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Persistent pain

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.


Adult persistent pain

  •  Patients with acute pain and new neurological symptoms eg Cauda Equina Syndrome (CES)
  • Patients requiring acute mental health services
  • Concerns pertinent to any medical/surgical condition which raise the possibility of serious underlying disease (malignancy or infection) should be reviewed by the appropriate specialty either via emergency department or high priority outpatient appointment

Paediatric persistent pain

  • Concerns pertinent to any medical/surgical condition which raise the possibility of serious underlying disease (malignancy or infection) should be reviewed by the appropriate specialty either via emergency department or high priority outpatient appointment


Before referring to a persistent pain service please consider the following:

  • The patient should:
    • have persistent pain resulting in functional impairment from physical disability and/or psychosocial issues
    • have persistent pain that has been fully investigated
    • be referred to the PPMS by their General Practitioner (GP). Referrals from internal medical or surgical specialist are accepted if the condition is considered a category 1 priority only.  All other conditions need to be referred by the patient’s GP
    • have a GP prepared to work closely with the PPMS and to provide ongoing community management.
  • The patient should not:
    • have unstable, non-therapeutic drug dependence without concurrent treatment by a drug and alcohol specialist
    • have an active, untreated mental health condition
    • be undergoing treatment from other specialist services for the same pain problem without mutual awareness and agreement of cross referral by both teams.
  • Patients who may not benefit include those:
    • with cognitive impairment that prevents understanding of treatment and management goals (unless adequate support from carer +/- social support network)
    • accepted under a WorkCover claim or actively involved in litigation, who should be considered for alternate pathways
    • that have been seen by another PPMS within the last 12 months
    • where there is a clear statement by a PPMS that there are no further or new therapeutic options

Clinician resources

Patient resouces

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Cancer pain where the patient’s specialist treating team is requesting Persistent Pain Management Service (PPMS) input
    • Patients on a palliative care pathway where the patient’s specialist treating team is requesting PPMS input
    • New onset neuropathic pain of less than 6 weeks duration relating to a recent diagnosis of a condition for example:
      • herpes zoster (risk for post herpetic neuralgia)
      • ischaemic pain
      • trigeminal neuralgia
      • brachial plexopathy
      • diabetic neuropathy
      • multiple sclerosis
      • spinal cord injury
      • post stroke pain
    • Worsening post-surgical/procedure pain or complication e.g. pleural tap of less than 3 months duration (where a post-operative complication has been excluded)
    • Newly diagnosed or suspected complex regional pain syndrome (CRPS). Note that this is a diagnosis of exclusion.  Diagnosis becomes more reliable greater than 6 weeks after the triggering event and can often not be made before 4 weeks.
  • Category 2
    (appointment within 90 calendar days)
    • Sub-acute pain (defined as lasting 6 to 12 weeks) with risk of functional deterioration
    • Exacerbation of neuropathic pain from pre-existing conditions as listed in Category 1
    • Patients with frequent emergency department / primary care presentations for exacerbations of persistent pain despite attempts at management
    • Complex pain presentation resulting in marked psychological distress (note that patient must also be under the care of a mental health clinician)
    • Complex pain presentation resulting in marked functional impairment
    • Pain with onset less than 6 months ago that is resulting in psychological and/or functional impairment, that is not responding to primary care management
    • Functional impairment as a result of severe or complex side effects from pain medications that are not able to be managed in primary care
  • Category 3
    (appointment within 365 calendar days)
    • Pain with onset more than 6 months ago that is resulting in psychological and/or functional impairment, that is not responding to primary care management

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention not otherwise accessible to the patient
  • For advice regarding management
  • To engage in an ongoing shared care approach between primary and secondary care
  • Reassurance for GP/second opinion
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)

2. Essential referral information Referral will be returned without this

  • Pain history:
    • date of injury/onset of pain
    • likely proposed mechanism of injury
    • location and nature of pain
    • history of treatment for pain
  • Physical examination findings
  • Provisional diagnosis (if determined) from either GP or another treating specialist for the condition/s
  • Assessments by other persistent pain service providers and/or other specialist services including psychiatry/psychology/Alcohol Tobacco and Other Drugs Service (ATODS)
  • Current treatment from or referral to other specialist services for the same pain problem
  • Medications including past analgesia/medication trialled for pain condition
  • Any past medical history
  • Statement of history, even if negative, of the following:
    • History of alcohol/substance abuse and/or medication misuse
    • History of opiates/drugs of dependence for more than eight weeks
    • Use of medicinal marijuana / CBD oil
  • Any patient that is prescribed one of the following medications should be checked through Q script by the relevant Health Professional.
    • all schedule 8 medicines (e.g. opioids, alprazolam, nabiximols, dexamphetamine)
    • the following schedule 4 medicines:
      • all benzodiazepines
      • codeine
      • gabapentin
      • pregabalin
      • quetiapine
      • tramadol
      • zolpidem
      • zopiclone.
  • Functional status
  • Psychological stressors / psychiatric history / cognitive function

Investigations as listed below depending on the reason for referral.  Please refer to Choosing Wisely Australia to reduce unnecessary tests, treatments and procedures

Back pain

  • Orthopaedic or neurosurgery report (if available)
  • Previous relevant diagnostic imaging: CT/MRI/Other (if available)

Headaches/Cranial Nerve Pain

  • Recent neurology report (if available)
  • Previous relevant diagnostic imaging: CT/MRI/Other (if available)

Joint pain

  • Rheumatology report (if available)

Neuropathic pain

  • Previous nerve conduction studies where relevant (if available)

Chronic visceral pain

  • Urology and gastroenterology reports (if available)

Chronic pelvic pain

  • Obstetric/gynaecological history
  • Past procedures and treatment outcomes

Malignancy pain

  • Past procedures and treatment outcomes
  • Oncology or palliative care reports

3. Additional referral information Useful for processing the referral

  • Other relevant reports from any providers in a public or private sector related to the presenting problem
  • Family and social history

Musculoskeletal pain/osteoporosis/chronic high dose opioids:

  • Vitamin D, ionised calcium, magnesium
  • Bone mineral density
  • Testosterone level
  • If inflammatory arthropathies include ESR, CRP results

Neuropathic pain:

  • Results relevant to diagnosing aetiology of peripheral neuropathy
  • HbA1c (if diabetic)

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

 

Version: 12
Last updated: 24 January 2023

© State of Queensland (Queensland Health) 2023

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au.

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