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. Author manuscript; available in PMC: 2026 Jul 2.
Published in final edited form as: Acad Pediatr. 2025 Jul 2;25(8):102877. doi: 10.1016/j.acap.2025.102877

Variation in Acute Pain Management of Youth with Non-Fatal Firearm Injuries

Christian D Pulcini 1, Mark Zamani 2, Elizabeth R Alpern 3, Sofia Chaudhary 4, Peter F Ehrlich 5, Joel A Fein 6, Monika Goyal 7, Matt Hall 8, Stephen Hargarten 9, Jennifer A Hoffmann 3, Rachel Myers 6, Karen M Sheehan 3, Bonnie T Zima 10, Eric W Fleegler 11, on behalf of the CHARGE Group
PMCID: PMC12289321  NIHMSID: NIHMS2094944  PMID: 40614961

Abstract

Objective:

Firearm injuries are a leading cause of morbidity among youth, yet acute pain management practices have not been well characterized. Our objective was to evaluate acute pain medication administration by key sociodemographic characteristics and injury severity after non-fatal firearm injuries.

Methods:

We performed a retrospective cross-sectional analysis utilizing Pediatric Health Information System at 40 US children’s hospitals from 2016–2021. We included inpatient and ED only encounters for patients 0–21 years old with a firearm injury diagnosis. The main outcome was administration of analgesic medications: none, non-opioid only, or at least one opioid. We included sociodemographic and injury severity score. Multivariable logistic regression was utilized to determine characteristics associated with the outcome.

Results:

We included 4,924 patients with non-fatal firearm injuries. By ED discharge vs. admission, 39.0% vs. 3.5% received no analgesia. For the 2,522 patients discharged from the ED, younger children were more likely to receive no analgesia. Non-Hispanic White and Hispanic patients were more likely to receive no analgesia compared to non-Hispanic Black patients (aOR 1.67 [95% CI 1.31, 2.31]; aOR 1.53 [1.18, 1.98], respectively). Receipt of opioids was lower among 5–9-year-old patients (aOR 0.40 [0.29, 0.54]), females (aOR 0.77 [0.62, 0.97]), and non-Hispanic White (aOR 0.59 [0.62, 0.75) and Hispanic patients (aOR 0.52 [0.40, 0.67]).

Conclusion:

Among youth with non-fatal firearm injuries, analgesia administration varied greatest in the ED discharged population. This suggests a need for further investigation into pain management practices focused on differences and potential undertreatment of pain in youth with non-fatal firearm injury.

Keywords: Pain Management, Firearm Injury, Emergency Department, Inpatient

BACKGROUND

Firearm injuries are one of the leading causes of morbidity and mortality among youth.1–6 An estimated 11,141 emergency department (ED) visits occurred in 2018 for non-fatal firearm injuries among children aged 0–18 years in the United States (US).7 Despite the high incidence of such injuries, little is known about the acute care that children receive following a non-fatal firearm injury.

Variability in pain management exists for youth across multiple conditions, and appropriate pain management is a known challenge across the spectrum of pediatric care.8–10 As such, the optimal and equitable approach to the administration of various forms of analgesia for painful injuries (such as those due to firearms) is an ongoing focus of research across the spectrum of ED, inpatient, and outpatient pediatric care, with particular focus on the short and long-term harms of under and over administration of opioid medications.11–16

The overall goal of the study therefore is to gain a deeper understanding of the acute pain management received after non-fatal firearm injury among youth in the US. The objective of this study was to evaluate acute pain medication administration in youth with a non-fatal firearm injury who present to children’s hospitals, focusing on key sociodemographic characteristics and injury severity. We hypothesized that variability would exist in pain medication administration by age group, sex, race and ethnicity, insurance status, and injury severity based upon prior literature.17

METHODS

Study Design and Data Source

We conducted a retrospective cross-sectional analysis of patients injured by firearms from January 1st, 2016-December 31st, 2021 who presented to US children’s hospitals participating in the Pediatric Health Information System (PHIS) database (Children’s Hospital Association, Lenexa, KS). Among 49 children’s hospitals participating in PHIS, we used data from 40 children’s hospitals (representative of all regions in the US) with non-fatal firearm injuries across the study period. We excluded 9 children’s hospitals due to a lack of cases of non-fatal firearm injury during the period studied.

Study Population

We included inpatient (including observation) and ED only encounters for patients 0–21 years old with a firearm injury diagnosis, defined by International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, excluding non-powder firearm injuries (eTable 1)18,19 from 2016–2021. We excluded transfers in and out of the hospitals and patients who died during the visit. Only the index encounter for each patient was included.

Outcome Measure

The outcome measure was the administration of pain medications based on billing data in PHIS. Administration of pain medications was categorized as (1) no analgesia, (2) non-opioid pain medication only, and (3) at least one opioid medication. For pain medication administration, we limited our definition to medications administered during the ED visit and the first day of inpatient stay, as the most critical period to assess and manage pain adequately. We included medications commonly used for pain management and excluded those with alternative indications for administration (eTable 2).20

Study Variables

Sociodemographic characteristics included age group (0–4, 5–9, 10–14, 15–18, 19–21 years old), sex (female, male), combined race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic other), and insurance type (private, public, uninsured/other). Acknowledging race and ethnicity are social constructs, and inequities in pain management have previously been described among minoritized populations, race and ethnicity were included as covariates in the analyses.21–25 Race and ethnicity were either self-reported or assigned based on each hospital’s policies. Clinical characteristics included disposition if admitted to the hospital (inpatient acute care floor vs. intensive care unit), and injury severity score (ISS), which is utilized to characterize trauma severity,26 as follows: 0 (none to minimal), 1–4 (minor), 5–14 (moderate), 15–24 (serious), ≥25 (critical).27

Data Analysis

We conducted descriptive analysis with counts and frequencies of pain medication administration by sociodemographic and clinical characteristics. Chi-square tests of proportions assessed differences in the proportion of patients with non-fatal firearm injuries who received pain medication. We utilized multivariable logistic regression to determine sociodemographic characteristics (age group, sex, race and ethnicity, insurance type) and ISS associated with the administration of pain medications. Complete case analysis was performed for the multivariable logistic regression, therefore if there was missing data the patient was excluded from the analysis. Due to low volumes at many hospitals, we were unable to cluster this model on hospital. We set the largest group as the reference category for each variable. We constructed two models stratified by disposition (discharged from the ED versus admitted).

We performed a sub-analysis of the five hospitals that provided care for the greatest number of patients with non-fatal firearm injuries to evaluate whether pain management practices at these hospitals had similar results when adjusted for hospital clustering. We utilized Generalized Estimating Equations clustered on hospital with an independence correlation structure to provide population averaged estimates across the top 5 hospitals. To achieve model convergence, we had to collapse ISS into two groups (0–3, ≥4).

Results were reported as adjusted odds ratios (aORs) and 95% confidence intervals (CI). All hypothesis testing was 2-sided, with statistical significance set at p < 0.05. All statistical analysis were performed with SAS version 9.4 (SAS Institute, Inc, Cary, NC). This study was deemed not human subjects research by the University of Vermont Institutional Review Board.

RESULTS

Participant characteristics

We included 4,924 patients with non-fatal firearm injuries of which 2,522 discharged from the ED (95.2% initial encounters) and 2,402 were admitted (97.3% initial encounters). The largest groups were 15–18 years old (49.1%), male (81.2%), non-Hispanic Black (61.5%), and publicly insured (69.3%). Sociodemographic characteristics of patients discharged from ED versus admitted were similar. A higher proportion of patients discharged from the ED had lower injury severity scores (87.7% with ISS 1–4, 7.0% ISS 5–14) (Table 1) than admitted patients (47.6% with ISS 1–4, 46.7% ISS 5–14) (Table 2).

Table 1.

Sociodemographic and clinical characteristics of children and youth aged 0–21 years with emergency department discharge after non-fatal firearm injury by type of pain medication administration.

Pain Medication
Total N=2522* None N=983 (15.0%) Non-Opioids Only N=379 (39.0%) >1 Opioid N=1160 (46.0%)
Age (yrs)
 0 to 4 156 (6.2) 70 (44.9) 19 (12.2) 67 (42.9)
 5 to 9 284 (11.3) 163 (57.4) 47 (16.5) 74 (26.1)
 10 to 14 668 (26.5) 292 (43.7) 120 (18) 256 (38.3)
 15 to 18 1239 (49.1) 405 (32.7) 184 (14.9) 650 (52.5)
 19 to 21 175 (6.9) 53 (30.3) 9 (5.1) 113 (64.6)
Sex
 Male 2029 (81.2) 787 (38.8) 279 (13.8) 963 (47.5)
 Female 470 (18.8) 186 (39.6) 99 (21.1) 185 (39.4)
 Missing 23 10 1 12
Race and Ethnicity
 Non-Hispanic Black 1552 (61.5) 520 (33.5) 213 (13.7) 819 (52.8)
 Non-Hispanic White 470 (18.6) 240 (51.1) 75 (16) 155 (33)
 Hispanic 362 (14.4) 167 (46.1) 73 (20.2) 122 (33.7)
 Other 138 (5.5) 56 (40.6) 18 (13) 64 (46.4)
Insurance type
 Private 422 (16.7) 198 (46.9) 69 (16.4) 155 (36.7)
 Public 1747 (69.3) 651 (37.3) 276 (15.8) 820 (46.9)
 Uninsured/Other 353 (14) 134 (38) 34 (9.6) 185 (52.4)
Injury Severity Score
 0 (none to minimal) 120 (5.1) 75 (62.5) 25 (20.8) 20 (16.7)
 1–4 (minor) 2054 (87.7) 766 (37.3) 314 (15.3) 974 (47.4)
 5–14 (moderate) 164 (7) 34 (20.7) 4 (2.4) 126 (76.8)
 15–24 (serious) 0 0 0 0
 25+ (critical) 3 (0.1) 1 (33.3) 1 (33.3) 1 (33.3)
 Missing 181 107 35 39
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*

Total reported in column percentages, and pain medication reported in row percentages.

Table 2.

Sociodemographic and clinical characteristics among children and youth aged 0–21 years who are admitted to inpatient for non-fatal firearm injury by type of pain administration

Pain Medication
Total N=2402* None N=83 (3.5%) Non-Opioids Only N=109 (4.5%) >1 Opioid N=2210 (92.0%)
Age
 0 to 4 266 (11.1) 14 (5.3) 10 (3.8) 242 (91)
 5 to 9 253 (10.5) 9 (3.6) 9 (3.6) 235 (92.9)
 10 to 14 707 (29.4) 23 (3.3) 32 (4.5) 652 (92.2)
 15 to 18 1083 (45.1) 36 (3.3) 55 (5.1) 992 (91.6)
 19 to 21 93 (3.9) 1 (11) 3 (3.2) 89 (95.7)
Sex
 Male 1858 (78.2) 68 (3.7) 84 (4.5) 1706 (91.8)
 Female 519 (21.8) 14 (2.7) 25 (4.8) 480 (92.5)
 Missing 25 1 0 24
Race
 Non-Hispanic Black 1510 (62.9) 40 (2.6) 64 (4.2) 1406 (93.1)
 Non-Hispanic White 421 (17.5) 16 (3.8) 22 (5.2) 383 (91)
 Hispanic 336 (14) 17 (5.1) 14 (4.2) 305 (90.8)
 Other 135 (5.6) 10 (7.4) 9 (6.7) 116 (85.9)
Insurance status
 Private 364 (15.2) 17 (4.7) 17 (4.7) 330 (90.7)
 Public 1852 (77.1) 56 (3) 81 (4.4) 1715 (92.6)
 Uninsured/Other 186 (7.7) 10 (5.4) 11 (5.9) 165 (88.7)
Disposition
 Inpatient Floor 1972 (82.1) 75 (3.8) 103 (5.2) 1794 (91)
 Intensive Care Unit 430 (17.9) 8 (1.9) 6 (1.4) 416 (96.7)
Injury Severity Score
 0 (none to minimal) 20 (0.9) 6 (30) 2 (10) 12 (60)
 1–4 (minor) 1118 (47.6) 46 (4.1) 74 (6.6) 998 (89.3)
 5–14 (moderate) 1097 (46.7) 19 (1.7) 23 (2.1) 1055 (96.2)
 15–24 (serious) 45 (1.9) 0 0 45 (100)
 25+ (critical) 68 (2.9) 3 (4.4) 0 65 (95.6)
 Missing 54 9 10 35
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*

Total reported in column percentages, and Pain Medication reported in row percentages.

Among patients discharged from the ED, 983 (39.0%) received no pain medications, 379 (15.0%) received only non-opioids, and 1160 (46.0%) received at least one opioid. Among admitted patients, 83 (3.5%) received no medications, 109 (4.5%) received only non-opioids, and 2210 (92.0%) received opioids. Of those admitted to the hospital, 1972 (82.1%) were admitted to the acute care floor and 430 (17.9%) were admitted to the intensive care unit. In the ED discharge cohort, groups that most frequently received opioids were 18–21-year-olds (64.6%), males (47.5%), non-Hispanic Black (52.8%), public insurance (46.9%), and ISS of 5–14 (76.8%).

Multivariable Analysis of Analgesia Administration for Patients Discharged from the ED

Among patients discharged from the ED, the adjusted odds of receiving no analgesia were higher among 5–9-year-olds (adjusted odds ratio [aOR] 2.32, 95% CI 1.74, 3.08) compared to 15–18-year-olds, and among Hispanic (aOR 1.53, 95% CI 1.18, 1.98) and non-Hispanic White patients (aOR 1.67, 95% CI 1.31,2.13) compared to non-Hispanic Black patients. For ISS, those with an ISS score of 0 (aOR 2.33, 95% CI 1.57, 3.46) were more likely to receive no analgesia, and those with an ISS score of 5–14 (aOR 0.51, 95% CI 0.34–0.75) were less likely to receive no analgesia compared to an ISS of 1–4. (Figure 1).

Figure 1.

Figure 1.

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Multivariable analysis of sociodemographic and clinical characteristics of children and youth aged 0–21 years with emergency department discharge after non-fatal firearm injury by type of pain medication administration

Compared to 15–18-year-olds, the adjusted odds of receiving non-opioids only were lower among 19–21-year-olds (aOR 0.37, 95% CI 0.18, 0.78). Females had higher adjusted odds of receiving non-opioids only (aOR 1.67, 95% CI 1.27, 2.20) compared to males, and Hispanic patients had higher adjusted odds of receiving non-opioids only (aOR 1.49, 95% CI 1.08, 2.06) compared to non-Hispanic Black patients. Uninsured patients had lower adjusted odds of receiving non-opioids only (aOR 0.54, 95% CI 0.35, 0.83) compared to those with public insurance. Those with an ISS of 5–14 were less likely than those with an ISS of 1–4. to receive non-opioid analgesics only (aOR 0.15, 95% CI 0.06, 0.41).

The adjusted odds of receiving opioids were lower among 5–9-year-olds (aOR 0.40, 95% CI 0.29, 0.54) and 10–14-year-olds (aOR 0.61, 95% CI 0.50, 0.76), and higher among 19–21-year-olds (aOR 1.54, 95% CI 1.07, 2.23) compared to 15–18-year-olds. Females had lower adjusted odds of receiving opioids (aOR 0.77, 95% CI 0.62, 0.97). Both Hispanic (aOR 0.52, 95% CI 0.40, 0.67) and non-Hispanic White patients (aOR 0.59, 95% CI 0.46, 0.75) had lower adjusted odds of receiving opioids than non-Hispanic Black patients. The patients with an ISS of 0 were less likely to receive an opioid medication (aOR 0.27, 95% CI 0.16, 0.44) and those with an ISS of 5–14 were more likely to receive an opioid medication (aOR 3.17, 95% CI 2.16, 4.64) than those with an ISS of 1–4.

Multivariable Analysis of Analgesia Administration for Admitted Patients

Among patients admitted to the hospital, Hispanic patients (aOR 2.23, 95% CI 1.20, 4.11) and patients classified as ‘other’ race and ethnicity (aOR 3.09, 95% CI 1.42, 6.72) had higher adjusted odds of receiving no analgesia compared to non-Hispanic Black patients (Figure 2). Those with an ISS of 0 were more likely to receive no analgesia (aOR 10.06, 95% CI 3.60–28.20) than those with an ISS of 1–4, while those with a higher ISS (5–14) were less likely to receive no analgesia (aOR 0.45, 95% CI 0.26–0.78).

Figure 2.

Figure 2.

Open in a new tab

Multivariable analysis of sociodemographic and clinical characteristics of children and youth aged 0–21 years who are admitted to inpatient for non-fatal firearm injury by type of pain administration

There were no significant differences in receipt of non-opioids only by age group, sex, race, ethnicity, or insurance. Those with an ISS of 5–14 were less likely than those with an ISS 1–4 to receive a non-opioid only (aOR 0.30, 95% CI 0.19–0.48).

Patients with ‘other’ race and ethnicity had lower adjusted odds of receiving opioids (aOR 0.49, 95% CI 0.28,0.88) than non-Hispanic Black patients. There were no significant differences in receipt of opioids by age group, sex, or insurance. Among those with an ISS of 0, they were less likely to receive opioids (aOR 0.18, 95% CI 0.07, 0.46) than those with an ISS of 1–4, while those with an ISS of 5–14 were more likely to receive at least one opioid (aOR 2.92, 95% CI 2.03, 4.21).

Sub-analysis of five hospitals with the greatest number of injured patients

Five hospitals accounted for 869/2522 (34.4%) ED patients and 951/2402 (39.6%) of admitted patients. The frequency of administration of pain medication was similar to the overall cohorts (eTable 3 & eTable 4).

DISCUSSION

Amongst patients whose injuries were less severe and thus discharged from the ED, pain medication administration varied substantially across sociodemographic and clinical characteristics. The greatest variability existed among those who received opioids, with lower adjusted odds of receiving opioids for younger patients, females, and non-Hispanic White and Hispanic patients relative to non-Hispanic Black patients, as well as those with lower injury severity scores. There was much less variation in pain medication administration among those admitted to the hospital. Expectedly, those with less severe injury were more likely to receive no analgesia and less likely to receive opioids, and those with higher severity were less likely to receive no analgesia and more likely to receive opioid analgesia. Importantly, 39% of patients discharged from the ED received no analgesia and approximately 5% of those admitted did not receive any analgesia after non-fatal firearm injuries.

Previous research suggests that undertreatment of pain can lead to symptoms of posttraumatic stress in children after injury.28 Alternatively, the growing concern that outpatient use of opioids contributes to the rise in opioid-related deaths may influence clinician ordering patterns even in the acute care setting.11,12,29 Careful assessment and discussion with patients and families is necessary while more research is performed to better characterize the differences identified in our study, notably as we could not capture quantitative or qualitative assessment of pain.30,31

Our findings are not necessarily consistent with prior literature describing racial and ethnic disparities in opioid pain medication administration for emergency conditions causing severe pain, such as long-bone fractures and appendicitis.22,23 It is important to note, however, that we did not find significant variability in administration of opioid pain medications when we examined those patients admitted to inpatient settings. Our analysis did not specifically focus on racial and ethnic disparities in pain management after non-fatal firearm injury, and future research should more systematically evaluate the individual, institutional, community, and regional factors that could more clearly contribute to these differences.

Our data illustrate the need for more research on the treatment of pediatric pain in acute care settings after firearm injury, and based on prior literature, it would be beneficial to involve the patient and family’s direct input into the research on the local level.8,32,33 To our knowledge, there are no established guidelines or consensus to treat pain after pediatric firearm injuries, however the call for improvement is a longstanding one.10,16 The need for individual and interventional research that can lead to strategies to improve pain management for pediatric non-fatal firearm injury is perhaps best demonstrated in our study by the high number of individuals who received no analgesia after non-fatal firearm injury (39.0% discharged from the ED versus 3.5% of those admitted). Therefore, recommendations based on our findings which demonstrate variability in pain management include: 1) support of individual and interventional research focused on pain management after non-fatal firearm injury, 2) utilization of quality improvement methodology to rapidly assess and improve pain management on the local level, and 3) frame initiatives in health equity, and address potential biases at the individual, institutional, and regional levels, to ensure equitable and consistent approaches to pain medication administration after pediatric non-fatal firearm injury. Specific focus is needed on the balance of non-opioids and opioid administration, in which we found many significant differences by age group, sex, race and ethnicity, insurance status, and clinical severity.

There are several limitations to our study. We could not identify if and what pain medications were administered in the prehospital setting. It is plausible that some patient groups received specific pain medications in the prehospital setting more often than others, therefore influencing our results; further evaluation incorporating prehospital data would be beneficial. We were unable evaluate individual (ex. history of substance abuse), community, and regional factors which may contribute to the administration of analgesic medications. We did not analyze pain medication administration specifically by intent given the inaccuracies described in determining intent in large databases, therefore we cannot reflect on clinician, institutional, or regional bias affecting pain management by intent.34,35 In the PHIS database, pain scores were not available to characterize pain severity and likely need for pain treatment. Timing of pain medication administration was also not available. Lastly, many youths afflicted by firearm injury are treated at non-children’s hospitals and our sample was exclusively from children’s hospitals, limiting generalizability.

CONCLUSIONS

We identified significant variability of pain management for patients discharged from the ED with a non-fatal firearm injury. Approaches to further investigate and improve differences in pain management for non-fatal firearm injuries should be considered at the local, regional, and national level, particularly incorporating the perspective of patients and families.

Supplementary Material

MMC1

What’s New.

Administration of pain medications varied across sociodemographic and clinical characteristics for youth discharged from the ED. For patients admitted to the hospital, there was much less variation. Many youths received no pain medication during ED stay after non-fatal firearm injury.

Acknowledgements

Dr.’s Alpern and Goyal: Funding support on NIH/NICHD 5R24HD087149–04 Building Research Capacity for Firearm Safety Among Children. No other authors received support for this work. Dr. Fleegler: Patricia J. O’Malley, MD, Endowed Scholar in Pediatric Emergency Medicine Research.

Footnotes

Declarations of interest

none

Conflict of Interest

All authors have no conflicts of interest to disclose.

Financial Disclosure

All authors have no financial relationships relevant to this article to disclose.

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