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Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

Background: In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind., Methods: With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings., Results and Conclusions: This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Introduction: Acute pain remains highly prevalent in the Emergency Department (ED) setting. This double-blind, randomized, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED in the adult population of the STOP! trial., Methods: Patients presenting to the ED requiring analgesia for acute pain (pain score of 4-7 on the Numerical Rating Scale) due to minor trauma were randomized in a 1:1 ratio to receive methoxyflurane (up to 6 mL) or placebo (normal saline), both via a Penthrox ® (Medical Developments International Limited, Scoresby, Australia) inhaler. Rescue medication (paracetamol/opioids) was available immediately upon request. Change from baseline in visual analog scale (VAS) pain intensity was the primary endpoint., Results: 300 adult and adolescent patients were randomized; data are presented for the adult subgroup (N = 204). Mean baseline VAS pain score was ~66 mm in both groups. The mean change from baseline to 5, 10, 15 and 20 min was greater for methoxyflurane (-20.7, -27.4, -33.3 and -34.8 mm, respectively) than placebo (-8.0, -11.1, -12.3 and -15.2 mm, respectively). The primary analysis showed a highly significant treatment effect overall across all four time points (-17.4 mm; 95% confidence interval: -22.3 to -12.5 mm; p < 0.0001). Median time to first pain relief was 5 min with methoxyflurane [versus 20 min with placebo; (hazard ratio: 2.32; 95% CI: 1.63, 3.30; p < 0.0001)]; 79.4% of methoxyflurane-treated patients experienced pain relief within 1-10 inhalations. 22.8% of placebo-treated patients requested rescue medication within 20 min compared with 2.0% of methoxyflurane-treated patients (p = 0.0003). Methoxyflurane treatment was rated 'Excellent', 'Very Good' or 'Good' by 77.6% of patients, 74.5% of physicians and 72.5% of nurses. Treatment-related adverse events (mostly dizziness/headache) were reported by 42.2% of patients receiving methoxyflurane and 14.9% of patients receiving placebo; none caused withdrawal and the majority were mild and transient., Conclusion: The results of this study support the evidence from previous trials that low-dose methoxyflurane administered via the Penthrox inhaler is a well-tolerated, efficacious and rapid-acting analgesic., Funding: Medical Developments International (MDI) Limited and Mundipharma Research GmbH & Co.KG., Trial Registration: Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

Objective: To evaluate the short-term efficacy and safety of methoxyflurane for the treatment of acute pain in patients presenting to an emergency department (ED) with minor trauma., Methods: STOP! was a randomised, double-blind, multicentre, placebo-controlled study conducted at six sites in the UK. A total of 300 patients, 90 of whom were adolescent patients (age 12-17 years), were randomised 150:150 to receive either methoxyflurane via a Penthrox inhaler or placebo. The primary end point of the study was the change in pain intensity as measured using the visual analogue scale (VAS) from baseline to 5, 10, 15 and 20 min after the start of study drug inhalation. Patients were supplied with one inhaler containing 3 mL methoxyflurane or 5 mL placebo after enrolment and initial assessments. Age group (adolescent/adult) and baseline VAS score were controlled for in the statistical analyses., Results: A total of 149 patients received methoxyflurane, and 149 patients received placebo. Demographic and baseline characteristics were comparable between the groups. Methoxyflurane reduced pain severity significantly more than placebo (p<0.0001) at all time points tested, with the greatest estimated treatment effect of -18.5 mm (adjusted change from baseline) seen at 15 min after the start of treatment. Methoxyflurane was well tolerated, with the majority of adverse reactions being mild, transient and in line with anticipated pharmacological action., Conclusion: The results of this study suggest that methoxyflurane administered via the Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic., Trial Registration Number: NCT01420159., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: Undertreatment of trauma-related pain is common in the pre-hospital and hospital settings owing to barriers to the use of traditional standard of care analgesics. Low-dose methoxyflurane is an inhaled non-opioid analgesic with a rapid onset of pain relief that is approved for emergency relief of moderate-to-severe trauma-related pain in adults. This analysis was performed to compare the efficacy and safety of low-dose methoxyflurane with standard of care analgesics in adults with trauma-related pain. Methods: A meta-analysis was performed on pooled data from randomized controlled trials identified via a systematic review. The primary endpoint was the pain intensity difference between baseline and various time intervals (5, 10, 15, 20, and 30 minutes) after initiation of treatment. Results: The pain intensity difference was statistically superior with low-dose methoxyflurane compared with standard of care analgesics (overall estimated treatment effect=11.88, 95% CI=9.75– 14.00; P< 0.0001). The superiority of low-dose methoxyflurane was demonstrated at 5 minutes after treatment initiation and was maintained across all timepoints. Significantly more patients treated with methoxyflurane achieved response criteria of pain intensity ≤ 30 mm on a visual analog scale, and relative reductions in pain intensity of ≥ 30% and ≥ 50%, compared with patients who received standard of care analgesics. The median time to pain relief was shorter with methoxyflurane than with standard of care analgesics. The findings were consistent in a subgroup of elderly patients (aged ≥ 65 years). Conclusion: Methoxyflurane can be considered as an alternative to standard of care analgesics in pre-hospital and hospital settings for treatment of adult patients with acute trauma-related pain. [ABSTRACT FROM AUTHOR]