Approximately 50%-70% of the 119 million emergency department (ED) visits in the United States have pain as one of the chief complaints. The majority of these visits requiring analgesia are due to medical events rather than injury. Unfortunately, training of emergency physicians in the essentials of pain management has been lacking. The assessment of patients with chronic pain is even more difficult given the confusion around concepts of dependence, tolerance, addiction, pseudoaddiction, and the fear emergency physicians feel when they suspect that their expertise is being abused by patients seeking prescription analgesics for unintended purposes. This chapter discusses the principles of managing patients with chronic pain in the ED setting, with a particular emphasis on patients with low back pain, migraine and headache syndromes, and abdominal pain of various etiologies, as well as the unique issues of pain management in the elderly. © 2011 John Wiley & Sons Ltd.