St Emlyn’s Lesson Plans
Chronic pain: a useful emergency consultation
Assess new symptoms in someone with chronic pain and practise agreeing a useful plan when no new emergency is found.
Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 18 minutes in total.
When we meet: We will discuss new warning symptoms, requests for medicines and how to agree follow-up when pain remains difficult to manage.
For facilitators
Send: the learner preparation link before teaching.
Bring: The two short handovers in the preparation fallback, a blank care-plan outline and a medicines-reconciliation checklist. No drug doses or new prescribing decisions are needed for the conversation exercise.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.
Core preparation
NICE NG193: Chronic pain · About 10 minutes
Read NG193’s person-centred assessment recommendations and the distinction between chronic primary and secondary pain.
https://www.nice.org.uk/guidance/ng193/chapter/recommendations
NICE NG215: Dependence and withdrawal · About 5 minutes
Read NG215's recommendations on discussing dependence and withdrawal, including the risks of abruptly changing an established medicine.
https://www.nice.org.uk/guidance/ng215/chapter/Recommendations
Think about (allow 3 minutes): How would you explain that no new emergency has been found without suggesting the person’s pain is unimportant?
Picture the scene
Just before a break, a colleague asks you to see someone who attends repeatedly with back pain. What has the handover led you to assume before you meet them?
By the end of the session
- Assess what is new or dangerous without letting previous attendance replace a fresh history.
- Use language that validates suffering while keeping treatment decisions honest and proportionate.
- Agree a short-term plan and continuity arrangements, including safe review of medicines associated with dependence.
After the session
- Replace one label in your next handover with the person’s actual symptoms, changes and concerns.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 18 minutes in total.
Before learners arrive
- Read NG193’s scope carefully and check local acute back-pain, frequent-attendance and pain-service pathways. Identify pharmacy and out-of-hours prescribing support.
- Use neutral, factual handovers. Choose a fictional or fully de-identified example so the discussion remains about care rather than a recognisable patient.
Equipment: The two short handovers in the preparation fallback, a blank care-plan outline and a medicines-reconciliation checklist. No drug doses or new prescribing decisions are needed for the conversation exercise.
Setup: Work in threes: clinician, patient and observer. Each learner takes two minutes as clinician, followed by one minute for feedback and repeating a phrase, then rotates. The observer identifies what helped the conversation and what made it harder. Learners may pass on a role if the topic is personally difficult.
If the preparation has not been completed
Use the five-minute opening to compare these handovers: 'They are back again with the usual back pain' and 'This person has longstanding back pain and says it is different today; we need to ask what has changed.' Give learners a minute to note privately what each wording leads them to assume, then compare the questions they would ask. Keep the NICE assessment principles open. In the 30-minute plan, use five minutes here and reduce the new-danger case from eight to seven minutes.
Suggested session plan
- 0–5 min — Notice assumptions. Use private reflection on the hook, then discuss how wording shapes attention.
- 5–17 min — Find the new danger. Work through the first case and identify when the old label must be set aside.
- 17–33 min — Practise a useful conversation. Repeat the second consultation after specific feedback; spend most time on explanation and an achievable plan.
- 33–40 min — Medication and continuity. Identify who can safely review prescriptions and what to do when usual services are closed.
- 40–45 min — Close. Each person rewrites one stigmatising handover phrase as observable information.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
A familiar patient with a different problem
A 46-year-old with longstanding back pain has attended several times. Today they say the pain is different and they cannot manage at home. The triage note says “usual pain”.
Add this information as the discussion develops:
- Ask learners to begin the consultation without using the attendance history as the diagnosis.
- Reveal new urinary difficulty and a change in leg sensation.
- Pause before giving any further findings and ask what urgency and assessment are now required.
Ask the group:
- Which question would let the person explain what is different today?
- What new features need focused examination and the local emergency spinal pathway?
- How could knowledge of the old care plan help, and how could it mislead?
- What language would you use when asking a senior for help?
Discussion notes
Points to draw out:
- Repeated attendance does not protect against a new emergency. Assess the change, red flags, neurological function and relevant alternative diagnoses, and escalate through the appropriate local pathway.
- A care plan is useful context, not permission to ignore new findings. Document the current assessment and reasons for action.
- Validation does not require accepting every proposed diagnosis or treatment. A useful opening is to recognise the impact, ask what has changed and explain what the ED can assess today.
Common misconceptions:
- Diagnostic overshadowing from “known chronic pain”.
- Assuming distress is evidence against serious pathology.
For a more experienced group: Ask the group to identify a point at which a new care plan could improve continuity without creating a barrier to future emergency assessment.
No new emergency, still substantial suffering
A 38-year-old with established chronic primary pain has poor sleep, reduced mobility and worries about employment. Today’s assessment finds no new emergency. They request a larger opioid prescription because previous short prescriptions seemed to help briefly.
Add this information as the discussion develops:
- Ask a learner to acknowledge the pain and explain the assessment without saying “nothing is wrong”.
- Reveal regular prescribed opioid use and fear of withdrawal if medication runs out.
- The patient has a planned pain-service appointment but no clear interim contact.
Ask the group:
- How would you distinguish acute analgesia needs from a long-term prescribing decision?
- Which functional goal could be agreed for tonight or the next few days?
- Who can help reconcile the medicines and arrange continuity?
- How would you discuss a boundary without humiliating or abandoning the patient?
Discussion notes
Points to draw out:
- NICE NG193 emphasises collaborative assessment and distinguishes chronic primary from secondary pain. Its recommendation against starting opioids for chronic primary pain is not a rule to withhold assessment or all analgesia from every person with chronic pain.
- Review the existing regimen, benefits, harms and possible withdrawal with the patient and relevant prescriber. NG215 generally advises against abrupt cessation of dependence-forming medicines; urgent risks may require a different senior-led plan.
- Agree a feasible plan with specific contacts, expected next steps and safety-netting. Seek pharmacy, pain, primary-care or mental-health support when indicated; do not assume one service can resolve every need immediately.
Common misconceptions:
- Describing someone as “drug seeking” before exploring the request.
- Promising complete pain relief or changing a complex long-term regimen without continuity.
- Assuming problematic medicine use never occurs instead of assessing it respectfully.
For a more experienced group: Introduce evidence of sedation or unsafe combined medicines and practise a safety conversation that remains respectful.
Important clinical points
- Do not let an existing pain label delay assessment of new neurological or systemic features.
- Do not abruptly stop regular dependence-forming medication in most circumstances without an appropriate clinical plan.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- How would you explain a reassuring assessment without invalidating pain?
- When should a care plan be overridden?
- What makes a discharge plan achievable after normal services close?
Key teaching points:
- Take the person’s pain seriously even when assessment finds no new emergency.
- Assess new or changed symptoms on their own merits.
- Explain prescribing decisions and agree a practical plan for ongoing care.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Primary and secondary pain can coexist, and medicines may bring both benefit and harm. Avoid universal statements about a patient group; make an individual assessment with the appropriate team.
If the discussion drifts
What does this person need from us today, what new danger have we assessed, and what can we realistically offer?
For a more experienced group
Review a fictional multidisciplinary care plan for language that may discourage future help-seeking and rewrite it to preserve both safety and consistency.
A 30-minute version
30-minute option: assumptions 4, new danger 8, consultation rehearsal 13, plan and closing 5. Omit the medication-combination extension.
Evidence and guidance
- NICE NG193: Chronic pain — Person-centred assessment of all chronic pain; prescribing recommendations distinguish chronic primary pain.https://www.nice.org.uk/guidance/ng193/chapter/recommendations
- NICE NG215: Dependence and withdrawal — Shared prescribing review and gradual withdrawal in most cases.https://www.nice.org.uk/guidance/ng215/chapter/Recommendations
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Adult acute assessment
The cases integrate new symptoms, long-term illness and practical management.
RCEM 2021 curriculum (2025 update): SLO7 Complex workplace situations
Learners practise difficult consultations and safe boundaries without stigma.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
Clinical review: awaiting clinician sign-off
The references have been checked during editing. A named clinician has not yet signed off the revised lesson collection. Use current local guidance when preparing to teach; editorial updates do not constitute clinical approval.
First published 2020-06-09 · Iain Beardsell.