• 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.