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Objectives: To assess the relationship between older adults' perceptions of shared decision-making in the selection of an analgesic to take at home for acute musculoskeletal pain and (1) patient satisfaction with the analgesic and (2) changes in pain scores at 1 week. Design: Cross-sectional study. Setting: Single academic emergency department. Participants: Individuals aged 65 and older with acute musculoskeletal pain. Measurements: Two components of shared decision-making were assessed: information provided to the patient about the medication choice and patient participation in the selection of the analgesic. Optimal satisfaction with the analgesic was defined as being �a lot� satisfied. Pain scores were assessed in the ED and at 1 week using a 0-to-10 scale. Results: Of 159 individuals reached by telephone, 111 met all eligibility criteria and completed the survey. Fifty-two percent of participants reported receiving information about pain medication options, and 31% reported participating in analgesic selection. Participants who received information were more likely to report optimal satisfaction with the pain medication than those who did not (67% vs 34%; P < .001). Participants who participated in the decision were also more likely to report optimal satisfaction with the analgesic (71% vs 43%; P = .008) and had a greater average decrease in pain score (4.1 vs 2.9; P = .05). After adjusting for measured confounders, participants who reported receiving information remained more likely to report optimal satisfaction with the analgesic (63% vs 38%; P = .04). Conclusion: Shared decision-making in analgesic selection for older adults with acute musculoskeletal pain may improve outcomes.