Results

EP Demographic and Experience Characteristics

A total of 15 EPs participated in qualitative interviews; more than half were male (n = 9, 60.0%) and around half (n = 8, 53.3%) identified as White (Table 1). Study participants predominantly practiced in the Northeast (n = 11, 73.3%), had a median of 23.0 years of experience working in an emergency setting postresidency/fellowship (range from 11.0 to 29.0 years), and worked a median of 14.0 shifts per month in a clinical emergency setting and/or performing clinical tasks (range 8.0 to 20.0 shifts).

Demographic characteristics | Emergency physicians (N = 15) n (%)
Sex | 
Male | 9 (60.0)
Female | 6 (40.0)
Race/Ethnicity | 
White | 8 (53.3)
Asian American or Pacific Islander | 4 (26.7)
Black or African American | 1 (6.7)
Hispanic or Latino | 1 (6.7)
Prefer not to answer | 1 (6.7)
Geographic region | 
Northeast (CT, MA, NJ, NY, RI) | 11 (73.3)
South (FL, TX, GA) | 3 (20.0)
West (CA) | 1 (6.7)
Clinical experience & characteristics | Median (range)
Years of experience postresidency/fellowship | 23.0 (11-29)
Number of clinical shifts per month | 14.0 (8-20)
Percentage of adult patients | 90.0 (70-98)

All EPs reported working shifts within a hospital-based ED (n = 15, 100%); among this group, 8 (53.3%) provided care at community medical centers, 6 (40.0%) provided care in academic medical centers, and 1 participant did not report the hospital type.

EPs estimated that a median of 60.0% of patients (range 25.0% to 99.0%) presented to the ED with acutely painful conditions or complaints. Almost three-quarters reported that at least half of these patients described their pain as severe. All EPs reported evaluating patients presenting with traumatic injuries (eg, injuries resulting from a fall or motor vehicle accident), including bone fractures, ligament strains, and lacerations. Although asked about their overall approaches to acute pain management, EPs also reported treating a range of other acute pain conditions. These included abdominal, gastrointestinal, urological, gynecological, and cerebrovascular conditions (eg, stroke), headaches and migraines, general chest pain, acute back pain or muscle strains, and sickle cell crises.

EPs’ Role and Approach in Acute Pain Management

All EPs reported being primarily responsible for patients’ pain management in the ED and for prescribing pain medications at discharge. Thirteen EPs reported coordinating acute pain management with other health care providers, most commonly nurses. Around half coordinated with advanced practice providers (APPs); however, some noted that APPs functioned independently in the ED, with EPs being consulted as needed.

When managing acute pain, 12 EPs described focusing on reducing their patient’s pain to a tolerable level, as fully eliminating pain was not considered realistic. Nine EPs reported following self-developed pain protocols, which were informed by their medical training and personal experiences; however, they noted these protocols were informal and varied based on the type of condition being treated, patient characteristics, and familiarity with certain medications. Around half noted their facility had protocols in place for pain management, though they were often condition-specific, including clinical pathway protocols (eg, sickle cell pathway protocol), algorithm-driven recommendations, monitoring requirements, and formulary limitations.

Areas of Focus for Pain Management in the ED

When planning pain management regimens, EPs described key considerations, including past and current medical conditions, pain severity, risk of adverse effects (AEs), and patient preferences. Nearly all EPs reported considering comorbidities, including kidney failure or metabolic disorders, mental health conditions, obesity, and hypotension (Table 2). EPs also reported considering pain severity and the underlying condition when selecting treatment, including conditions such as sickle cell crisis, bone fracture, kidney or gallbladder stones, back pain or muscle strain, and dental pain.

 | n (%)
Comorbidities | 14 (93.3)
Type of medical condition | 14 (93.3)
Pain severity | 14 (93.3)
Medication interactions, allergies, or tolerability | 12 (80.0)
Potential medication-related AEs | 10 (66.7)
Opioid misuse | 9 (60.0)
Age | 8 (53.3)
Considerations of medication administration route | 7 (46.7)
Patient-reported satisfaction with care | 4 (26.7)
Chronic pain and opioid experience | 4 (26.7)
Other substance use | 2 (13.3)

Two-thirds (n = 10) of EPs described challenges managing acute pain among medically complex patient populations, including those with chronic pain, opioid tolerance, or a history of opioid use disorder. Similarly, one-third of EPs noted issues balancing pain relief with the risk of AEs. Further, approximately half of EPs (n = 7) described incorporating patients’ pain management preferences into their approach, while 5 EPs noted they only consider patients’ medication preferences in certain contexts. For example, patients with a history of opioid use disorder may request specific classes of pain medications to avoid risk of returning to opioid misuse.

Emergency Physician-Perceived Impacts of Inadequate Pain Management

Nearly all EPs (n = 13) discussed their perceptions of the impact of inadequately managed acute pain, with more than half (n = 8) of EPs reporting broad and debilitating AE on patients (Table 3). Further, EPs noted negative impacts on the ability to perform ADLs, return to work or productivity, and social functioning and relationships.

 | n (%)
Broad adverse effects | 8 (53.3)
Ability to perform ADLs | 6 (40.0)
Return to work or productivity | 5 (33.3)
Social functioning and relationships | 4 (26.7)
Short, brief, or limited adverse impact | 3 (20.0)
Emotional functioning | 2 (13.3)

Perceived Advantages and Disadvantages of Acute Pain Medications

When asked how satisfied they were overall with the medications available for managing acute pain in adults at the time of the interviews, one-third (n = 5) of participants reported they were satisfied; however, the majority were only somewhat satisfied (n = 9). Satisfaction was based on physician self-report. Similarly, when asked about their perceptions of patient satisfaction with pain medications available, 10 EPs felt their patients were at least somewhat satisfied. Accordingly, EPs provided descriptions of advantages and disadvantages of available acute pain medications (ie, opioid medications, NSAIDs, and acetaminophen), including analgesic effectiveness and potential AE (Table 4). Table 4 summarizes medication advantages and disadvantages as described by participants and does not represent a comprehensive list of pharmacologic properties for each medication class.

 | Opioids | NSAIDS | Acetaminophen
Advantages |  |  | 
Analgesic effectiveness | X | X | X
Ability for intravenous administration |  | X | 
Nonopioid/nonaddictive |  | X | X
Safety/tolerability in select patients |  |  | X
Disadvantages |  |  | 
Risk of medication-related AEs | X | X | 
Addiction, dependence, or diversion risk | X |  | 
Challenges prescribing to at-risk populations | X | X | 
Tolerability or contraindication concerns | X | X | 
Modest analgesic effect compared with opioids |  | X | X
Impacts on liver function |  |  | X
Risk of overdose | X |  | 

Opioid-specific Considerations

Six EPs reported being comfortable prescribing opioids, whereas 8 reported varying levels of comfort; one participant was uncomfortable prescribing opioids. An advantage of opioid medications, as described by over half of EPs, was effectiveness in managing acute pain (Table 4). Conversely, participants reported multiple disadvantages of opioid medications, including prescribing challenges in at-risk populations, such as the elderly or those with respiratory comorbidities.

They also described opioid-related adverse drug events (ORADEs), including drowsiness, sedation, altered cognition, constipation, respiratory depression, and the potential for overdose. Nearly all EPs expressed concern about the risk of addiction, dependence, and diversion. Four EPs indicated that prescribing short courses of opioids may help mitigate these risks.

All participants described administrative factors or tasks involved in prescribing opioid medications, such as state monitoring programs and the need to navigate formulary restrictions or quantity limits. Some EPs experienced prescribing limitations due to stock shortages. About half of EPs reported these requirements as burdensome, whereas others felt they were manageable and served an important role in reducing opioid misuse risk.

Nonopioid Pain Medication Considerations

Seven EPs reported NSAIDs were effective in reducing acute pain and inflammation as a first-line treatment (Table 4). Other reported advantages of NSAIDs included intravenous administration and their nonaddictive, nonopioid properties. In contrast, nearly all EPs (n = 14) reported disadvantages of NSAIDs, including risk of AEs (eg, renal failure or gastric bleeding), along with challenges prescribing NSAIDs to at-risk patient populations, such as those with renal conditions or gastrointestinal issues.

EPs also described acetaminophen as a treatment for acute pain. Seven cited at least 1 advantage, including analgesic benefit, nonaddictive properties, and safety or tolerability for select patients. However, 9 EPs identified disadvantages, most notably liver-related concerns and modest analgesic effectiveness (Table 4).

Other Analgesics and Nonpharmaceutical Acute Pain Management Methods

Although nearly all EPs discussed acetaminophen, NSAIDs, and opioids, alternative pharmacologic and nonpharmacologic approaches were mentioned less often. These included anxiolytics or sedatives (n = 6), select adjunctive therapies (eg, topical agents [n = 4], nerve blocks [n = 2], ketamine [n = 5]), and nonpharmacologic strategies, such as heat or ice and limb support.

EPs valued ketamine, sedatives, nerve blocks, and muscle relaxants for selected circumstances but described limitations, including monitoring requirements, AE, short duration of effect, and limited outpatient suitability. Given their infrequent mention, these pain management approaches were not a primary focus of the analysis.

Ideal Pain Management Therapies in the ED

EPs described characteristics of an ideal pain medication, including an improved safety profile, absence of drug interactions, good patient tolerability, and nonaddictive or noneuphoric properties (Table 5). Eight EPs emphasized the importance of convenience in medication administration, such as rapid onset, lower required doses, prolonged analgesic effects, and flexibility in routes of administration. Additionally, 7 highlighted the need for high analgesic efficacy. Other desirable features included a novel mechanism of action, nonopioid formulation, and affordability or insurance accessibility.

Ideal pain medication characteristics | n (%)
Improved safety profile, well tolerated, no drug interactions | 13 (86.7)
Nonaddictive or noneuphoric | 11 (73.3)
More convenient drug administration | 8 (53.3)
High analgesic efficacy | 7 (46.7)
Inexpensive, covered by insurance | 2 (13.3)
Nonopioid | 2 (13.3)
Novel mechanism of action | 2 (13.3)

Representative quotes supporting these themes are provided in Table 6.

Topic | Quotes
Emergency physicians’ role and approach in acute pain management | “My goal is not zero pain, my goal is comfortable enough to be able to be more relaxed and to take them out of acute distress from pain.” (EP111)“it depends… what the patient is coming in for. So, if it’s a kidney stone usually I start with anti-inflammatories and…if it’s a muscle strain, usually non-steroidals like ibuprofen and then a muscle relaxer. [If] it’s a fracture, then if their blood pressure can tolerate it, then I will probably give them some opiates. [It] just really depends what that complaint is.” (EP108)
Areas of focus for pain management in the ED | “Patients with a history of chronic pain is [sic] very, very tough. Patients with a history of substance abuse, psychiatric patients…patients who are demented is huge, elderly patient populations with multiple drug interactions, constipation… with general populace, but especially with the elderly are particularly tough.” (EP103)“…Adverse reaction in any way; hypotension, potential for abuse, constipation, nausea, vomiting. I want to give them something that works but I don't wanna invite more problems, headaches, concerns, secondary to the medication... I think adverse reactions are a huge [challenge].” (EP115)
Emergency physician-perceived impacts of inadequate pain management | “[Patients are] destroyed by inadequate pain management. Inadequate pain management is probably the reason why we have an opiate problem.” (EP113)“[P]eople can’t go about their daily activities if they’re in pain, right? You can’t work, you can’t take care of yourself, you can’t interact with your friends and family. You can’t do things that you enjoy doing when you’re in pain. So, people’s lives and lifestyles and quality of life are very negatively impacted by being in pain.” (EP108)
Perceived advantages and disadvantages of acute pain medications | “I think that we as, as a medical community, I think that it would be nice to have other options. And the options that we have… are more limited, because a lot of people, they can’t tolerate the NSAIDs, and they also have sometimes, a not-so-great safety profile long-term—and that they can cause GI bleeds and renal dysfunction. So, it would definitely be nice to have other options—now that opioids are considered to be dependent.” (EP107)“I think non-steroidals are really good but they have their own side effects. GI upset and a lotta GI potentially issues, especially if the person’s not eating, and then they’re having kidney issues. It’s just problematic. [S]ometimes in acute pain, non-steroidals are just not enough, at least initially. And then with everything going on with opiates, it’s just very, very difficult to be confident in the fact that you’re writing this prescription, and that you’re not compromising your patient in some way… It’s very complicated, especially in an emergency setting where, 1) you’re trying to adequately treat acute pain, and then, 2) you don’t really know these patients.” (EP108)
Opioid-specific considerations | “[P]atients with unstable vitals. If they have an acute medical condition that causes systemic effects and as a result their vital signs are unstable, if they're hypotensive or hypoxic secondary to an acute respiratory issue that's also causing pain, it's difficult to administer drugs that may also make the patient more hypotensive or suppress their respiratory status further. So, that's difficult.” (EP106)“…I try to stay away from opiates. I don’t want someone giving ‘em out to their friends or finding out they like them…they could try it once and become addicted and I try to stay away from—young people, giving them a prescription…” (EP110)“[T]he [ePrescription] system kind of verifies that you are the prescriber of these opioids— the system pushes a confirmation to your phone that you have to click and say that you are this person…I accept it as part of the process, but I’d rather not spend those whatever it is, few minutes, doing that process.” (EP109)“I think they're checks and balances. And, you know, in the beginning, the state monitoring programs were difficult to access[…] and a barrier, but now with the electronic medical records it’s just one click away and not very difficult to do.” (EP104)
Ideal pain management therapies in the ED | “[S]omething that’s a strong enough pain medication, but something that’s not habit forming or addictive or harmful.” (EP101)“Definitely patients should be pain free because that's initially why they come to the emergency room, to have their pain treated.” (EP114)“Ideally, the medication would affect those pain receptors and give patients adequate acute pain control… without causing neurological analgesia.” (EP108)