Discussion

This qualitative study explored the EPs’ perspectives on acute pain management in the ED, including perceived barriers to treatment and the consequences of inadequately controlled pain on patients. Participants reported a substantial proportion of ED visits involve acutely painful medical conditions, consistent with prior research.2, 3, 4 EPs described treating a broad range of acutely painful conditions, most commonly traumatic injuries, but also conditions with complex pathophysiology or associated complications, such as acute low back pain or sickle cell-related pain. These scenarios may be particularly challenging because clinicians must balance effective analgesia with medication-related risk.26,27

EPs described using both nonopioid analgesics, including NSAIDs and acetaminophen, and opioids to manage moderate-to-severe acute pain in the ED.28,29 Most participants were only somewhat satisfied with pain medications commonly used in routine ED practice during the study period, and described important tradeoffs across treatment options, particularly the challenge of balancing pain relief with safety. These findings suggest that dissatisfaction reflected the limitations and tradeoffs associated with therapies commonly used in ED practice during the study period, rather than a simple lack of treatment options. Participants frequently raised concerns regarding ORADEs, including respiratory depression, constipation, and altered cognition. These perceptions are consistent with prior literature identifying ORADEs as common and clinically important complications of opioid therapy.30, 31, 32 For example, qualitative research conducted outside of the US, EPs described “fear” of adverse events when administering opioids, such as respiratory depression, as a barrier to effective opioid use in emergency care.33

Even short-term opioid use has been associated with risk of ORADEs, which may adversely affect patient outcomes and increase health care resource utilization, costs, and mortality.30 In the present study, EPs’ concerns about these risks appeared to shape both prescribing decisions and overall satisfaction with acute pain treatment options discussed by participants.

Nearly all participating EPs also expressed concern about opioid addiction, dependence, or diversion. In a recent study of 29 geographically diverse EDs, opioid use among adult trauma patients was associated with a significantly increased risk of “at-risk opioid use” within 3-months, and patients receiving an opioid prescription at ED discharge had a nearly 5-fold risk compared with patients not receiving opioids.34 These concerns are also reflected in qualitative research, which suggests that some patients may underuse prescribed opioids or feel apprehension about taking them because of fear of addiction.17,18,35

These findings should also be interpreted in the context of a rapidly evolving opioid policy environment. Over the last decade, pain treatment guidelines and prescribing practices have changed substantially, including the introduction of state-level limits on the duration and quantity of initial opioid prescriptions.36, 37, 38 Broader policy efforts have also encouraged the use of nonopioid alternatives in ED settings.39 Although opioid prescribing practices have historically varied across EDs and individual providers,40,41 the impact of recent utilization management policies on addiction rates remains uncertain.38,40

All participating EPs reported administrative burdens associated with prescribing opioid medications, including state monitoring programs, formulary restrictions, and quantity limits. These requirements result in increased administrative burden that may contribute to provider burnout,42 a phenomenon disproportionately affecting EPs,43,44 and may also delay timely pain treatment.17 In this context, participants’ desire for treatment options with lower administrative complexity is understandable and clinically relevant.

EPs valued NSAIDs and acetaminophen for their nonaddictive mechanisms of action but reported mixed perceptions of their effectiveness for moderate-to-severe acute pain. Participants also identified important safety concerns, including hepatotoxicity for acetaminophen and renal dysfunction or gastrointestinal bleeding for NSAIDs. These risks are consistent with the published literature,31 and underscore the need to balance analgesic effectiveness with medication-related risk through patient-centric treatment strategies.

EPs infrequently described other nonopioid or nonpharmacologic approaches used in multimodal acute pain management, including ketamine, sedatives, nerve blocks, and muscle relaxants. Although these approaches were valued for pain reduction, sedation, or dissociative effects, participants also described limitations, such as short duration of effect, adverse events, and restrictions related to administration or outpatient use. Because the interviews were conducted in March 2024, participant perspectives reflect the acute pain treatment landscape before approval of newer nonopioid therapies, such as suzetrigine, an oral, selective voltage-gated sodium channel 1.8 (NaV1.8) pain signal inhibitor approved in the US in January 2025 for the management of moderate-to-severe acute pain in adults.45, 46, 47, 48 Future research should evaluate whether therapies, such as suzetrigine, may help address the unmet needs identified by EPs in this study, particularly the need for effective analgesia with fewer safety, administrative, and addiction-related concerns.

Nearly all EPs indicated inadequately managed acute pain can have widespread negative effects on patients, including impaired daily functioning, reduced quality of life, and difficulty returning to work. These findings are consistent with prior literature showing many patients are discharged from the ED while still experiencing significant pain.5,6 Persistent pain after discharge may contribute to ongoing functional impairment and reliance on alternative or suboptimal pain relief strategies.19,20 Together, these findings highlight the importance of timely and effective acute pain management.

The challenges identified by participants contributed to a desire for novel analgesics that are effective, safe, well tolerated, nonaddictive or noneuphoric, and easy to administer. These desired characteristics reflect both the clinical complexity of acute pain management in the ED and the limitations of treatment options available during the study period.

This qualitative study provides important insight into EPs’ experiences managing acute pain in the ED. Participants described barriers to effective pain management, including clinical complexity, medication-related risks, and administrative burden. They also reported that inadequately managed acute pain can substantially affect patients’ functioning and quality of life. Although opioid and nonopioid therapies available during the study period offered important benefits, participants emphasized these options also have meaningful limitations. Overall, findings suggest an unmet need for acute pain treatments that provide effective analgesia while minimizing safety concerns, administrative burden, and addiction potential.