Abstract Physicians in the emergency department (ED) are facing a number of unique challenges in the currently changing healthcare and economic climates. Dramatic increases in ED patient volumes have been noted nationwide with visits related to prescription opioid abuse and misuse alone having increased by 111% between 2004 and 2008. Ironically, several challenges ED physicians are facing arise from regulatory and economic initiatives which were originally designed for the protection of patients. Regulatory requirements to address pain as the fifth vital sign, along with entities utilizing patient satisfaction based reimbursement, have inadvertently created an environment conducive to exploitation by the prescription opioid abuser. A literature review revealed an informational gap with regard to the impact economic and regulatory factors exert on the management of patients, exhibiting drug seeking behavior, by ED physicians. The lack of available information is the basis for this original research. A descriptive, cross-sectional, non-experimental study was conducted over a two month period (October - November, 2013) to elicit opinions of ED physicians regarding the management of opioid seeking patients. Respondents were asked to include opinions on factors perceived to impact treatment of this patient population. Of the ED physicians surveyed, 71% reported a perceived pressure to prescribe opioids to avoid administrative and regulatory criticism and 98% perceive patient satisfaction scores as being too highly emphasized by reimbursement entities as a means of evaluating healthcare quality. Rising patient volumes and changes in the healthcare climate were also cited as factors impacting management practices when treating patients exhibiting drug seeking behavior. Emergency department physicians have a unique role in providing unrestricted access of care for the public. This role, in conjunction with the aforementioned concerns, has served to create an environment conducive to the potentiation of prescription opioid misuse and abuse.