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Advice for Referrers to the Pain Service

General Notes

Normally referral to the Service is made from General Practitioners and Secondary care specialists, as well as from the Musculoskeletal Interface Services.  We are in general happy to see any patient who has chronic pain although there are a few things, discussed below, that should be considered before referral. 

For professionals, useful information and guidance on initial assessment and management of pain is available in the recently published pathway, produced by the British Pain Society, on "Pain - Initial Assessment and Early Management" at Map of Medicine. 

In addition to this, the Scottish Intercollegiate Guidelines Network (SIGN) have recently published useful guidelines on management of chronic pain, including a flow-chart on Chronic pain assessment, early management and care planning in non-specialist settings.

At the Pain Clinic, patients will be seen by a Pain Medicine specialist and be offered a comprehensive and specialised assessment.  Chronic pain is a complex condition and can be associated with a wide range of causes, some of which are difficult to identify. We know that people have real pain despite having clear scans and tests. It is often difficult to completely relieve chronic pain. Our aim is to alleviate pain as much as possible and to improve quality of life and to aid patients with their self-management of their pain..

While we try to to make a full and appropriate assessment of the patient's pain and to ensure that an important diagnosis has not been missed, we are not primarily a diagnostic centre, although the specialist expertise available in the clinic may help with diagnosis of pain syndromes such as complex regional pain syndromes (CRPS), myofascial pain syndromes, abdominal entrapment neuropathies  and other pain syndromes.  For some conditions, notably headache, rheumatological conditions, gynaecological symptoms etc, if a diagnosis has not yet been made it may be more suitable for the patient to be seen by a relevant specialist first.

 We are not able to accept direct referral for acupuncture. TENS or specialist pain psychology - onward referral for these is made within the service, if appropriate, after assessment by the Pain Consultants.  In some circumstances the Pain Self Management Team is able to receive direct referrals, specifically for the Pain Management Programme, from General Practitioners and other professionals.

 

Before referral, referrers should ensure that:

If the patient has back pain, then assess for Red Flags and, if present, they should be directly referred appropriately.


Appropriate Conditions For Initial Referral

 

  • People with problematic pain conditions (e.g chronic benign pain or difficult cancer pain) especially if the person is distressed and disabled by the pain. Examples: chronic back pain; osteoarthritis; fibromyalgia; pain with unclear pathology; phantom limb pain; complex regional pain syndrome (early referral recommended); poorly controlled trigeminal neuralgia (early referral recommended)
  • Analgesic advice or guidance
  • Consideration of other specialist pain interventions (e.g.  injections, TENS)
  • To assist the patient in feeling confident that their pain is properly managed and to help them accept the long term prognosis, possibly as preparation for referral to the Pain Self Management Service
  • Recent onset sciatica and Chronic spinal pain - though we would recommend that many such cases would be better initally referred to the Spinal Assessment and Treatment Service (SATS) or the MSKESP or MSKCATS services depending on locality.  We are happy to take referrals from the SATS, MSKESP and MSKCAT services for patients with musculoskeletal pain where the clinicians in those services feel that they need  specialist medication advice e.g. anti neuropathic agents, advice about opiate prescribing and long term control, or specialist intervention (such as nerve blocks, epidural steroid injection etc)

 Please also see the newly published Map of Medicine / British Pain Society pathways for Pain - initial assessment and early management,  Chronic widespread pain - initial assessmentLow back and radicular pain, Neuropathic Pain and Chronic Pelvic Pain.

 People with chronic benign pain who do not need specialist medical input for the above reasons, but who want help to cope with their pain can be referred directly to the Pain Self Management Service.

 

Inappropriate Conditions For Initial Referral

 

Some conditions are not considered appropriate for initial referral, as further specialist investigation may be needed. It is for the responsible clinician to decide whether an initial referral to the Pain Clinic would be correct or whether to refer to other services.

  • New neurological symptoms or signs, except unilateral sciatica.
  • Recent trauma.
  • Inflammatory conditions, such as suspected connective tissue disorders, polyarthropathies or ankylosing spondylitis (consider initial referral to Rheumatology).
  • Headache disorders may be more appropriate for initial assessment in Neurology.
  • Pain problems where treatable pathology has not been adequately assessed and excluded (e.g. abdominal or pelvic pain) - consider referral to appropriate specialist

 When there has been a clear statement by a Pain Consultant that there are no further reasonable therapeutic options other than for a rehabilitative approach, the patient should not normally be re-referred with the same pain problem.  Referral by the Pain Consultants for the Pain Self Management Programme normally carries the implication that further interventional treaments are unlikely to be available or appropriate.

 

 

Information to be included in referral

 

Please give a thorough medical history and, to avoid these being repeated unknowingly, documentation of:

  • Previous pain treatments tried and their outcome (efficacy / side effects).  
  • Investigations already performed.  We are aware, of course, that a significant number will not have a firm diagnosis despite this.
  • Reason for making the referral e.g. specialist medical advice/treatment or self management advice/support.
  • Relevant psychosocial information
  • Current medications

Important note regarding re-referral of patients
Continuity of care is important, as well as it being much better to avoid reinventing the wheel in assessing.  If you are re-referring patients please ensure that the Consultant who saw the patient previously is named and that the referral is directed to that Consultant.  This is particularly important with Choose and Book referrals - if you do not tell us that patients have been seen before they will be assigned new appointments and will probably wait longer and may see a Consultant who does not know them. 

 

 

General Advice

 

  • Encourage self-help and responsibility for control of pain.  General information on pain and its management may be helpful, and it may be useful to direct patients towards this website.  Its direct address, for ease of navigation, is www.glospain.nhs.uk.
  • Be aware of past history of anxiety and depression. Treat depression early.
  • Ensure adequate verbal and written information is given about diagnosis and management of pain.
  • Ensure that common misconceptions about pain have been discussed with the patient.

 

 

 

 

 

 

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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
email: pain.webmaster[at]glos.nhs.uk

Page updated 15/02/2016