Updated European Society for Emergency Medicine Guidelines for acute pain management in emergency departments and prehospital care

Acute pain management in European emergency settings faces persistent challenges, including inadequate clinical knowledge, training deficits, heightened emphasis on opioid stewardship, and concerns regarding drug-seeking behaviors. Despite previous guidelines, oligoanalgesia remains prevalent, with many patients experiencing suboptimal pain control. The evolving clinical landscape necessitated updating the 2020 European Society for Emergency Medicine (EUSEM) guidelines, considering emergent technological advances, the ongoing opioid crisis, aging populations, and continued pressure on emergency services. EUSEM launched the European Pain Initiative (EPI) to provide evidence-based recommendations for acute pain management in emergency settings and published guidelines in 2020. EPI convened a new project to review and update the previous guideline, rooted in the changing clinical landscape and experience. A systematic literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching MEDLINE, Cochrane database, Google Scholar, and EMBASE from January 2020 to May 2025. Publications were evaluated against predetermined inclusion and exclusion criteria, with evidence levels assigned to assist in developing management recommendations. The literature findings were integrated with the clinical experience of the EPI panel to reach a consensus on flexible, adaptable guidelines suitable for diverse European settings. These updated guidelines provide evidence-based recommendations for adult (≥16 years) and pediatric (≥1-≤15 years) patients in emergency and prehospital settings, promoting a multimodal approach to acute pain management. The recommendations integrate the Channels-Enzymes-Receptors Targeted Analgesia framework with WHO analgesic ladder principles and emphasize systematic pain assessment, flexible routes of administration, and patient-specific decision-making. Nonopioid and multimodal strategies are prioritized, with opioids reserved for appropriate indications.