Hrev_master [page 108] [Emergency Care Journal 2023; 19:11665] Emergency Care Journal 2023; volume 19:11165 Dear Editor, We eagerly read the recent article published in the Journal of Clinical Medicine entitled “The Pain Management of Trauma Patients in the Emergency Department” by Fabbri et al.1 The study determined that insufficient analgesia is due to a lack of public health confidence in the use of opioids. As described by the authors,1 only 3% of patients received the right assessment of pain and its related management, despite 77% of patients experiencing severe pain. Furthermore, this reluctance could be attributed to legal barriers to prescribing, increased monitoring needs, and fears that analgesia masks other trauma symptoms. To supply this reluctance, a recent systematic review, pub- lished in the American Journal of Emergency Medicine,2 highlight- ed the importance of the use of Sufentanil for the management of adults with acute pain in the emergency department and pre-hospi- tals. Sufentanil is a lipophilic, synthetic opioid that is selective for the µ-opioid receptor and believed to have one of the highest ther- apeutic indices of all available opioids and it could be delivered by multiple routes, such as intravenous, intrathecal, and sublingual. However, a lack of evidence is highlighted in these systematic reviews where only 4 articles were included,3-6 with a great bias of heterogeneity. Although Sufentanil was found to provide acute pain relief that was superior to placebo and not inferior to IV mor- phine,5 none of these studies analyzed the effects of Sufentanil administered by sublingual, and this represents a gap because the sublingual route could be a faster and less invasive route to admin- istration. In another systematic review,7 focused on sublingual Sufentanil tablet (SST) and its utility as an analgesic agent for pain procedures, authors observed that sublingual Sufentanil provided an excellent analgesic option for patients undergoing intervention- al pain procedures, with a better assessment than those with IV morphine, and a lower cost per treatment when compared to IV opioids. This letter suggests some points regarding the methods and analyses of their study. Intranasal (IN) use of Sufentanil remains off-label and there are currently no published data available on equianalgesic dosing between the IV and IN routes, dosing regi- mens varied widely across the included studies. Although several authors 8-11 focused their research on studying the effect of Sufentanil on pain management, especially in major surgery, such as orthopedics, abdominal, plastic, or pulmonary surgeries, howev- er, the optimal dose of Sufentanil in the adult population with acute pain remains unclear, especially, using the sublingual route. Indeed, it was not mentioned the use of Sufentanil in patients with facial trauma where the use of the endonasal route could be diffi- cult to manage. Furthermore, to our knowledge and experiences, it could be difficult to administer and prepare Sufentanil using intra- venous or endonasal routes in patients not collaborative or with cognitive disorders. Therefore, considering the possibility of these variables influ- encing the results, it is suggested to evaluate their effect on Sufentanil by sublingual route in future studies. It is essential to manage pain quickly and effectively in the emergency setting. The European Society of Emergency Medicine (EUSEM) guidelines12 on emergency pain strongly recommend using a de-escalation approach rather than pain escalation. Following the assessment of a patient’s pain, the appropriate analgesic must be selected, consid- ering its benefits and risks with reference to the individual patient and considering both pharmacological and non-pharmacological approaches. It would be necessary to consider the use of pre-hos- pital pain management drugs which can be administered to differ- ent types of patients and with a spectrum of side effects that are easier to manage not only by physicians but also by nurses. The management of moderate to severe trauma pain in the ED could be improved by increasing the use of pain rating scales and developing and implementing effective pain management proto- cols. It should be noted that in some European countries, such as Italy, ambulance personnel are not authorized to administer opioid analgesics. With specific protocols, an easier route of administra- Correspondence: Gianluca Pucciarelli, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy. E-mail: gianluca.pucciarelli@uniroma2.it Key words: sublingual Sufentanil; pain management; pre-hospital; Emergency Medical Services. Conflict of interest: the authors declare no potential conflict of inter- est, and all authors confirm accuracy. Received: 16 August 2023. Accepted: 1 September 2023. Early view: 8 September 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11665 doi:10.4081/ecj.2023.11665 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Sublingual Sufentanil: an option for pre-hospital pain management in trauma patients Gianluca Pucciarelli,1 Enrico Lucenti,2 Andrea Andreucci,3 Fabio De Iaco,4 Vito Torrano,5 Franco Marinangeli,6 Giovanni Sbrana7 1Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome; 2Emergency Medical Service, Local Health Authority, Piacenza; 3Emergency Medical Service, Rimini; 4Emergency Department, Maria Vittoria Hospital, Turin; 5Department Emergency and Urgency Anesthesia and Intensive Care, Unit 1, ASST Grande Ospedale Niguarda, Milan; 6Department of Clinical Medicine, Public Health and Life and Environmental Sciences, University of L’Aquila, L’Aquila; 7Emergency Department and Pre-hospital Emergency Medicine, South East Tuscany, Grosseto, Italy Non -co mmerc ial us e o nly tion, and lower side effects, Sufentanil could be administered not only by physicians but also by the nursing staff. For example, it could be fundamental to develop a specific educational program to improve the nurses’ knowledge and skills to administer Sufentanil in pre-hospital and hospital settings.13 This represents a great advantage for patients who could receive treatment quickly with positive consequences on their state of health, prognosis, and qual- ity of life. Although the achievement of these results is valuable, we believe that future studies should analyze the role of Sufentanil using different routes. Finally, due to the lack of studies aimed at evaluating the role of Sufentanil in the conditions of the implemen- tation of nursing clinical practice guidelines, we believe that more accurate and more evaluations can help prevent this common com- plication in the future. References 1. Fabbri A, Voza A, Riccardi A, et al. The pain management of trauma patients in the emergency department. J Clin Med. 2023;12:3289. 2. Hutchings C, Yadav K, Cheung WJ, et al. A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting. Am J Emerg Med 2023;70:10-8. 3. Blancher M, Maignan M, Clape C, et al. Intranasal sufentanil versus intravenous morphine for acute severe trauma pain: A double-blind randomized non-inferiority study. PLoS Med 2019;16:e1002849. 4. Lemoel F, Contenti J, Cibiera C, et al. Intranasal sufentanil given in the emergency department triage zone for severe acute traumatic pain: a randomized double-blind controlled trial. Intern Emerg Med 2019;14:571-9. 5. Bounes V, Barthelemy R, Diez O, et al. Sufentanil is not supe- rior to morphine for the treatment of acute traumatic pain in an emergency setting: a randomized, double-blind, out-of-hospi- tal trial. Ann Emerg Med 2010;56:509-16. 6. Sin B, Jeffrey I, Halpern Z, et al. Intranasal Sufentanil versus intravenous morphine for acute pain in the emergency depart. ment: a randomized pilot trial. J Emerg Med 2019;56:301-7. 7. Koushik SS, Schwartz RH, Cherkalin D, et al. A review of sub- lingual Sufentanil tablet (SST) and its utility as an analgesic agent for pain procedures. Curr Pain Headache Rep 2022;26: 145-9. 8. Lindemann C, Strube P, Fisahn C, et al. Patient-controlled sub- lingual sufentanil tablet system versus intravenous opioid anal- gesia for postoperative pain management after lumbar spinal fusion surgery. Eur Spine J 2023;32:321-8. 9. Angelini A, Parise GM, Cerchiaro M, et al. Sublingual Sufentanil tablet system (SSTS-Zalviso((R))) for postoperative analgesia after orthopedic surgery: a retrospective study. J Clin Med 2022;11:6864. 10. Groen JV, Boon SC, Minderhoud MW, et al. Sublingual Sufentanil versus Standard-of-care (patient-controlled analge- sia with epidural Ropivacaine/Sufentanil or intravenous mor- phine) for postoperative pain following pancreatoduodenecto- my: a randomized trial. J Pain Res 2022;15:1775-86. 11. Lomangino I, Berni A, Lloret Madrid A, et al. Sublingual Sufentanil in pain management after pulmonary resection: a ran- domized prospective study. Ann Thorac Surg 2022;113: 1867-72. 12. Hachimi-Idrissi S, Coffey F, Hautz WE, et al. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med 2020;15:1125-39. 13. Sacerdote P, Coluzzi F, Fanelli A. Sublingual sufentanil, a new opportunity for the improvement of postoperative pain manage- ment in Italy. Eur Rev Med Pharmacol Sci 2016;20:1411-22. Letter [Emergency Care Journal 2023; 19:11665] [page 109] Non -co mmerc ial us e o nly