Scenario 1: Mr. Smith is a 42-year-old male who has come to the ED because he is in severe pain from a chronic low back condition lasting at least 10 years. He cannot stand upright. He moved into town when his company closed two months ago so he could stay with his sister. He is unemployed. He says his meds—duloxetine, tramadol, and celecoxib—are running out. There is no pain clinic in the community, and he has no family physician.

Scenario 2: Mrs. Smith is a 51-year-old female with 15 years of chronic neuropathic leg pain. She has been discharged by her family physician because her urine tested positive for cocaine twice—she admits this because she is desperate to get care. The physician rapidly tapered her off opioids (in 10 days), and she has just finished a horrible week of withdrawal. She comes into the ED with severe pain and has no analgesic prescriptions.

These types of scenarios are not rare in emergency medicine. After all, we are the safety net for health care. Patients with varying types of chronic medical conditions and nowhere else to go end up in the emergency department and are routinely seen in county hospitals. Emergency physicians have had no training in any chronic medical condition, including chronic pain with its inherent biases and risks of opioid misuse. Just as we do not provide ongoing care for patients with insulin-dependent diabetes, we should not provide ongoing care for patients with chronic pain. There is a difference, however: patients with the former can continue to receive insulin and can often be cared for in hospital or community clinics, whereas the latter are shunned. Further, emergency physicians have received zero training in chronic pain and so often have a starting viewpoint that this is “not our problem.”

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.

When you talk to patients with chronic pain who have been successfully managed, they will usually state how they have learned to deal with their problem and how their coping skills have improved. They will tell you that medications ultimately played a minor role—essential for getting the pain under control at the start but less important as other steps are taken. The American Pain Society will tell you that mindfulness is an essential primary aspect of care for these patients. Patients with fibromyalgia will experience a 75 percent decrease in pain if they complete and maintain a four-day-a-week exercise program for at least four to six weeks. How does this help us in the ED? We need to sit down with these patients and help them review how they are in charge of their illness; dependency on others is a sign of failure. Specifically, areas patients need to work on include:

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:

• 300 mg gabapentin a day for seizure disorders but up to 3,600 mg for pain
• 25–75 mg nortriptylline for depression but up to 250 mg for neuropathic pain

Still, all patients with chronic pain are treated the same way with medications: “start low and go slow,” avoiding adverse effects and identifying the lowest effective dose possible. The starting dose you are comfortable prescribing will be the same starting dose a pain physician would use, but they then take up to three months to get to the right dose and combination of medications.

It is up to the ED group as a whole to work with the hospital and community to identify potential resources for patients with chronic pain; that way, the nursing staff and the physicians can guide the patients properly. It is not our role to care for them on an ongoing basis but to educate and start them in the right direction. We are also there for acute worsening of their pain and to identify other pathologies as causes of new or worsening pain. In the end, our role for patients with chronic pain is almost the same as for every other chronic medical condition.

Dr. Ducharme is editor in chief of the Canadian Journal of Emergency Medicine, clinical professor of medicine at McMaster University, and chief medical officer of McKesson Canada.