Tapentadol Use for Pain Management in St Luke’s General Hospital Emergency Department
Dr Carolina Anthea Nicolaou¹, Dr Justin Fernandes Coelho¹
Supervising Consultant: Dr Sophia Tribelhorn
(Emergency Medicine, St Luke’s General Hospital, Kilkenny)
¹ St Luke’s General Hospital, Kilkenny, Ireland
Abstract
Background
Pain remains one of the most common presenting complaints in emergency departments (EDs) worldwide. Despite the availability of evidence-based pain management frameworks, significant variation in analgesic prescribing practices persists, and pain is frequently undertreated or inadequately reassessed. Tapentadol (Palexia®), a centrally acting μ-opioid receptor agonist and noradrenaline reuptake inhibitor, is increasingly used in emergency settings for acute pain management.
Aim
This audit aimed to assess the appropriateness of tapentadol prescribing within the Emergency Department of St Luke’s General Hospital, Kilkenny, with particular focus on adherence to the World Health Organization (WHO) analgesic ladder and documentation of pain assessment.
Methods
A retrospective chart review was conducted over a two-month period between 01 September and 31 October 2025. Thirty consecutive patient charts involving tapentadol administration were identified through the ED restricted drug register and reviewed for demographic data, pain characteristics, comorbidities, analgesic prescribing patterns, and pain score documentation.
Results
Thirty patient charts were reviewed. Only 6.7% of patients were managed fully in accordance with the WHO analgesic ladder. In 63% of cases, the analgesic ladder was not followed at all, while 30% demonstrated partial adherence with omission of intermediate analgesic steps. Initial pain scores were documented in only 23% of patients, and repeat pain assessments following analgesia were recorded in just 14%. Tapentadol prescribing was most commonly associated with back pain and chronic musculoskeletal conditions.
Conclusions
This audit demonstrates poor adherence to WHO pain management principles and inadequate pain reassessment practices within the emergency department setting. Improvements in clinician education, structured pain documentation, and reinforcement of multimodal analgesic approaches are recommended to optimise pain management practices and reduce inappropriate opioid use.
Keywords
Tapentadol; pain management; emergency medicine; WHO analgesic ladder; opioid prescribing; multimodal analgesia; audit; emergency department
Introduction
Pain is among the most frequent reasons for presentation to emergency departments and remains a major contributor to patient distress, healthcare utilisation, and reduced quality of care. Effective pain management represents a fundamental responsibility of emergency physicians; however, previous studies have consistently demonstrated substantial variability in analgesic prescribing practices and persistent undertreatment of pain in acute care settings.
The World Health Organization (WHO) analgesic ladder remains one of the most widely recognised frameworks for structured pain management. Originally developed for cancer-related pain, the three-step ladder recommends escalation of analgesic therapy according to pain severity, beginning with non-opioid agents such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), progressing to weak opioids, and subsequently strong opioids for moderate to severe pain.
Contemporary pain management strategies increasingly emphasise multimodal analgesia and opioid-sparing approaches to minimise opioid-related adverse effects and dependence. Nevertheless, opioid medications continue to play an important role in the management of acute severe pain within emergency settings.
Tapentadol (Palexia®) is a centrally acting analgesic combining μ-opioid receptor agonism with noradrenaline reuptake inhibition. Compared with traditional opioids such as oxycodone and morphine, tapentadol demonstrates comparable analgesic efficacy with improved gastrointestinal tolerability and reduced rates of nausea, vomiting, and constipation. These characteristics have contributed to its growing use within emergency medicine practice.
This audit aimed to evaluate tapentadol prescribing practices within the Emergency Department of St Luke’s General Hospital, Kilkenny, and assess adherence to WHO analgesic ladder principles and pain documentation standards.
Aim
The primary aim of this audit was to assess the appropriateness of tapentadol prescribing within the emergency department population, with specific focus on compliance with the WHO analgesic ladder and documentation of pain assessment and reassessment.
Methods
Study Design
A retrospective chart review was conducted in the Emergency Department of St Luke’s General Hospital, Kilkenny, Ireland.
Data Collection
Patient charts were identified through the ED restricted drug register over a two-month period from 01 September to 31 October 2025. Thirty consecutive patient charts involving administration of tapentadol were reviewed.
Data collected included:
- Patient demographics
- Comorbidities
- Presenting pain characteristics
- Traumatic versus non-traumatic pain
- Documentation of pain scores
- Analgesic prescribing patterns
- Adherence to WHO analgesic ladder principles
Pain management practices were evaluated according to the WHO analgesic ladder framework.
Results
Patient Demographics
Thirty patient charts were reviewed (N = 30), including 13 female and 17 male patients.
Among female patients, 77% of tapentadol prescriptions occurred in individuals aged over 60 years. In contrast, male patients demonstrated a more even age distribution across prescribing groups.
Comorbidities
Sixty-three percent of patients had two or more significant comorbidities, while only 27% had one comorbidity or fewer.
The most common underlying conditions included:
- Chronic back pain, including arthritis, spinal stenosis, and intervertebral disc disease (37%)
- Chronic musculoskeletal pain (10%)
- Non-mechanical chronic pain conditions such as fibromyalgia and malignancy-related pain (10%)
Nature of Pain Presentations
Most tapentadol prescriptions were associated with non-traumatic pain presentations (63%), while traumatic pain accounted for 37% of cases.
Back pain represented the most common indication for tapentadol prescribing (40%), followed by:
- Musculoskeletal pain (33%)
- Non-mechanical pain syndromes (27%)
The majority of back pain presentations were atraumatic in nature.
Pain Score Documentation
Pain assessment documentation was poor overall:
- Only 23% of patients had an initial pain score documented
- Only 14% underwent repeat pain assessment following analgesic administration
This demonstrates limited compliance with standard pain reassessment practices within the emergency department.
Adherence to the WHO Analgesic Ladder
Only 6.7% of patients received analgesia fully consistent with WHO analgesic ladder principles.
In 30% of cases:
- Simple analgesics such as paracetamol or NSAIDs were initially administered
- Intermediate analgesic steps were omitted
- Patients progressed directly to strong opioids
In 63% of cases:
- The WHO analgesic ladder was not followed at all
- Tapentadol was frequently administered as the sole analgesic agent
Tapentadol alone was prescribed without prior stepwise analgesic escalation in 17% of patients.
Discussion
This audit demonstrates substantial deviation from evidence-based pain management principles within the emergency department setting.
The WHO analgesic ladder was fully adhered to in only a minority of cases, suggesting inconsistent application of structured pain management frameworks. Several contributing factors may explain these findings.
Firstly, clinician familiarity with the WHO analgesic ladder and multimodal analgesic principles may vary significantly within busy emergency department environments. Operational pressures, staff shortages, and time constraints may encourage rapid escalation to opioid therapy rather than gradual stepwise analgesic titration.
Secondly, patient-specific clinical factors may limit the use of first-line analgesics. Comorbidities such as renal impairment, anticoagulant use, respiratory disease, and gastrointestinal risk may preclude NSAID administration. Additionally, many patients presenting with chronic pain may already have trialled simple analgesics prior to ED attendance.
Back pain represented the most common indication for tapentadol prescribing, particularly among patients with chronic poorly controlled musculoskeletal disease. Importantly, the primary objective of acute back pain management in the emergency setting is not necessarily complete elimination of pain, but rather reduction of pain to a tolerable and functionally manageable level while excluding serious underlying pathology.
The audit also identified poor compliance with pain assessment and reassessment documentation. Pain scoring is an essential component of safe analgesic practice and provides objective evidence regarding treatment effectiveness. The low rates of repeat pain assessment suggest that ongoing evaluation of analgesic response remains insufficiently integrated into routine clinical practice.
The investigators acknowledge that this audit was limited to patients receiving tapentadol and therefore does not reflect pain management practices among patients treated appropriately with alternative analgesic regimens.
Recommendations
Several interventions may improve pain management practices within the emergency department:
- Educational sessions reinforcing WHO analgesic ladder principles and multimodal analgesia strategies
- Placement of analgesic reference posters in clinical work areas
- Introduction of dedicated pain score documentation sheets within patient charts
- Regular reinforcement of pain reassessment practices during departmental meetings
- Repeat audit following implementation of improvement measures
Conclusion
This audit demonstrates poor adherence to WHO analgesic ladder principles and inadequate pain documentation practices within the emergency department setting. The majority of patients receiving tapentadol were not managed according to structured stepwise analgesic principles, while pain reassessment following treatment was infrequently documented.
Although operational pressures and patient-specific clinical factors contribute to analgesic decision-making in emergency medicine, improvements in clinician education, structured documentation, and multimodal pain management practices are required to optimise patient care and support safer opioid prescribing practices.
A repeat audit following implementation of targeted educational and documentation interventions is recommended to assess improvement in pain management standards.
Open Access & Copyright
© 2026 The Authors. Published by the European Medical Specialist Review (EMSR) under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).