Introduction: The opioid crisis in North America has led to more rigorous prescribing guidelines in various practice settings. Recent studies suggest that the Emergency Department is an environment with increased opioid prescribing, leading to increased rates of long-term use and dependence in opioid naive patients. Prior reviews of international opioid prescribing guidelines have demonstrated overall congruence of practice recommendations, although these are focused on primary care prescribers. The goal of this study was to review international opioid prescribing guidelines for recommendations relevant to emergency department practitioners. Methods: The search strategies of prior congruence studies were reproduced, updated and supplemented by electronic database and specialty organization searches. Only the most recent iteration of a published guideline was included, unless it was a limited update of a prior more comprehensive guideline, in which case both were assessed. Prescribing guidelines were included if they represented national practice statements, national or international specialty organizations generating guidelines. Sub-national or regional guidelines were excluded due to local practice bias tendency. Included guidelines were independently reviewed for evidence evaluation and recommendation formulation frameworks, relevance of recommendations for emergency medicine (EM) practice (and supporting levels of evidence), inclusion of EM authors (and corresponding conflict of interest statements), and involvement of EM-relevant stakeholders in reviewing guideline publications. Results: Sixteen international and specialty organization guidelines were included in the review. Evidence evaluation and recommendation formulation frameworks were incompletely reported (12/16), and used a multitude of evaluation processes when reported. Two guidelines included EM-relevant recommendations based on weak evidence. Three guidelines included EM authors, one of which reported a conflict of interest. None of the included guidelines were reviewed by EM-relevant stakeholder organizations prior to publication. Conclusion: International and specialty organization opioid prescribing guidelines virtually ignore relevant recommendations for EM practice, and any supporting evidence is weak. Emergency practitioners are nearly absent from authorship groups, and are excluded from external review of draft documents prior to final publication. This study reinforces the urgent need for EM organizations to create guidance documents around opioid prescribing for their own practitioners, and involving appropriate EM stakeholders.