Relief of pain and discomfort is a critical component of the mission of every health care provider to reduce suffering. Pain management is of paramount importance in the provision of care at every level. This is an era of increasing patient expectations of care, yet also there exists an ongoing scourge of opiate abuse. ED visits for opioid overdoses rose 30% in all parts of the USA from July 2016 through September 2017. Deaths from narcotic overdose in the USA now exceed those from motor vehicle crashes. The concept of an “opiate-free” emergency department has been posited. The emergency practitioner is presented with clinical and political challenges which did not exist in the past. This article elucidates current pharmacologic options regarding analgesia in the emergency setting, with some possible future options.