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Introduction Healthy People 2010 seeks to eliminate racial and ethnic disparities in health care; however, disparities due to age and race have been described in emergency department pain treatment. Although pain is a common patient complaint in emergency departments, many people receive no analgesia. This study examined the influence of patient and provider characteristics on ED and discharge analgesia and opioid prescribing practices. Methods This descriptive study used chart review of selected variables from ED patients 18 years and older who presented with musculoskeletal pain and were treated by core ED faculty. Logistic regression analyses were performed to determine whether analgesia- and opioid-prescribing disparities existed and were influenced by patient and provider characteristics. Results A total of 868 patient records were examined. Physician characteristics and wide variation in practice were the only sources of disparities in the prescription of analgesics in the emergency department, but patient characteristics including race, age, chronic pain, and trauma influenced prescription of ED opioids and discharge analgesics. No gender or financial status disparities were found. Fewer opioids and discharge analgesics were prescribed for black patients than for white patients. Younger patients, those with trauma, and those with chronic pain received more opioids and discharge analgesics compared with older patients and those without trauma or chronic pain. Providers who completed emergency medicine residencies and had fewer than 3 years' experience prescribed more analgesics in the emergency department. Discussion Pain management in our emergency department is widely variable, with some disparities based on patient and physician characteristics. Multicenter prospective studies are needed to validate these findings and examine knowledge and attitude development about pain and its management. Protocols for nurse-initiated analgesia may help improve and standardize ED pain care.

Purpose: To describe an interesting and instructive case of knee pain from nurse practitioner (NP) practice and discuss the epidemiology, pathophysiology, clinical evaluation, and treatment of osteosarcoma. Data sources: Findings from the history, physical examination, diagnostic testing, and follow-up of the case of an 18-year-old male who first presented with nontraumatic, diffuse left knee pain of 2.5-month duration. Conclusions: At follow-up, after a trial of conservative treatment, a lesion suspicious for osteosarcoma was seen in the proximal tibia. Osteosarcoma is a rare but dangerous cause of chronic extremity pain, especially in children and adolescents. Implications for practice: NPs must consider malignant bone tumors in the differential diagnosis of traumatic and nontraumatic extremity pain of extended duration, especially in children and adolescents. Thorough, persistent follow-up on recommended tests and referrals is necessary to ensure that important findings are not missed. The care of uninsured patients requires particular attention to cost concerns and access issues.

Lori Prewitt Moore is Emergency Room Nurse, University of South Alabama Medical Center, Mobile, Ala. Janet Kaye Heins is Emergency Room Nurse, University of South Alabama Medical Center, Mobile, Ala. Alan Heins is Emergency Room Physician, University of South Alabama College of Medicine, Mobile, Ala. For correspondence, write: Lori Prewitt Moore, University of South Alabama Medical Center, 2451 Fillingim St, Mobile, AL 36617; E-mail: loripmoore@comcast.net. J Emerg Nurs 2007;33:352-5. 0099-1767/$32.00 Copyright n 2007 by the Emergency Nurses Association. doi: 10.1016/j.jen.2007.01.019

Objective: Adequate treatment of patients’ pain is a top priority for the World Health Organization (WHO), American Medical Association (AMA), and American College of Emergency Physicians (ACEP), but “adequate” is not clearly defined. Most previous studies of emergency department (ED) pain treatments have centered on musculoskeletal pain in terms of rates of analgesia and disparities in treatment based on race and age. This study will examine complaints of pain other than musculoskeletal and will focus on treatment disparities that may result from differences in patient and physician characteristics.Methods: This retrospective study is of ED patients 18 years and older with nonmusculoskeletal pain who were seen by ED faculty over a period of eight weeks. Logistic regression and c2 tests were performed to quantify effects of doctor, patient, and clinical characteristics on rates of ED analgesia, ED opioids, and analgesic prescriptions at discharge.Results: A total of 1,360 patients were included. There was wide variation in the type and frequency of ED analgesia depending on the attending doctor. For example, patients seen by one specific ED doctor were less than half as likely to receive any analgesia and seven times less likely to receive an opioid than those seen by another doctor. Age, race, doctor’s training and experience, and whether the patient had chronic pain were important predictors of ED analgesia. There were similar findings for ED opioids and discharge analgesics.Conclusion: Pain practices in EDs are highly variable and seem inadequate when measured against the goals of WHO, AMA, and ACEP. Patient age, race, and type of pain and the physician’s identity, training, and experience all contribute to practice variation. Further research is needed to identify the causes of these variations, and there is a need to develop interventions to standardize and improve pain assessment and treatment.