Chronic pain - Revision history

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Ostermayer: Created page with "==Background== Chronic pain is defined as pain lasting >3 months or beyond expected tissue healing timeDowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. ''MMWR Recomm Rep''. 2022;71(No. RR-3):1-95. Affects approximately 50 million US adults; ~20 million experience "high-impact" chronic pain that limits daily activities *Pain is the ch..."

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Created page with "==Background== *Chronic pain is defined as pain lasting >3 months or beyond expected tissue healing time<ref name="cdc2022">Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. ''MMWR Recomm Rep''. 2022;71(No. RR-3):1-95.</ref> *Affects approximately 50 million US adults; ~20 million experience "high-impact" chronic pain that limits daily activities<ref name="cdc2022"/> *Pain is the ch..."

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==Background==
*Chronic pain is defined as pain lasting >3 months or beyond expected tissue healing time<ref name="cdc2022">Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. ''MMWR Recomm Rep''. 2022;71(No. RR-3):1-95.</ref>
*Affects approximately 50 million US adults; ~20 million experience "high-impact" chronic pain that limits daily activities<ref name="cdc2022"/>
*Pain is the chief complaint in up to 70% of all ED visits<ref name="motov">Motov S, Strayer R, Hayes BD, et al. Pain management in the emergency department: a clinical review. ''Clin Exp Emerg Med''. 2022;9(2):118-132.</ref>
*Subacute pain (1-3 months) represents a critical window for prevention of chronification
*Emergency physicians are not the primary drivers of chronic opioid prescriptions, but ED visits represent an important touchpoint for intervention<ref name="acep2020">Hatten BW, Cantrill SV, Dubin JS, et al. Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. ''Ann Emerg Med''. 2020;76(3):e13-e39.</ref>
*1-5% of opioid-naive patients prescribed opioids in the ED may develop prolonged use<ref name="acep2020"/>

==Classification==
*'''Nociceptive''' — activation of peripheral pain receptors; somatic (MSK, cutaneous) or visceral
*'''Neuropathic''' — damage or dysfunction of the somatosensory nervous system (e.g., [[diabetic neuropathy]], [[post-herpetic neuralgia]], [[complex regional pain syndrome]])
*'''Nociplastic''' — altered nociceptive processing without clear tissue or nerve damage (e.g., [[fibromyalgia]], [[irritable bowel syndrome]], chronic primary pain)
*'''Mixed''' — most common in practice; often has nociceptive + neuropathic + central sensitization components

==Common Chronic Pain Presentations==
*'''[[Low back pain]]''' — most common chronic pain complaint in the ED
*'''[[Headache]] / [[Migraine]]'''
*'''Abdominal/pelvic pain''' — chronic abdominal pain, [[endometriosis]], [[irritable bowel syndrome]]
*'''MSK pain''' — [[osteoarthritis]], [[fibromyalgia]], myofascial pain
*'''Neuropathic pain''' — [[diabetic neuropathy]], [[complex regional pain syndrome]], radiculopathy
*'''[[Sickle cell disease]] pain crises''' (managed per separate disease-specific protocols; excluded from CDC opioid guidelines)
*'''Cancer-related pain''' (excluded from CDC opioid guidelines; treat aggressively)

==Evaluation==
*'''Rule out dangerous etiologies''' masquerading as chronic pain exacerbations (the primary role of the EP)
*Identify new or worsening pathology requiring urgent intervention
*Assess functional status and current treatment regimen
*Screen for opioid use disorder and substance misuse

===History===
*Onset, character, location, radiation, severity, aggravating/alleviating factors
*Prior workup and diagnoses
*Current pain management regimen — ask specifically about:
**Prescribed medications (opioids, gabapentinoids, muscle relaxants, antidepressants)
**OTC medications ([[acetaminophen]], [[NSAIDs]])
**Non-prescribed substances (kratom, [[tianeptine]], cannabis, illicit opioids)
**Non-pharmacologic treatments (PT, injections, neurostimulation)
*Functional impact: work, sleep, ADLs
*History of substance use disorder
*Who manages their pain (PCP, pain specialist)

===Red Flags===
*'''[[Cauda equina syndrome]]''' — bilateral leg weakness, saddle anesthesia, bowel/bladder dysfunction
*'''[[Epidural abscess]] / [[spinal epidural abscess]]''' — fever + back pain + neurologic deficit (especially in IVDU or immunocompromised)
*'''Malignancy''' — new or worsening pain in cancer patients, unexplained weight loss, night sweats
*'''[[Aortic dissection]] / [[AAA]]''' — new tearing chest/back/abdominal pain
*'''Fracture''' — new pain after trauma, especially in osteoporotic patients
*'''[[Necrotizing fasciitis]]''' — pain out of proportion with skin findings, rapidly progressing
*'''Visceral emergency''' — [[bowel obstruction]], [[ovarian torsion]], [[ectopic pregnancy]], [[appendicitis]]

===Workup===
*Imaging and labs should be guided by clinical concern for acute pathology, NOT routinely obtained for chronic pain exacerbations
*Check PDMP (Prescription Drug Monitoring Program) — recommended before prescribing opioids<ref name="cdc2022"/>
*Consider [[EKG]] if on QT-prolonging medications ([[methadone]], certain antidepressants)

==Management==
*Set realistic expectations — the goal is improved function and symptom management, not elimination of pain
*Use multimodal analgesia whenever possible
*Non-opioid therapies are preferred for chronic pain exacerbations in the ED<ref name="acep2020"/>
*'''Do not routinely prescribe opioids to treat an acute exacerbation of non-cancer chronic pain''' for patients discharged from the ED (ACEP Level C recommendation)<ref name="acep2020"/>
*Do not abruptly discontinue or taper a patient's home chronic opioid regimen from the ED
*'''Do not co-prescribe opioids + benzodiazepines''' for pain (ACEP consensus recommendation)<ref name="acep2020"/>

===Non-Pharmacologic Therapies===
*Heat/ice application
*Positioning and splinting
*Referral to physical therapy
*Brief counseling on activity modification and self-management strategies

===Pharmacologic Therapies — Non-Opioid (First Line)===

====Acetaminophen====
*1000 mg PO/IV q6-8h (max 3-4 g/day; 2 g/day if hepatic impairment or chronic [[alcohol]] use)
*Safe and effective for many pain types; often underutilized
*IV formulation available but costly; PO equivalent in efficacy for most indications

====NSAIDs====
*[[Ibuprofen]] 400-800 mg PO q6-8h
*[[Ketorolac]] 15-30 mg IV/IM (not to exceed 5 days total course; avoid in renal disease, GI bleed risk, elderly, pregnancy)
*[[Naproxen]] 250-500 mg PO q12h
*Avoid in [[CKD]], [[GI bleed]] risk, [[CHF]], third trimester [[pregnancy]]
*Effective for MSK pain, renal colic, headache

====Ketamine (Subdissociative Dose)====
*'''IV''': 0.1-0.3 mg/kg over 15 minutes<ref name="sdk">Motov S, Drapkin J, Likourezos A, et al. Sub-dissociative dose ketamine administration for managing pain in the emergency department. ''World J Emerg Med''. 2018;9(4):249-255.</ref>
**Lower end (0.1 mg/kg) preferred in elderly and obese patients
**Short infusion over 15 min reduces psychoperceptual side effects vs. IV push
*'''Intranasal''': 0.5-1 mg/kg via atomizer
*'''Nebulized''': 0.75 mg/kg via breath-actuated nebulizer<ref name="nebket">Nguyen T, Mai M, Choudhary A, et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine. ''Ann Emerg Med''. 2024;84(4):354-362.</ref>
*Continuous infusion: 0.15-0.2 mg/kg/hr, titrated q30 min<ref name="sdk"/>
*Particularly useful in opioid-tolerant patients, central sensitization, and as opioid-sparing adjunct
*Common side effects: dizziness, nausea, feeling of unreality (transient, typically <30 min)
*Avoid in patients with active psychosis; safe in controlled [[hypertension]] and elevated [[ICP]] (previously disproven concern)
*No respiratory monitoring required at subdissociative doses

====Gabapentinoids====
*Useful for neuropathic pain
*Generally best initiated by PCP/pain specialist rather than ED
*Use caution when combined with opioids (risk of respiratory depression)

====Lidocaine====
*'''IV lidocaine''': 1-1.5 mg/kg over 10-15 min — mixed evidence; may consider for refractory pain
*Topical lidocaine patches for localized MSK or neuropathic pain

====Muscle Relaxants====
*[[Cyclobenzaprine]] 5-10 mg PO — for acute MSK spasm
*[[Methocarbamol]] 750-1500 mg PO — less sedating alternative
*[[Baclofen]] — avoid initiating from ED (complex dosing, withdrawal risk)
*Avoid [[carisoprodol]] (high abuse potential)
*Avoid co-prescribing with opioids or benzodiazepines

====Trigger Point Injections====
*Effective for myofascial pain with identifiable trigger points
*Use lidocaine or bupivacaine ± small volume of corticosteroid
*Can be performed in the ED for low back pain, neck pain, and shoulder girdle pain

===Opioids===
*Acute exacerbation of cancer-related pain
*[[Sickle cell]] vaso-occlusive crisis (disease-specific protocols apply)
*Severe acute-on-chronic pain after non-opioid therapies have been maximized or are contraindicated
*Short-term bridge while awaiting definitive intervention (e.g., surgical repair)
*If prescribing opioids
**Use '''immediate-release''' formulations only (never initiate ER/LA from the ED)<ref name="cdc2022"/>
**Prescribe the '''lowest effective dose''' for the '''shortest feasible duration''' (≤3-7 days)<ref name="cdc2022"/>
**Check the '''PDMP''' before prescribing<ref name="cdc2022"/>
**Avoid co-prescribing with [[benzodiazepines]] or other sedative-hypnotics<ref name="acep2020"/>
**Counsel on risks, safe storage, and disposal
**Consider co-prescribing [[naloxone]] if risk factors for overdose are present<ref name="cdc2022"/>

===Special Population: Patients on Buprenorphine/Methadone Maintenance===
*'''Do NOT discontinue buprenorphine or methadone''' in the setting of acute pain<ref name="alford">Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. ''Ann Intern Med''. 2006;144(2):127-134.</ref>
*The maintenance dose does NOT provide adequate analgesia (analgesic duration 4-8 hours vs. withdrawal suppression 24-48 hours)<ref name="alford"/>
*These patients are opioid-tolerant and may require '''higher than typical doses''' of short-acting full-agonist opioids for acute pain<ref name="alford"/>
*'''Multimodal analgesia''' is essential: maximize NSAIDs, acetaminophen, ketamine, nerve blocks
*For patients on '''buprenorphine''':
**Continue home buprenorphine dose
**Can administer additional full-agonist opioids on top (buprenorphine's "ceiling effect" is for euphoria/respiratory depression, NOT for blocking analgesia from added full agonists in most clinical scenarios)
**Consider splitting buprenorphine into q8h dosing for added analgesic benefit
*For patients on '''methadone''':
**Verify dose with the methadone clinic
**Continue home dose; add short-acting opioids PRN for acute pain
**Think of methadone as "basal insulin" — patients still need "bolus" analgesia for acute pain
*Consult addiction medicine if available; notify outpatient provider of ED visit and any medication changes

===Special Population: Patients on Naltrexone===
*Oral naltrexone: effective opioid blockade for 24-72 hours
*Extended-release injectable naltrexone (Vivitrol): blockade for up to 30 days
*Opioids will have reduced or absent analgesic effect while naltrexone is active
*Management strategy: maximize non-opioid multimodal analgesia (ketamine, NSAIDs, nerve blocks, regional anesthesia)
*For severe pain requiring opioids: may need very high doses to overcome blockade (risk of respiratory depression when blockade wears off — discuss with toxicology/pain)

==Disposition==
*Most chronic pain exacerbations can be safely discharged with adequate analgesia and follow-up
*'''Discharge with:'''
**Appropriate short-term analgesic prescriptions (prefer non-opioids)
**Clear follow-up plan with PCP or pain specialist (within 1-2 weeks)
**Patient education on multimodal self-management
**Naloxone prescription if on chronic opioids or identified risk for overdose
*'''Admission considerations:'''
**Acute pathology requiring inpatient workup or intervention
**Pain crisis refractory to ED management (e.g., severe sickle cell crisis)
**Concern for inability to manage pain safely at home (e.g., suicidality, severe functional decline)
**Need for IV analgesic regimen not feasible outpatient

==See Also==
*[[Opioid toxicity]]
*[[Opioid withdrawal]]
*[[Buprenorphine]]
*[[Low back pain]]
*[[Headache]]
*[[Sickle cell disease]]
*[[Fibromyalgia]]
*[[Complex regional pain syndrome]]
*[[Ketamine]]
*[[Kratom toxicity]]
*[[Tianeptine toxicity]]

==External Links==
*[https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/index.html 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain — At a Glance]
*[https://www.acep.org/patient-care/clinical-policies/opioids ACEP Clinical Policy: Opioids in Adult Patients in the Emergency Department]
*[https://pami.emergency.med.jax.ufl.edu/resources/dosing-guide/ UF PAMI Pain Management and Dosing Guide]
*[https://bridgetotreatment.org/wp-content/uploads/protocol-packet.pdf CA Bridge: ED Buprenorphine Quick Start and Acute Pain Protocols]

==References==
{{reflist|2}}

[[Category:Pharmacology]]

← Older revision		Revision as of 09:09, 22 March 2026
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	==Classification==		==Classification==
	*~~'''~~Nociceptive~~'''~~ — activation of peripheral pain receptors; somatic (MSK, cutaneous) or visceral		*Nociceptive — activation of peripheral pain receptors; somatic (MSK, cutaneous) or visceral
	*~~'''~~Neuropathic~~'''~~ — damage or dysfunction of the somatosensory nervous system (e.g., [[diabetic neuropathy]], [[post-herpetic neuralgia]], [[complex regional pain syndrome]])		*Neuropathic — damage or dysfunction of the somatosensory nervous system (e.g., [[diabetic neuropathy]], [[post-herpetic neuralgia]], [[complex regional pain syndrome]])
	*~~'''~~Nociplastic~~'''~~ — altered nociceptive processing without clear tissue or nerve damage (e.g., [[fibromyalgia]], [[irritable bowel syndrome]], chronic primary pain)		*Nociplastic — altered nociceptive processing without clear tissue or nerve damage (e.g., [[fibromyalgia]], [[irritable bowel syndrome]], chronic primary pain)
	*~~'''~~Mixed~~'''~~ — most common in practice; often has nociceptive + neuropathic + central sensitization components		*Mixed — most common in practice; often has nociceptive + neuropathic + central sensitization components

	==Common Chronic Pain Presentations==		==Common Chronic Pain Presentations==
	*~~'''~~[[Low back pain]]~~'''~~ — most common chronic pain complaint in the ED		*[[Low back pain]] — most common chronic pain complaint in the ED
	*~~'''~~[[Headache]] / [[Migraine]]~~'''~~		*[[Headache]] / [[Migraine]]
	*~~'''~~Abdominal/pelvic pain~~'''~~ — chronic abdominal pain, [[endometriosis]], [[irritable bowel syndrome]]		*Abdominal/pelvic pain — chronic abdominal pain, [[endometriosis]], [[irritable bowel syndrome]]
	*~~'''~~MSK pain~~'''~~ — [[osteoarthritis]], [[fibromyalgia]], myofascial pain		*MSK pain — [[osteoarthritis]], [[fibromyalgia]], myofascial pain
	*~~'''~~Neuropathic pain~~'''~~ — [[diabetic neuropathy]], [[complex regional pain syndrome]], radiculopathy		*Neuropathic pain — [[diabetic neuropathy]], [[complex regional pain syndrome]], radiculopathy
	*~~'''~~[[Sickle cell disease]] pain crises~~'''~~ (managed per separate disease-specific protocols; excluded from CDC opioid guidelines)		*[[Sickle cell disease]] pain crises (managed per separate disease-specific protocols; excluded from CDC opioid guidelines)
	*~~'''~~Cancer-related pain~~'''~~ (excluded from CDC opioid guidelines; treat aggressively)		*Cancer-related pain (excluded from CDC opioid guidelines; treat aggressively)

	==Evaluation==		==Evaluation==
	*~~'''~~Rule out dangerous etiologies~~'''~~ masquerading as chronic pain exacerbations (the primary role of the EP)		*Rule out dangerous etiologies masquerading as chronic pain exacerbations (the primary role of the EP)
	*Identify new or worsening pathology requiring urgent intervention		*Identify new or worsening pathology requiring urgent intervention
	*Assess functional status and current treatment regimen		*Assess functional status and current treatment regimen
Line 41:		Line 41:

	===Red Flags===		===Red Flags===
	*~~'''~~[[Cauda equina syndrome]]~~'''~~ — bilateral leg weakness, saddle anesthesia, bowel/bladder dysfunction		*[[Cauda equina syndrome]] — bilateral leg weakness, saddle anesthesia, bowel/bladder dysfunction
	*~~'''~~[[Epidural abscess]] / [[spinal epidural abscess]]~~'''~~ — fever + back pain + neurologic deficit (especially in IVDU or immunocompromised)		*[[Epidural abscess]] / [[spinal epidural abscess]] — fever + back pain + neurologic deficit (especially in IVDU or immunocompromised)
	*~~'''~~Malignancy~~'''~~ — new or worsening pain in cancer patients, unexplained weight loss, night sweats		*Malignancy — new or worsening pain in cancer patients, unexplained weight loss, night sweats
	*~~'''~~[[Aortic dissection]] / [[AAA]]~~'''~~ — new tearing chest/back/abdominal pain		*[[Aortic dissection]] / [[AAA]] — new tearing chest/back/abdominal pain
	*~~'''~~Fracture~~'''~~ — new pain after trauma, especially in osteoporotic patients		*Fracture — new pain after trauma, especially in osteoporotic patients
	*~~'''~~[[Necrotizing fasciitis]]~~'''~~ — pain out of proportion with skin findings, rapidly progressing		*[[Necrotizing fasciitis]] — pain out of proportion with skin findings, rapidly progressing
	*'''Visceral emergency''' — [[bowel obstruction]], [[ovarian torsion]], [[ectopic pregnancy]], [[appendicitis]]		*'''Visceral emergency''' — [[bowel obstruction]], [[ovarian torsion]], [[ectopic pregnancy]], [[appendicitis]]

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	**Lower end (0.1 mg/kg) preferred in elderly and obese patients		**Lower end (0.1 mg/kg) preferred in elderly and obese patients
	**Short infusion over 15 min reduces psychoperceptual side effects vs. IV push		**Short infusion over 15 min reduces psychoperceptual side effects vs. IV push
	*~~'''~~Intranasal~~'''~~: 0.5-1 mg/kg via atomizer		*Intranasal: 0.5-1 mg/kg via atomizer
	*~~'''~~Nebulized~~'''~~: 0.75 mg/kg via breath-actuated nebulizer<ref name="nebket">Nguyen T, Mai M, Choudhary A, et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine. ''Ann Emerg Med''. 2024;84(4):354-362.</ref>		*Nebulized: 0.75 mg/kg via breath-actuated nebulizer<ref name="nebket">Nguyen T, Mai M, Choudhary A, et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine. ''Ann Emerg Med''. 2024;84(4):354-362.</ref>
	*Continuous infusion: 0.15-0.2 mg/kg/hr, titrated q30 min<ref name="sdk"/>		*Continuous infusion: 0.15-0.2 mg/kg/hr, titrated q30 min<ref name="sdk"/>
	*Particularly useful in opioid-tolerant patients, central sensitization, and as opioid-sparing adjunct		*Particularly useful in opioid-tolerant patients, central sensitization, and as opioid-sparing adjunct
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	====Lidocaine====		====Lidocaine====
	*~~'''~~IV lidocaine~~'''~~: 1-1.5 mg/kg over 10-15 min — mixed evidence; may consider for refractory pain		*IV lidocaine: 1-1.5 mg/kg over 10-15 min — mixed evidence; may consider for refractory pain
	*Topical lidocaine patches for localized MSK or neuropathic pain		*Topical lidocaine patches for localized MSK or neuropathic pain

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	*If prescribing opioids		*If prescribing opioids
	**Use '''immediate-release''' formulations only (never initiate ER/LA from the ED)<ref name="cdc2022"/>		**Use '''immediate-release''' formulations only (never initiate ER/LA from the ED)<ref name="cdc2022"/>
	**Prescribe the ~~'''~~lowest effective dose~~'''~~ for the ~~'''~~shortest feasible duration~~'''~~ (≤3-7 days)<ref name="cdc2022"/>		**Prescribe the lowest effective dose for the shortest feasible duration (≤3-7 days)<ref name="cdc2022"/>
	**Check the ~~'''~~PDMP~~'''~~ before prescribing<ref name="cdc2022"/>		**Check the PDMP before prescribing<ref name="cdc2022"/>
	**Avoid co-prescribing with [[benzodiazepines]] or other sedative-hypnotics<ref name="acep2020"/>		**Avoid co-prescribing with [[benzodiazepines]] or other sedative-hypnotics<ref name="acep2020"/>
	**Counsel on risks, safe storage, and disposal		**Counsel on risks, safe storage, and disposal
Line 131:		Line 131:
	*'''Do NOT discontinue buprenorphine or methadone''' in the setting of acute pain<ref name="alford">Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. ''Ann Intern Med''. 2006;144(2):127-134.</ref>		*'''Do NOT discontinue buprenorphine or methadone''' in the setting of acute pain<ref name="alford">Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. ''Ann Intern Med''. 2006;144(2):127-134.</ref>
	*The maintenance dose does NOT provide adequate analgesia (analgesic duration 4-8 hours vs. withdrawal suppression 24-48 hours)<ref name="alford"/>		*The maintenance dose does NOT provide adequate analgesia (analgesic duration 4-8 hours vs. withdrawal suppression 24-48 hours)<ref name="alford"/>
	*These patients are opioid-tolerant and may require ~~'''~~higher than typical doses~~'''~~ of short-acting full-agonist opioids for acute pain<ref name="alford"/>		*These patients are opioid-tolerant and may require higher than typical doses of short-acting full-agonist opioids for acute pain<ref name="alford"/>
	*~~'''~~Multimodal analgesia~~'''~~ is essential: maximize NSAIDs, acetaminophen, ketamine, nerve blocks		*Multimodal analgesia is essential: maximize NSAIDs, acetaminophen, ketamine, nerve blocks
	*For patients on ~~'''~~buprenorphine~~'''~~:		*For patients on buprenorphine:
	**Continue home buprenorphine dose		**Continue home buprenorphine dose
	**Can administer additional full-agonist opioids on top (buprenorphine's "ceiling effect" is for euphoria/respiratory depression, NOT for blocking analgesia from added full agonists in most clinical scenarios)		**Can administer additional full-agonist opioids on top (buprenorphine's "ceiling effect" is for euphoria/respiratory depression, NOT for blocking analgesia from added full agonists in most clinical scenarios)
	**Consider splitting buprenorphine into q8h dosing for added analgesic benefit		**Consider splitting buprenorphine into q8h dosing for added analgesic benefit
	*For patients on ~~'''~~methadone~~'''~~:		*For patients on methadone:
	**Verify dose with the methadone clinic		**Verify dose with the methadone clinic
	**Continue home dose; add short-acting opioids PRN for acute pain		**Continue home dose; add short-acting opioids PRN for acute pain
Line 152:		Line 152:
	==Disposition==		==Disposition==
	*Most chronic pain exacerbations can be safely discharged with adequate analgesia and follow-up		*Most chronic pain exacerbations can be safely discharged with adequate analgesia and follow-up
	*~~'''~~Discharge with:~~'''~~		*Discharge with:
	**Appropriate short-term analgesic prescriptions (prefer non-opioids)		**Appropriate short-term analgesic prescriptions (prefer non-opioids)
	**Clear follow-up plan with PCP or pain specialist (within 1-2 weeks)		**Clear follow-up plan with PCP or pain specialist (within 1-2 weeks)
	**Patient education on multimodal self-management		**Patient education on multimodal self-management
	**Naloxone prescription if on chronic opioids or identified risk for overdose		**Naloxone prescription if on chronic opioids or identified risk for overdose
	*~~'''~~Admission considerations:~~'''~~		*Admission considerations:
	**Acute pathology requiring inpatient workup or intervention		**Acute pathology requiring inpatient workup or intervention
	**Pain crisis refractory to ED management (e.g., severe sickle cell crisis)		**Pain crisis refractory to ED management (e.g., severe sickle cell crisis)