In MDM Policy & Practice, LDI Senior Fellows Zachary Meisel, Jeanmarie Perrone, Karin Rhodes, and colleagues assess the factors physicians consider when treating pain with opioids in the emergency department (ED). With 42% of all ED visits in the United States related to pain, the ED is an ideal setting to target to curtail the current opioid overdose epidemic and develop opioid prescription guidelines and policies. The researchers interviewed 52 physicians at a national emergency medicine conference. They identified three main domains that contributed to the participants’ opioid prescribing patterns: 1) provider assessment of pain characteristics, 2) patient-based considerations, and 3) practice environment. Pain characteristics include the characteristics of various acute and chronic pain syndromes, including physicians’ empathy due to their own experience with pain. Patient characteristics include “trustworthiness”, race and ethnicity, and the concerns for risk of misuse. Practice environment characteristics include hospital policy, legislation/regulation, and guidelines. Provider decision to prescribe opioids in the emergency department is highly nuanced. Physicians are interested in guidance and are concerned about the competing pressures to improve patient satisfaction scores on one hand and inflexible policies that do not allow for patient-centered decisions on the other. Results from this study can guide policymakers seeking to optimize pain control in the ED and develop guidelines that provide decision support without restricting physicians’ ability to make patient-centered care decisions.