Acute chest pain is a common and high-stakes emergency department (ED) presentation, frequently associated with acute coronary syndrome (ACS). Opioids such as morphine and fentanyl are used when symptoms persist despite nitrates, but little is known about whether prescribing differs between advanced care providers (ACPs) and physicians.

To compare intravenous (IV) morphine and fentanyl prescribing patterns for ACS-related chest pain between ACPs and physicians in an academic ED.

We performed a retrospective study of adult patients with ACS presenting to an academic ED from January 2021 to January 2024. The primary outcome was IV morphine administration; the secondary outcome was IV fentanyl administration. Multivariable logistic regression adjusted for demographics, clinical factors, and nitroglycerin administration prior to opioid. Firth's penalized logistic regression was conducted as sensitivity analysis.

Among 2055 patients, 154 (7.5 %) were treated by ACPs and 1901 (92.5 %) by physicians. Morphine use was similar between groups (42.2 % vs 42.8 %, p  = 0.93), while fentanyl was less common with ACPs (5.8 % vs 11.6 %, p  = 0.03). In adjusted models, ACP vs Physician status was not significantly associated with morphine (OR 0.78, 95 % CI 0.49–1.24) or fentanyl use (OR 1.10, 95 % CI 0.50–2.49). Nitroglycerin prior to opioid was strongly associated with reduced opioid administration. Sensitivity analyses confirmed these findings.

Opioid prescribing for ACS-related chest pain did not differ significantly between ACPs and physicians after adjustment. Prescribing decisions were driven more by patient factors and treatment sequencing, supporting comparable roles for ACPs and physicians in ED ACS pain management.