Headline change
The guideline fundamentally reorients acute pain management by making opioid stewardship central and prioritizing non-opioid and multimodal analgesia as first-line treatments.
Bedside action
Prioritize multimodal analgesia, combining non-opioid pharmacological and non-pharmacological methods, and reserve opioids strictly for severe pain where benefits clearly outweigh risks.
The European Society for Emergency Medicine (EUSEM) has released its 2025 guidelines for acute pain management, a critical update reflecting significant shifts in clinical practice over the past five years. Driven by the opioid crisis and advancements in non-opioid and technological interventions, these guidelines advocate for a multimodal, mechanism-based approach to pain relief, prioritizing patient safety and effective outcomes while reducing opioid reliance.
Versus the Previous Version
This 2025 update represents a substantial evolution from the 2020 edition, driven by the escalating opioid crisis, new therapeutic options, and the integration of technology in clinical practice. The previous guideline laid foundational principles, while this version introduces several paradigm shifts.
Opioid Use & Stewardship
Previous version
The prior guideline acknowledged fear of opioid dependence and abuse as a barrier to pain management, but did not make opioid stewardship a central tenet.
This version
This guideline makes opioid stewardship central, prioritizing paracetamol, NSAIDs, and adjunctive therapies as first-line agents, reserving opioids for cases where benefits clearly outweigh risks.
Clinical impact Clinicians must actively reduce opioid prescribing, opting for non-opioid alternatives and multimodal strategies as primary interventions.
Multimodal Analgesia
Previous version
The 2020 guideline mentioned non-pharmacological and pharmacological methods but did not explicitly define or emphasize 'multimodal analgesia' as a core strategy.
This version
The 2025 guideline explicitly recommends multimodal analgesia, combining pharmacological and non-pharmacological approaches to reduce opioid reliance and improve outcomes.
Clinical impact Integrate diverse pain relief methods, including non-pharmacological options, early in the treatment pathway to enhance efficacy and minimize side effects.
Mechanism-Based Approach
Previous version
The previous guideline referred to the WHO pain ladder as a general guide, without a specific mechanism-based framework for pharmacological choices.
This version
This edition introduces and recommends the CERTA (Channels-Enzymes-Receptors Targeted Analgesia) approach for multimodal analgesia, targeting pain pathways mechanistically.
Clinical impact Consider the underlying pain mechanisms when selecting analgesics, combining agents with different targets (channels, enzymes, receptors) for balanced relief.
Technological Integration
Previous version
The 2020 guideline did not mention the role of advanced technology in pain assessment or management.
This version
The 2025 guideline highlights the growing role of technological advances, including VR, telemedicine, and AI, in personalizing and standardizing care.
Clinical impact Explore and adopt new technologies for pain assessment and patient education to improve care efficiency and patient engagement.
Ketamine & Methoxyflurane
Previous version
The 2020 guideline mentioned ketamine as an option for severe pain but did not highlight its opioid-sparing role or the expanded evidence for its use.
This version
The 2025 guideline emphasizes ketamine at sub-dissociative doses as an effective, opioid-sparing option with rapid onset, and highlights the expanded evidence for methoxyflurane.
Clinical impact Utilize ketamine and methoxyflurane more readily as effective non-opioid or opioid-sparing alternatives, especially in pre-hospital and ED settings.
Vulnerable Populations
Previous version
The 2020 guideline noted challenges in assessing pain in children and the elderly, but did not outline specific refined approaches.
This version
This edition places special attention on vulnerable groups, including children, the elderly, and patients with cognitive or substance use disorders, emphasizing tailored, structured pain assessment.
Clinical impact Employ age-appropriate and cognitive-status-adapted pain assessment tools and strategies for pediatric, geriatric, and cognitively impaired patients.
Practice Notes
These practical considerations highlight key areas for immediate impact on acute pain management in emergency settings.
Do not miss
Always consider multimodal analgesia as the default approach.
Combining non-opioid pharmacological and non-pharmacological methods reduces opioid reliance, improves pain control, and minimizes adverse effects, aligning with current opioid stewardship principles.
Caution
Exercise extreme caution with opioid prescribing and prioritize non-opioid alternatives.
The opioid crisis necessitates a shift away from routine opioid use; reserve them only for severe pain when non-opioid options are insufficient and benefits clearly outweigh risks.
Do not miss
Implement early and systematic pain assessment from first contact to discharge.
Regular, accurate assessment using validated tools (NRS, VAS, observational scales) is foundational for effective, individualized pain management and prevents oligoanalgesia.
Implementation
Integrate non-pharmacological interventions early, either alone or in combination with medications.
Simple techniques like splinting, psychological support, distraction, and positioning can significantly reduce pain, fear, and anxiety, often with minimal resources.
Special population
Adapt pain assessment tools for non-verbal patients, including young children and those with cognitive impairment.
Utilize age-appropriate observational scales (Wong-Baker FACES, FLACC, CRIES, PAINAD) to ensure pain is recognized and treated in patients unable to self-report.
Caution
Be aware of the environmental and occupational hazards associated with nitrous oxide.
While effective, nitrous oxide is a potent greenhouse gas and chronic exposure can lead to staff health issues; consider alternatives and ensure proper scavenging and ventilation.