Pain is one of the most common reasons patients come to the emergency department. Yet, despite modern analgesics, protocols, and guidelines, many patients still leave the ED having experienced unnecessary suffering. The updated European Society for Emergency Medicine guidelines remind us of a simple but often forgotten truth: pain management is not a single medication order; it is a clinical process.

The goal is not only to reduce a number on the pain scale. The goal is to reduce suffering, preserve function, treat the cause, avoid harm, and discharge the patient safely.

That is the heart of pain stewardship.

The old model: “Pain equals medicine”

In many emergency departments, pain management still follows a predictable pattern:

Patient has pain.
Pain score is high.
Give medication.
Move on to the next patient.

This is understandable. The ED is crowded, noisy, time-pressured, and unpredictable. But this model fails because pain is not only a pharmacological problem.

Pain is physiology, psychology, inflammation, fear, tissue injury, movement, ischemia, swelling, memory, and expectation.

A fractured wrist hurts not only because bone is injured. It hurts because every small movement reactivates nociceptors. A renal colic patient suffers not only from ureteric spasm, but also from fear, autonomic activation, nausea, and loss of control. A child with a laceration is not only experiencing tissue pain; they are experiencing threat.

So the modern ED question should not be:

“What drug should I give?”

It should be:

“What is driving this patient’s pain, and how can I interrupt that pain safely from several directions?”

The new model: pain stewardship

Pain stewardship means giving the right analgesia, to the right patient, by the right route, at the right time, with reassessment, while minimizing avoidable harm.

It is not anti-opioid.
It is not “weak analgesia.”
It is not delaying treatment.

It is disciplined, multimodal, patient-specific pain care.

The updated EUSEM guideline emphasizes a multimodal, multidisciplinary approach that prioritizes nonopioid and nonpharmacological strategies where appropriate, while reserving opioids for situations where the expected benefit clearly outweighs the risk.

A simple way to say it:

Pain stewardship is not opioid avoidance. It is opioid wisdom.

Step 1: Assess pain early — and believe the patient

The first intervention is not morphine, ketamine, paracetamol, or ibuprofen.

The first intervention is assessment.

Pain should be assessed and recorded early after arrival. EUSEM recommends baseline pain assessment within at least 15 minutes of arrival to emergency services. Assessment should use a tool appropriate to the patient: NRS, VAS, faces scale, behavioral scale, or multidimensional tools when feasible.

But assessment is more than asking, “What is your pain from zero to ten?”

A good ED pain assessment asks:

Where is the pain?
What is the likely mechanism?
Is it inflammatory, ischemic, traumatic, visceral, neuropathic, procedural, or mixed?
Can the patient self-report reliably?
Is there cognitive impairment, language barrier, age-related limitation, intoxication, fear, or distress?
What would meaningful improvement look like for this patient?

One major pitfall is clinician underestimation of pain. The guideline highlights provider underestimation as a persistent barrier to good pain care. This matters because untreated pain is not benign; it worsens sympathetic activation, agitation, hypertension, tachycardia, immobility, poor cooperation, and patient distrust.

Step 2: Use the traffic-light approach

The updated EUSEM guideline introduces a practical “traffic light” model for acute pain in emergency settings. It divides patients into three groups based on pain severity and guides escalation or de-escalation of analgesia.

Green: mild pain

NRS/VAS <4

This is usually managed with simple oral analgesia such as paracetamol or an NSAID, if there are no contraindications.

But “mild” does not mean “ignore.” Mild pain still needs a plan, explanation, cause treatment, and reassessment.

Orange: moderate pain

NRS/VAS 4–6

Moderate pain needs more than casual prescribing. The key is to add analgesia with a different mechanism or route, not simply repeat the same class.

For example, depending on the patient and local availability, options may include paracetamol, NSAIDs, inhaled analgesia, intranasal agents, ketamine, opioids, topical local anesthetic, or nerve blocks.

Red: severe pain

NRS/VAS 7–10

Severe pain requires rapid treatment and close reassessment. Options may include fast-onset intranasal, sublingual, buccal, nebulized, or IV analgesia; ketamine; opioids; and regional nerve blocks when appropriate.

The principle is urgent but thoughtful escalation.

Not “give everything.”
Not “wait until imaging.”
Not “opioids only.”

Rather:

Treat now, monitor closely, and use multiple pathways.

Step 3: Think physiology, not just pharmacy

Pain travels through pathways. If we understand the pathway, we choose better treatments.

Tissue injury releases inflammatory mediators. These sensitize peripheral nociceptors. Signals travel through peripheral nerves into the spinal cord, ascend to the brain, and are shaped by emotion, fear, memory, and expectation.

That gives us several treatment targets:

Inflammation can be reduced with NSAIDs when safe.
Central pain processing can be reduced with paracetamol and other agents.
Severe nociceptive transmission can be reduced with opioids when indicated.
NMDA-mediated sensitization can be reduced with ketamine.
Peripheral nerve transmission can be interrupted with regional anesthesia.
Movement-related nociception can be reduced with splinting and immobilization.
Fear amplification can be reduced with explanation, reassurance, and procedural preparation.

This is why multimodal analgesia works: it does not press one button harder; it presses several buttons intelligently.

Step 4: Treat pain beyond medication

One of the most important messages for the ED is this:

Analgesia is not only pharmacology.

For many patients, the most powerful analgesic is source control.

A dislocated shoulder needs reduction.
A fractured limb needs splinting.
A burn needs cooling.
An abscess needs drainage.
A tense hematoma may need decompression.
A child needs comfort, distraction, and a sense of safety.
A patient with limb ischemia needs reperfusion, not repeated opioid boluses.

EUSEM specifically emphasizes treating the underlying cause and using nonpharmacological strategies such as splinting, immobilization, heat or cold therapy, virtual or mixed reality where available, and distraction techniques for children.

In practice, think of five non-drug analgesics available in almost every ED:

Position
A comfortable position reduces muscle spasm and mechanical stimulation.

Immobilization
A good splint can dramatically reduce repeated nociceptor firing.

Ice, heat, elevation, compression
Used selectively, these reduce swelling, spasm, and inflammation.

Explanation
Fear increases pain. Clear explanation reduces threat perception.

Procedure planning
Topical anesthetic, nerve block, nitrous oxide, parental presence, or distraction can transform a painful procedure into a tolerable one.

The patient should feel: “They have a plan for my pain,” not “They gave me something and disappeared.”

Step 5: Reassess — close the loop

Pain management without reassessment is incomplete care.

The EUSEM approach recommends reassessment based on initial severity and route of administration. Severe pain should generally be reassessed at around 15 minutes. Mild to moderate pain is commonly reassessed around 30 minutes, with timing adjusted by route: IV, intranasal, inhaled, and sublingual routes need earlier reassessment; oral and intramuscular routes need longer.

This is the ED pain loop:

Assess → Treat → Reassess → Adjust → Document

Reassessment asks:

Has the pain improved?
Is the patient more functional?
Are there adverse effects?
Was the route effective?
Do we need another mechanism?
Can we de-escalate?
Is the diagnosis changing?

A pain score that remains 8/10 after treatment is not a documentation issue. It is a clinical signal.

Adult pain management: practical application

For adults with mild pain, oral paracetamol or NSAIDs are usually reasonable first-line options, depending on contraindications.

For moderate pain, treatment can escalate by adding a different class or route: inhaled analgesia, IV paracetamol, NSAIDs such as ketorolac where appropriate, ketamine, opioids, topical local anesthetic, or nerve blocks.

For severe pain, the guideline supports rapid escalation with options such as intranasal, sublingual, buccal, nebulized, or IV opioids; ketamine by appropriate routes; and nerve blocks where suitable.

Important adult safety points from the guideline:

Codeine and tramadol are not recommended because of pharmacological limitations and safety concerns.

Oxycodone is discouraged because of its association with higher euphoria compared with some other opioids.

Do not combine two NSAIDs. If the patient has received ibuprofen, adding diclofenac or ketorolac is generally unsafe and adds toxicity without meaningful benefit.

Metamizole requires caution because of the risk of serious agranulocytosis.

Naloxone should be available when opioids are used.

Discharge opioids, when necessary, should be minimal — generally no more than 2–3 days of dosing.

Pediatric pain management: the child is not a small adult

Children require the same seriousness but a different strategy.

The pediatric pathway prioritizes oral, intranasal, inhaled, topical, and other less invasive routes whenever possible. For mild pain, oral paracetamol or ibuprofen is commonly used. For anticipated IV access or painful procedures, topical local anesthetic should be considered early because onset may require 30–60 minutes.

For moderate pain, options include nitrous oxide, oral opioids such as morphine where appropriate, IV paracetamol, IV NSAIDs, ketamine, and nerve block.

For severe pediatric pain, options include fentanyl or morphine by appropriate routes, ketamine, and nerve block.

Important pediatric cautions:

Codeine is contraindicated or not recommended in children.

Naloxone should be available when opioids are used.

Antiemetics such as ondansetron may be considered with opioids to reduce nausea and vomiting.

Do not stack NSAIDs.

The guideline notes that methoxyflurane has pediatric evidence, particularly for traumatic pain, but regulatory approval varies; it has been approved recently for children in Ireland, while remaining off-label in wider Europe.

Bridging analgesia: do not wait for the IV

A common ED failure is delaying analgesia because IV access is difficult or because the patient is waiting for a bed, imaging, or physician review.

The guideline supports considering inhaled or intranasal analgesia while definitive analgesia is being established. Nitrous oxide, methoxyflurane where available, and intranasal opioids such as fentanyl are examples discussed in the guideline.

This is highly practical.

A patient with severe pain should not wait 30 minutes for cannulation before receiving any relief. Inhaled and intranasal routes can provide early analgesia, reduce distress, and create time for definitive care.

This is especially valuable in:

fractures,
burns,
children,
prehospital care,
crowded EDs,
difficult IV access,
procedures,
severe anxiety with pain.

The biggest pitfalls in ED pain management

1. Waiting for the diagnosis before treating pain

Analgesia does not erase clinical reasoning. Treating pain does not mean ignoring red flags.

A patient can receive analgesia while still being evaluated for appendicitis, ischemia, fracture, sepsis, renal colic, or vascular catastrophe.

2. Recording pain once and never returning

Pain care is a loop, not a checkbox.

3. Defaulting to IV opioids

IV opioids have a place. But they are not the whole toolbox. Oral, intranasal, inhaled, sublingual, topical, nebulized, regional, and nonpharmacological options may be better in selected patients.

4. Escalating dose instead of changing mechanism

If the first medication fails, ask:

Is the pain inflammatory?
Is there muscle spasm?
Is there movement-related pain?
Would a nerve block help?
Is ketamine appropriate?
Is source control needed?
Is anxiety amplifying the pain?

Do not simply keep pushing the same pathway.

5. Combining drugs from the same class

Two NSAIDs are not “stronger analgesia.” They are often just more renal, gastrointestinal, and bleeding risk.

6. Ignoring the route

The route is part of the prescription. Oral is excellent when possible. Intranasal and inhaled routes are useful when rapid, needle-free analgesia is needed. IV is useful when titration and speed are important. IM analgesia is discouraged except in exceptional circumstances because of painful administration, unpredictable absorption, slower onset, and local complications.

7. Forgetting discharge stewardship

The ED prescription can start a long-term medication problem. When opioids are needed at discharge, they should be limited, clearly explained, and paired with a step-down plan.

A practical ED pain stewardship checklist

Before moving on from any patient with pain, ask:

Have I assessed and documented pain using an appropriate tool?

Have I treated the underlying cause where possible?

Have I used nonpharmacological analgesia: position, splint, ice/heat, elevation, explanation, distraction?

Have I chosen analgesia based on mechanism, not habit?

Have I selected the safest effective route?

Have I avoided unsafe combinations, especially NSAID stacking?

Have I reassessed after treatment?

Have I documented response and side effects?

If opioids were used, is naloxone available and monitoring appropriate?

If the patient is discharged, is the analgesic plan short, safe, and clear?

The culture change: pain is a vital clinical outcome

Emergency clinicians are trained to detect danger: airway failure, shock, sepsis, stroke, myocardial infarction, trauma.

But suffering also deserves structured care.

The updated EUSEM guideline makes it clear that successful ED pain management requires more than publishing a protocol. It requires staff training, documentation, audit, feedback, multidisciplinary cooperation, and a culture that treats pain relief as a core part of emergency medicine.

The best departments do not ask, “Did someone prescribe analgesia?”

They ask:

Was pain assessed early?
Was relief timely?
Was the treatment appropriate to the patient?
Was the patient reassessed?
Was opioid exposure minimized without undertreating pain?
Was the discharge plan safe?

Final message

Good ED pain management is not simply giving stronger medication.

It is recognizing that pain is a whole-system experience: tissue injury, nerves, inflammation, fear, movement, and meaning.

The modern approach is:

Measure it.
Believe it.
Treat the cause.
Use non-drug analgesia.
Choose mechanism-based medication.
Use opioids wisely.
Reassess.
Document.
Discharge safely.

In one sentence:

Pain stewardship means relieving suffering quickly while protecting the patient from avoidable harm.

That is emergency medicine at its best.