1. Learning about their illness/condition. We need to help educate them about the (minimal) role of the ED as well as what their condition is and why they have pain.
2. Developing coping skills. Catastrophizing, social isolation, and despair all lead to marked worsening of the pain. Dealing with flare-ups in their pain by coming to the ED demonstrates a failure to understand their condition and how to deal with the worse days. You might want to ask a social worker to get involved for this discussion, as well.
3. Learning what the community has to offer. That means the staff in the ED needs to know what is available: social work, support groups for fibromyalgia, etc.

It is my experience that this type of discussion rarely takes more than 10 to 15 minutes and is worth every minute. If we do not take the time to explain their responsibilities and the role of the ED, these patients will keep returning, expecting to get a prescription and developing an ever-increasing institutional dependency—a poor coping trait and a growing burden on the ED.

Managing Medications

We are all responsible for every script we write. No physician in the ED should initiate opioids for patients with chronic pain, renew prescriptions of opioids for such patients, or provide short-acting opioids to “get them out of the ED.” The latter creates institutional dependency and also accelerates tolerance. There is no positive for patients other than perhaps a two-hour decrease in pain, a pain they have had for years. Opioids should be reserved in opioid-dependent patients for acute breakthrough pain or for acute new injuries or conditions, such as a new fracture.

It is not our role to care for them on an ongoing basis but to educate them and start them in the right direction.

Other medications for pain, such as a tricyclic or gabapentinoid for new zoster-related neuropathic pain, may be of benefit and worth initiating. A SSRI, such as duloxetine for chronic osteoarthritis or low back pain, combined with acetaminophen or a NSAID may provide valid relief. Patients can follow up in a medical clinic without fear of bias and start on the long road to stabilization. We do the same for patients with hypertension, so why not for chronic pain? To do so, however, means we have to learn more about chronic pain conditions and the medications and doses required. Dosing for chronic pain may be very different than for other indications, for example: