Highlight
This multisite pediatric emergency department (ED) study demonstrates that timely administration of opioids during acute sickle cell disease (SCD) pain crises is associated with significantly reduced hospitalizations. Initiating opioid treatment within 60 minutes of ED arrival and administering the second opioid dose within 30 minutes yields the greatest decrease in hospitalization risk.
Study Background
Sickle cell disease (SCD) is a prevalent inherited hemoglobinopathy characterized by recurrent vaso-occlusive pain episodes that frequently prompt emergency department visits and hospital admissions. These acute pain crises cause severe morbidity in children and pose substantial challenges for healthcare systems. Guideline recommendations advocate for timely opioid administration to manage acute sickle cell pain effectively; however, robust evidence linking early opioid delivery in the ED to reduced hospitalizations remains unclear. Optimizing the timing of opioid dosing could improve patient outcomes, reduce healthcare utilization, and inform best practices among pediatric emergency providers.
Study Design
This investigation was a multisite cross-sectional study utilizing data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry, encompassing 12 pediatric EDs within children’s hospitals equipped with comprehensive SCD centers across the United States. The study period included all ED visits between January 1, 2019, and December 31, 2021, for children under 19 years of age presenting with uncomplicated SCD pain episodes. Visits involving any other SCD complications were excluded using primary diagnosis codes. The primary exposures were the timeliness of opioid administration, specifically: (1) time from ED arrival to the first opioid dose, dichotomized as ≤60 minutes versus >60 minutes, and (2) interval between the first and second opioid dose, dichotomized as ≤30, ≤45, and ≤60 minutes compared to longer intervals. The primary outcome was hospitalization subsequent to the ED visit. Initial data analysis occurred from April 2024 to April 2025, with post-analysis revisions from May to June 2025.
Key Findings
The study cohort included 2538 pediatric patients (mean age 12.0 ± 5.0 years; 50.9% male), encompassing 9233 ED visits, of which 54.4% resulted in hospitalization. Key results are summarized as follows:
- First-dose opioid administration within 60 minutes of arrival was independently associated with reduced odds of hospitalization (OR 0.84; 95% CI, 0.75–0.95).
- Among 7853 visits (85.1%) with ≥2 opioid doses, timely first-dose administration remained significantly associated with hospitalization reduction even if the second dose was delayed beyond 30 or 45 minutes (OR 0.85 [95% CI, 0.74–0.98] and OR 0.84 [95% CI, 0.72–0.97], respectively).
- The lowest hospitalization rates occurred when the first opioid dose was delivered within 60 minutes and the second dose followed within 30 minutes (OR 0.62; 95% CI, 0.52–0.75), with a similarly protective effect when the second dose was within 45 minutes (OR 0.70; 95% CI, 0.59–0.83) or 60 minutes (OR 0.78; 95% CI, 0.67–0.92).
These findings indicate a dose-dependent relationship where expedited opioid dosing correlates with improved ED outcomes and reduces the likelihood of inpatient admission.
Expert Commentary
These results reinforce existing SCD management guidelines emphasizing prompt pain control to mitigate disease burden and improve patient comfort. Timely opioid administration likely interrupts the cascade of vaso-occlusion and inflammatory pathways driving severe sickle cell pain, thereby averting progression to complications necessitating hospitalization. Moreover, rapid sequential dosing may enhance analgesic efficacy and patient satisfaction, aiding early discharge. Challenges include balancing opioid safety with adequate analgesia and optimizing ED workflows to meet these timing targets. The multi-institutional design enhances generalizability; however, residual confounding and unmeasured factors such as pain severity and ED staffing remain potential limitations. Future studies should explore mechanistic bases, patient-centered outcomes, and implementation strategies to integrate timely opioid delivery protocols. Given the opioid epidemic context, emphasis on safe, effective, and prompt analgesia tailored to pediatric SCD patients is paramount.
Conclusion
This large, cross-sectional study highlights the clinical importance of administering the first opioid dose within 60 minutes and the second dose within 30 minutes during acute sickle cell pain episodes in pediatric emergency settings. Timely opioid delivery correlates with substantially lower hospitalization rates, underscoring the need for ED protocols prioritizing rapid analgesic management in uncomplicated SCD pain. These findings have immediate implications for clinical practice, patient outcomes, and health resource utilization. Continued efforts to raise awareness, streamline ED pain care pathways, and conduct prospective intervention research are essential to optimize outcomes for children suffering sickle cell crises.
Funding and Clinical Trials Registration
The study was supported by Pediatric Emergency Care Applied Research Network Registry funding sources as detailed in the original publication. No specific clinical trial registration was indicated.
References
Gwarzo I, Coleman KD, McKinley K, Ellison AM, Alpern ER, Corboy J, Hariharan S, Topoz I, Wurtz M, Nielsen B, Cook LJ, Morris CR, Brandow AM, Campbell AD, Liem RI, Nuss R, Quinn CT, Thompson AA, Villella A, King AA, Baumann A, Frankenberger W, Brousseau DC. Opioid Timeliness in the Emergency Department and Hospitalizations for Acute Sickle Cell Pain. JAMA Pediatr. 2025 Sep 2:e252967. doi:10.1001/jamapediatrics.2025.2967. Epub ahead of print. PMID: 40892426; PMCID: PMC12406144.
