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Clinical Decisionmaking

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Emergency physicians vary widely in their prescribing of opioid analgesics for common, painful conditions

Although the current trend in emergency medicine is to treat pain aggressively and err on the side of adequate pain control, less than half of emergency department (ED) patients rate their pain control as "very good." A new study offers insight into pain control decisions of emergency physicians. It shows that even when faced with identical case scenarios for three common, painful conditions, there is considerable variation in physicians' decisions to prescribe opioid analgesics. Moreover, physicians often have different responses to the same piece of clinical information that may make opioids more or less appropriate.

For example, interviews with 634 emergency physicians revealed that at least 10 percent were unlikely and 10 percent were likely to prescribe an opioid for each of three conditions: migraine, back pain, and ankle fracture. Physician responses to a patient requesting "something strong" for the pain, were also highly variable. Ten percent said they would be negatively influenced by this request (perhaps suspecting potential for opioid abuse), and at least 10 percent said they would be positively influenced by it.

Each physician's prescribing practices were remarkably consistent across the three conditions. No physician or practice characteristic was significantly associated with physician responses. This may indicate that pain control education is largely based on idiosyncratic experiences with patients and senior physicians, independent of specialty or residency training.

Strategies for pain control in the ED should include consistent and formal physician education, according to the study's lead investigator, Joshua H. Tamayo-Sarver, Ph.D., of Case Western Reserve University School of Medicine. The study was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00059).

See "Variability in emergency physician decisionmaking about prescribing opioid analgesics," by Dr. Tamayo-Sarver, Neil V. Dawson, M.D., Rita K. Cydulka, M.D., M.S., and others, in the April 2004 Annals of Emergency Medicine 43, pp. 483-493.

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