid pain medication adequately, according to recent research from Nemours Children’s Health.1

Presented at the 67th American Society of Hematology (ASH) Annual Meeting and Exposition in Orlando, Florida, by Ibrahim Gwarzo, DrPH, MPH, MBBS, a research scientist at Nemours Children’s Health, these data indicate an overall issue in opioid prescription during recurrent pain episodes, which are the leading cause of emergency department (ED) visits among patients with SCD.1

The ASH has previously published guidelines for opioid dosage in patients with SCD; these emphasize the rapid initiation and frequent reassessment of tailored opioid dosing. Specifically, they indicated an ideal initiation time within 60 minutes of arriving in the ED. Additionally, in cases where second doses were necessary, the guidelines specify that they should be administered within 30 minutes of the first dose.2

“There have been persistent reports of delays before receiving any form of pain intervention,” Gwarzo told HCPLive in an exclusive interview. “This is despite the clinical guidelines, which recommend swift evaluation and administration of pain medications for these patients.”

Gwarzo and colleagues analyzed de-identified electronic health records of patients from >200 health systems participating in EPIC’s Cosmos research platform. All ED visits with a primary International Classification of Diseases (ICD-10) diagnosis code indicating an SCD pain crisis where ≥1 opioid pain medication was administered were included. Those taking place before 2019 or after 2024 were excluded, along with visits with diagnosis codes of any SCD complication. The study’s primary outcome was the timeliness of ED opioid pain medication for acute, uncomplicated SCD pain, expressed as the percentage of guideline adherence for first and second opioid doses.1

Investigators calculated guideline adherence as a percentage of overall visits where the first opioid dose was given within 60 minutes of arrival. For visits with multiple opioid doses, the second dose’s guideline adherence was calculated as the percentage of visits where the second dose was administered within 30 minutes of the first dose. Additionally, patient, visit, and facility factors were explored, including age, sex, type of healthcare setting, payer, and acuity level.1

A total of 228 were included, with a total of 394,725 ED visits from 40,977 unique patients. The median age was 31 years (interquartile range [IQR] 24-38), and 55.2% of participants were female. Patients paid through public insurance for 75% of visits.1

Across all visits, only 32.5% were guideline adherent for the first opioid dose (95% CI, 32.4-32.6%). For the 76.6% (n = 302,738) of visits with multiple doses, guideline adherence for the second dose was 9% (95% CI, 8.9-9.1%). Stratification by route of administration did not change adherence for the first dose, but investigators saw that orally administered opioids had higher guideline adherence at the second dose – 24.3% (95% CI, 23.7-24.8%) 0 compared to parental doses of 7.7% (95% CI, 7.6-7.8%) (P <.001).1

After univariate analysis, investigators saw that guideline adherence for the first dose was higher among patients aged ≤19 years (52%; 95% CI, 51.6-52.5%) compared to patients aged >19 years (29.6%; 95% CI, 29.5-29.8%) (P <.001). This relationship held for the second dose. Additionally, male patients were more likely to receive guideline-adherent therapy compared to females for the first dose (36.9%; 95% CI, 36.7-37.1% vs 28.9%; 95% CI, 28.7-29.1%; P <.001) and the second dose (10.6%; 95% CI, 10.4-10.8% vs 7.7%; 95% CI, 7.6-7.9%; P <.001).1

“There is a substantial gap we need to cover in terms of providing pain relief to patients in pain crises,” Gwarzo said. “Despite guidelines that have been around for nearly a decade, we are still falling behind for these patients, not providing enough pain relief for them in the emergency department.”

Editor's Note: Gwarzo reports a disclosure with the National Heart, Lung, and Blood Institute (NHLBI).

References

1. Gwarzo I, Dega HC, Brousseau D. Multicenter Evaluation of Guideline Adherence for the Timeliness of Pain Medication for Acute Sickle Cell Disease Pain. Abstract presented at the 67th American Society of Hematology Annual Meeting and Exposition. Orlando, FL. December 6-9, 2025.

2. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 Guidelines for Sickle Cell Disease: Management of acute and chronic pain. Blood Advances. 2020;4(12):2656-2701. doi:10.1182/bloodadvances.2020001851