One of the questions I receive most often in teleconsultation isn't which drug to give. It's whether to give it.
A nursing crew on an advanced life support vehicle, forty minutes of transport to the only hospital in the region, a patient with a femoral fracture and an NRS above 7. The question that comes to dispatch, almost always, is formulated as a request for authorization, not as a request for therapeutic advice. And this says a lot about where the real problem lies.
In October 2025, the European Society for Emergency Medicine published the update to its guidelines on acute pain management in emergency settings, developed within the European Pain Initiative. It's 138 pages, with a systematic literature review from January 2020 to May 2025 and a peer-reviewed version published in early 2026 in the European Journal of Emergency Medicine. The guidelines cover both the emergency department and prehospital care, both adults and children.
The document went almost unnoticed. I found no comments in the Anglo-Saxon FOAM community, no analysis on international EMS blogs, no structured discussion outside the EUSEM institutional channel. For a document addressing the single most common symptom in our practice, this seems like a gap worth filling.
The Problem the Guidelines Acknowledge
The most honest thing about the document is that it opens by acknowledging a failure.
Oligoanalgesia, that is, the undertreatment of pain, was first described in the literature in the late 1980s. In the nearly forty years since, national guidelines have been published across half of Europe, and the numbers haven't moved appreciably.
The data the document collects are, taken together, quite stark. In a Dutch retrospective review of 1,407 patients transported by ambulance, 70% reported pain, but only 31% had received a systematic assessment and 42% an analgesic. In a Norwegian prospective study of 764 emergency department patients, 77% were assessed for pain on arrival, but among those with moderate to severe pain only 14% received an analgesic. In an Italian observational study of 2,838 patients, 71% arrived with pain and one-third were treated pharmacologically. In a Swiss helicopter emergency medical service case series over ten years with 1,202 patients, oligoanalgesia was present in 43% of cases, and in three-quarters of these it wasn't failure to administer but insufficient dosing.
There's also an Italian data point that appears in the introductory chapter and deserves note: 12% of ambulances don't carry major analgesics and 10% don't carry any analgesics, compared to 42% of patients reporting moderate to unbearable pain. This is 2009 data. The fact that in 2025 it's still the available reference for our country is information in itself.
Why This Isn't a Comfort Issue
The chapter on management considerations contains the part that in my opinion should be read first, because it dismantles the implicit idea that analgesia is an act of clinical courtesy to be placed after the serious stuff.
Uncontrolled pain activates catecholamine release, with tachycardia, hypertension, and increased myocardial oxygen consumption, in patients who often already have underlying coronary artery disease. The document also reports an incidence of respiratory complications up to 18% in patients with untreated pain, hyperglycemia up to 34% in diabetics with acute pain, and a study in which 12% of patients who passed through the emergency department developed chronic pain at three months, with a substantial increase in probability compared to controls.
When we delay analgesia we're not postponing comfort. We're adding physiological load to a patient who already has enough, and in a proportion of cases we're contributing to damage that will last beyond the acute episode.
The Three Shifts
If you read the document looking for pharmacological novelty, you'll be disappointed: there isn't any. The review essentially confirms the armamentarium we already know. What changes lies elsewhere, and there are three shifts that in my opinion have more impact on prehospital practice than a new molecule would.
The first concerns the threshold. Assessment becomes the intervention. The document calls for baseline assessment within 15 minutes of first contact and precisely defines reassessment times: 15 minutes in severe pain, 15-30 minutes in moderate, 30-60 in mild. If reduction isn't present at reassessment, escalate. This isn't a generic recommendation: it's a time constraint that makes undertreatment measurable and therefore auditable. And it's the reason why, in a system that truly wants to improve, the first intervention isn't changing the protocol but starting to record the NRS three times instead of zero.
The second concerns the mechanism. The guidelines adopt the CERTA approach (Channels-Enzymes-Receptors Targeted Analgesia) alongside the modified WHO ladder. The selection criterion shifts from "how much does it hurt" to "which target am I hitting." It seems like an academic detail, but it's actually the operational rule behind the most concrete indication in the entire document: when analgesia is insufficient, add a drug from a different class, don't just increase the dose of what you're already using. From this also follows the contraindication to combining two different NSAIDs and the logic of combining opioid and ketamine.
The third concerns the route. This is, for prehospital care, the most relevant shift. Intranasal and nebulized routes enter firmly among recommended options, while the intramuscular route is defined as strongly discouraged and reserved for situations where no other route is feasible, due to unpredictable absorption, delayed onset, and pain from the administration itself.
The case of ketamine is emblematic of how these three shifts interweave. In the therapeutic options table for adults, ketamine no longer appears only in severe pain: it's among the options for moderate pain, with NRS between 4 and 6, via intravenous, intranasal, or nebulized routes. The review reports that intravenous doses of 0.15 mg/kg are as effective as 0.3 mg/kg, that nebulized ketamine at 0.75 mg/kg is comparable to intravenous administration at 0.3 mg/kg, and that intranasally analgesia is comparable or superior to intravenous morphine at 30 minutes, although at 120 minutes morphine remains more durable. Vomiting occurs in up to 30% of cases, and co-administration of an antiemetic is recommended.
Put this way, the repositioning is clear. Ketamine stops being the drug of last resort, the one you pull out when the patient is trapped and morphine isn't enough, and becomes a second-line analgesic that can be administered without venous access. For a crew managing a patient with moderate pain in a hostile environment, with a difficult vein and twenty minutes of approach time, this isn't a nuance.
What the Document Says to Stop Doing
A little-discussed part of the guidelines is the list of negative recommendations, which are always the hardest to implement because they don't touch knowledge but habit.
Codeine and tramadol are not recommended, due to pharmacological limitations, safety issues, and availability of superior alternatives. Oxycodone is discouraged due to higher incidence of euphoria compared to other opioids. Metamizole should be used with caution due to the risk of agranulocytosis, and here it's worth being precise: the document recommends caution, not exclusion, and the issue remains subject to discussion in countries where the drug is in common use. Discharge from the emergency setting should provide no more than two or three days of opioid therapy. And naloxone must be available wherever opioids are administered.
What Remains Outside
The guidelines were explicitly written to be applicable "regardless of medication access," that is, independent of drug availability. It's an honest choice, acknowledging how heterogeneous Europe is. But it's also the point where the document stops.
Because the question that comes to me in dispatch doesn't concern the choice between ketamine and fentanyl. It concerns who is authorized to administer what, with what coverage, in which system. The guidelines indicate that each professional must operate within their administration rights and scope of practice, which is correct and at the same time leaves the problem exactly where it was. A European document cannot resolve an issue that is regulatory and organizational before it is clinical. It can, however, make visible the cost of not resolving it, and in this the oligoanalgesia data do their job.
Finally, a transparency note that the document reports and is worth repeating: the 2025 update was supported by an unrestricted grant from Aguettant, while the 2020 edition was funded by Mundipharma. This isn't an element that invalidates the work, conducted with PRISMA methodology and 80% expert consensus, but in a document whose main thrust is reducing opioid use, it's information the reader has a right to have without having to search for it.
In Conclusion
What I take away from this reading isn't a protocol change. It's a different question to ask of one's system.
Not "do we have the right drugs," but: how many times do we measure pain on a typical call, and how many times do we remeasure it after doing something? Because everything else—the choice of drug, the route, the class—comes after. And in a system where NRS isn't recorded three times, no European guideline will ever produce a measurable effect.
How does it work in your system?
Guidelines for the management of acute pain in emergency situations, 2025 Update. European Society for Emergency Medicine, European Pain Initiative, October 2025. Peer-reviewed version: Hachimi-Idrissi S, et al. Updated European Society for Emergency Medicine Guidelines for acute pain management in emergency departments and prehospital care. Eur J Emerg Med, 2026. DOI: 10.1097/MEJ.0000000000001323
