Hrev_master [page 114] [Emergency Care Journal 2023; 19:11873] Emergency Care Journal 2023; volume 19:11873 In the recent letter by Pucciarelli et al.,1 the authors comment on an observation reported by Fabbri et al.2 that the pain is treated correctly only in a very small percentage of patients (3%), even those who experienced severe pain, suggesting as a possible solu- tion of this important unsolved issue the introduction (implemen- tation) of sublingual sufentanil use for pain treatment of trauma patients in the pre-hospital setting. As reported by Janati et al.,3 pain management remains a challenge for many emergency clini- cians for several reasons, which can be summarized in the lack of knowledge about the available pain control medications and opioid dosages, of experience with the drug’s use in the emergency department (ED) and pre-hospital settings, and proper supervision by the senior residents along with clinician’s fear regarding the drug’s side effects. By the Italian Law 38/2010 all Italian citizens, including adults and children, have the right to access palliative care and antalgic centers in case of either oncologic or non-onco- logic pain.4 This law represents in a single phrase “the right of not suffering”, thus incorporating and formalizing the provisions of the Charter of Rights on unnecessary pain brought by the Tribunal for Patients’ Rights in 2005 and leading to a crucial “cultural transfor- mation” for pain management by fostering the dignity and autono- my of the patient in the process of care. Accordingly, we have a problem with effective pain management if only 3% of patients with pain, including 77% of those with severe pain, received the right treatment in the emergency setting. It is well known that inap- propriate pain management can cause acute and chronic conse- quences, which include dysregulation of the neuroendocrine sys- tem with increased blood pressure and heart rate, the development of coagulation disorders, pulmonary edema, and heart attack, psy- chological consequences, such as anxiety, insomnia, depression, and social isolation, which are common causes for referral to the ED, and of increased costs for the health system.5-7 As a result, we must support educational interventions, including mandatory train- ing for medical and nursing staff to treat pain correctly and appro- priately in all emergency settings, both ED and pre-hospital. In 2020, the EUSEM Guidelines for the Management of Acute Pain in Emergency Situations stated that no more than 20–25 minutes should elapse from the initial assessment to the provision of pain relief (if appropriate).8 Working in an emergency setting, it is evi- dent that inserting an intravenous (IV) access is frequently unpleasant, time-consuming, and, in some cases, limited. On the other hand, oral drugs start to act slowly and take time to achieve their effect, whereas intramuscular treatments have a harsh, unpre- dictable onset.9 Thus, the development of non-parenterally deliv- ered analgesics with faster onsets as an alternative to the IV route is a potentially effective technique for ensuring earlier analgesia. Intranasal fentanyl10 and inhaled methoxyflurane11 are two valid alternatives for pain management, both in ED and pre-hospital set- tings, as they are simple to administer, quick, and effective, mak- ing analgesia more efficacious and faster. Sublingual sufentanil can also be a new excellent tool to achieve the goal of rapid and effective analgesia without resorting to the venous route, due to its characteristics such as ease of administration, high potency, and extended duration of action. A single 30 mcg dose dissolves sub- lingually within 5 min and showed an average bioavailability of 52% with plasma concentrations reaching therapeutic levels within 30 min, peaking by hour 1, and decreased below therapeutic levels by hour 3.12 A multicenter study of 76 patients presenting to the ED with moderate-to-severe pain secondary to trauma showed that a single-dose sublingual sufentanil 30 mcg was effective at signifi- cantly improving pain scores within 15 min and maintaining ade- quate analgesia at 2 hours without significant adverse events.13 In addition, the lack of requirement for IV placement, the easy admin- istration route, and the faster analgesic onset of sublingual sufen- tanil when compared to IV opioids make it a reasonable alternative to IV opioids in the ED setting.13 Another strategy to ensure early analgesia is certainly the development of nurse-guided analgesia protocols, which have been proven to be safe and effective in both ED and pre-hospital Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044 E-mail: E.Poggiali@ausl.pc.it Key words: sublingual Sufentanil; pain management; pre-hospital; Italian Law; emergency medicine. Contributions: EP and SS equally contributed to the work. LG critical- ly revised the manuscript. All the authors approved the final version. Conflicts of interest: EP and LG are members of the editorial board of Emergency Care Journal. The authors declare no conflict of interest. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it. Ethics approval and consent to participate: not necessary. Informed consent: not necessary. Received: 25 September 2023. Accepted: 25 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; 19:11873 doi:10.4081/ecj.2023.11873 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. When the solution is not on the tip but under the tongue Erika Poggiali,1 Lorenzo Ghiadoni,2 Sossio Serra3 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Department of Clinical and Experimental Medicine, University of Pisa, Pisa; 3Emergency Department, Maurizio Bufalini Hospital, Cesena, Italy Non -co mmerc ial us e o nly settings, although to date some legal restrictions limit their use to only certain medications in Italy.13 As reported in the study by Viglino et al., a nurse-directed protocol for multimodal analgesia combining inhaled methoxyflurane, paracetamol, and an oral opi- oid, initiated on admission to the ED, effectively reduces pain in patients with non-severe trauma within the first 15 min.14 Based on these observations, sublingual sufentanil could be used in the emergency setting by the nursing staff, having a safe side-effect profile and low risk of respiratory depression.15 For this reason, we appreciated the authors’ effort to promote sublingual sufentanil in the pre-hospital setting as the right choice for moderate/severe pain in trauma patients.1 Adequate management of pain is a moral and ethical impera- tive for emergency clinicians and nurses.16,17 Treating pain as soon as possible, avoiding delays, and using the right medication for each patient according to the work setting should be a duty and the primary endpoint for all emergency personnel, both medical and nursing. To achieve this goal, we must all work together using standardized protocols to avoid under- and over-treatment, partic- ularly in the pre-hospital setting, and encourage the direct role of nurses in administering therapies, ideally promoting the creation of a national network to spread the culture of pain management to “leave no one — doctors, nurses, patients — behind”, quoting a powerful UNESCO slogan.18 References 1. Pucciarelli G, Lucenti E, Andreucci A, et al. (2023). Sublingual Sufentanil: an option for pre-hospital pain manage- ment in trauma patients. Emerg Care J 2023;19:11665. 2. Fabbri A, Voza A, Riccardi A, et al. The pain management of trauma patients in the emergency department. J Clin Med 2023;12:3289. 3. Janati M, Kariman H, Memary E, et al. Educational interven- tion effect on pain management quality in emergency depar- tment; a clinical audit. Adv J Emerg Med 2018;2:e1. 4. Italian Regulation. Legge 15 marzo 2010, n. 38. Disposizioni per garantire l'accesso alle cure palliative e alla terapia del dolore. (10G0056) (GU Serie Generale n.65 del 19-03-2010). Available from: https://www.gazzettaufficiale.it/gunewslet- ter/dettaglio.jsp?service=1&datagu=2010-03-19&task=detta- glio&numgu=65&redaz=010G0056&tmstp=1269600292070 5. Langley P, Muller-Schwefe G, Nicolau A, et al. The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization. J Med Econ 2010;13:571e81. 6. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13:715-24. 7. Andersson V, Bergman S, Henoch I, et al. Pain and pain mana- gement in hospitalized patients before and after an interven- tion. Scand J Pain 2017;15:22-9. 8. 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. 9. Miner JR. Why don’t we have better pain treatments? Acad Emerg Med 2021;28:260–2. 10. Serra S, Spampinato MD, Riccardi A, et al. Intranasal Fentanyl for Acute Pain Management in Children, Adults and Elderly Patients in the Prehospital Emergency Service and in the Emergency Department: A Systematic Review. J Clin Med 2023;12:2609. 11. Mercadante S, Voza A, Serra S, et al. Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting: A Randomised, Open-Label, Active- Controlled, Multicentre Trial in Italy (MEDITA). Adv Ther 2019;36:3030-46. 12. Fisher DM, Chang P, Wada DR, et al. Pharmacokinetic Properties of a Sufentanil Sublingual Tablet Intended to Treat Acute Pain. Anesthesiology 2018;128:943-952. Correction in Anesthesiology 2018;129:859. 13. Butti L, Bierti O, Lanfrit R, et al. Evaluation of the effective- ness and efficiency of the triage emergency department nur- sing protocol for the management of pain. J Pain Res 2017;10: 2479-88. 14. Viglino D, Termoz Masson N, Verdetti A, et al. Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone. Intern Emerg Med 2019;14: 1139-45. 15. Leiman D, Jové M, Spahn GR, Palmer P. Patient and Healthcare Professional Satisfaction Ratings and Safety Profile of Sufentanil Sublingual Tablets for Treatment of Acute Pain: A Pooled Demographic Analysis. J Pain Res 2021;14: 805-13. 16. Federazione Nazionale Ordini Medici Chirurghi e Odontoiatri. [National Federation of the Order of Surgeons and Dentists.] Commentario al Codice di Deontologia Medica. [Commentary on the Code of Medical Ethics.] Available from: https://www.omceo.me.it/ordine/cod_deo/commentario.pdf 17. Federazione Nazionale Ordini Professioni Infermieristiche. [National Federation of Nursing Professions Orders.] Codice Deontologico delle Professioni Infermieristiche. [Code of Ethics for the Nursing Professions] Available from: https://www.fnopi.it/wp-content/uploads/2019/10/codice- deontologico-2019-correzione-1-agosto.pdf 18. UNESCO. United Nations World Water Development Report 2019. Available from: https://en.unesco.org/sites/default/ files/wwdr_2019_main_messages.pdf Editorial [Emergency Care Journal 2023; 19:11873] [page 115] Non -co mmerc ial us e o nly