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Pain Services

 

This guideline applies to adults aged 18 years and over



Introduction

Chronic pain is defined as pain persisting after the normal healing process has occurred or in the absence of tissue injury. It is sometimes defined as pain lasting for more than 3 months.

It affects up to 45% of the population. Unlike acute pain, which subsides as healing progresses, chronic pain causes the individual to experience physiological and psychological symptoms which can lead to significant and prolonged disability.

 

 

Red flags

  • Acute trauma
     
  • Signs of cauda equina syndrome
     
  • Suspected malignancy, such as significant unexpected weight loss, unremitting night pain or features suggestive of malignancy on systems review
     
  • Severe mental illness
     
  • Unmanaged suicide risk
     
  • Symptoms or signs of inflammatory joint disease or connective tissue disease
     
  • Symptoms or signs of cardio-respiratory disease
     
  • Clinically significant lymphadenopathy
     
  • Widespread or progressive neurological symptoms
     
  • Sepsis, infection or early complication from a pain service procedure requiring immediate hospital attention

 

 

Assessment

  • Nature and duration of pain
     
  • Red flags must be excluded
     
  • Alternative pathologies must be excluded through appropriate assessment and investigation, they must be optimally managed, and have obtained specialist opinion where required (for example, gastroenterology, rheumatology, neurology) 
     
  • Ideas, concerns, beliefs, fears and psychosocial factors contributing to the pain and how the pain affects the person’s life, lifestyle activities, work, sleep, wellbeing
     
  • Self management and pharmacological management tried in Primary Care
     
  • Any previous pain service assessments or interventions
     
  • Re-evaluate the diagnosis if the presentation changes


 

 

Investigations

  • Red flags must be excluded through appropriate investigations
     
  • Alternative pathologies must be excluded through appropriate investigation, obtaining specialist opinion where required
     
  • Re-evaluate if the presentation changes

 




Management

  • Use a shared decision making approach involving ideas, concerns, fears, beliefs and psychosocial factors, the patient’s strengths and skills on managing their pain and what helps when the pain is difficult to control
     
  • Treat the underlying cause whenever possible
     
  • Suspected Complex Regional Pain Syndrome within 6 months of onset – please start neuropathic analgesia and refer for urgent physiotherapy without delay
     
  • If chronic pain, discuss the nature of chronic pain, fluctuation of symptoms and flare ups, there can be improvements in quality of life even if the pain remains unchanged
     
  • Chronic pain care and support plan
     
  • Patient priorities, abilities and goals
     
  • What is already helping
     
  • What is their preferred approach to treatment including non medication approaches including Live Well With Pain, pacing, relaxation, sleep
     
  • Managing flare ups and setbacks

 

Live well with pain is a step by step online guide to living well with persistent pain

Home - Live Well with Pain

 

Pain cafes run across Cornwall to support patients to live well with pain. Information on the Pain Café locations and times can be found here

 

Prescribing advice for primary care management of persistent pain:

CKS Guidelines on mild to moderate pain

CKS Guidelines on neuropathic pain

CKS Guidelines on chronic pain

 

Advise that medication is unlikely to remove the pain – ‘painkiller’ is a misnomer. They can only turn the volume down on pain to help a patient do things. Consider the lowest dose to enable the patient to function. Use function as an outcome rather than percentage pain relief. If a patient is able to do what they want with 50% analgesic benefit from a medication, increasing the dose further to chase 100% can lead to increased side effects rather than further benefits.

 

 

Opioids

Opioids are effective for acute pain management, cancer pain and end of life. Their role in chronic-non-cancer pain is limited, the global opioid pandemic demonstrated massive harms.


Opioids may reduce pain for only a small number of patients in the short and medium term, usually less than 12 weeks. In the long term, they can increase a patient’s pain through neuroinflammation and opioid-induced hyperalgesia.

 

If starting opioids is agreed as part of the management plan, in addition to assessing safety, discussing the benefits, side effects and law requirements with driving:

  • Best practice advises to plan an opioid trial for 1 to 2 weeks with agreed functional improvement outcomes 
  • The patient should keep a diary of pain, activity, sleep and side effects
  • A significant improvement in function is usually expected to justify longer term prescribing.  A successful short term opioid trial does not predict long term efficacy. 
  • If there is no improvement in function at the end of the 2 week trial it is very unlikely that long term opioid therapy will be helpful.  If unsuccessful, taper and stop the medication within one week.
  • Review at 4 weeks and then longer term prescriptions 6 months or as clinically indicated


Patients undergoing major orthopaedic surgery such as hip or knee replacement do significantly better on multiple measures  if they are not taking long-term opioids. Consider other strategies including non-opioid analgesia and TENS. Patients will usually be asked to wean off opioid medications as much as possible by the surgical team while on the waiting list, before any operation is undertaken.

 

Long term prescribing best practice can be found here.  Of note a maximum dose of drug should be defined at initiation and should not exceed an oral morphine equivalent of 120mg/day.  Increasing above this dose is unlikely to yield further benefit but increases harm to the patient.

 

Escalating doses of opioid in the context of chronic non-cancer pain are likely to represent treatment failure,  tolerance and dependence. Opioids should then usually be weaned off, as according to Faculty of Pain Medicine guidance.

 

Be aware that in addition to the law requirements of opioids and driving, a patient on high dose morphine (around 200mg/24hours) could be as impaired as someone with a blood alcohol level illegal to drive.

 

Consider an opioid agreement if needed

 

Tapering and stopping opioid medication best practice can be found here. 

Discuss the rationale for stopping opioids including benefits of reducing long term harms and improved ability to engage in self management

Explain that usually stopping medicines can make them feel better and have less pain

Taper by 10% weekly or fortnightly

Agree an outcome and arrange monitoring and support during the taper/stop

 

Consider referral to We Are With You if required

 

 

 

Advice and Guidance

Advice and guidance referrals to Pain Services can often be considered initially and are encouraged.

GPs are now able to request Consultant advice regarding:

 

Information required

If the patient is already under a Pain Consultant, please include the details in the request, in order that discussions can be had with the relevant Consultant as required.

Please note:

Clinical responsibility remains with the GP until the patient is seen within secondary care.

 



Referral

Urgent Referral to Pain Clinic

The following conditions may require time sensitive interventions within a narrow time window:

  • Uncontrolled cancer pain in conjunction with the palliative care team – a weekly clinic is held for this
  • Suspected Complex Regional Pain Syndrome within 6 months of onset – please start management at time of referral
  • Complication from a Pain Service procedure excluding conditions that require acute admission



Routine Referral to Pain Clinic

The pain service is designed to help with the management of severe, intractable pain.

Some of this may be through interventions whether topical, medication or injected. Much of this is through pain management therapy where patients learn to live their life  with and around their pain. The Pain service helps with management, not a diagnosis.

 

Patients should have tried appropriate analgesia to improve their function, and engaged with appropriate physiotherapy, prior to referral.

 

  • Complex Regional Pain Syndrome over 6 months of onset
  • Chronic Post Surgical Pain Syndromes
  • Cervical and thoracic pain with red flags and alternative pathologies excluded that do not need spinal surgical review
  • Chronic abdominal, groin and pelvic pain with no alternative pathology found and all specialised medical and surgical options exhausted. IBS should be referred to gastroenterology as per RMS guidelines.
  • Neuropathic pain syndromes and disorders where all usual Primary Care management has been exhausted
  • Chronic pain syndromes where all usual Primary Care management has been exhausted
  • Complex medication or escalating strong analgesic needs, with red flags excluded, all medical and surgical options exhausted, no new pathology and Primary Care measures have been undertaken

 

Common reasons for returned referrals include: Insufficient information in referral, insufficient ruling out of red flag diagnoses, and referral to inappropriate service (eg lower back pain, headache and widespread pain/fibromyalgia should be managed as per RMS guidelines)

 


Exclusion Criteria

 


Pain Management


Referrals for Pain Management therapy should be made to Pain Clinic, the consultant will triage depending on individual need into the appropriate service.


The secondary care pain management programme is designed to help people learn to live with and around their pain. It is not a cure. It is designed for severe, intractable chronic pain, to help patients with persistent pain live better and happier lives. Psychological frameworks including compassion-focused and acceptance and commitment therapy are used to help patients set values-based goals, pace activity, optimise their sleep and medication management.

 

Information required for referral

Please detail the site of pain, the red flags excluded, examination findings and investigations performed, and the details of the clinician taking responsibility for this.  All red flags and investigation results require to be fully acted upon prior to referral.

Assessment for red flags should be a full and holistic multisystems assessment, the outcome of which should be appropriately documented within the referral.

Please include details of past medical history, current medication, and of all treatments trialled prior to referral (physiotherapy, simple analgesia, antineuropathics).

If the patient is already under a Pain Consultant, please include the details in the request, in order that discussions can be had with the relevant Consultant as required.

Please note:

Clinical responsibility remains with the GP until the patient is seen within secondary care.

 


Supporting Information

For professionals:

Faculty Of Pain Medicine Opioids Aware Opioids Aware | Faculty of Pain Medicine (fpm.ac.uk)

Faculty Of Pain Medicine Dose equivalents and changing opioids | Faculty of Pain Medicine (fpm.ac.uk)

Eclipse Chronic Pain In Cornwall eclipsesolutions.org/Cornwall/info.aspx?bnfotherid=7

MHRA Drug Safety Update.  Opioids: Risk Of Dependence And Addiction 23 September 2020

Opioids: risk of dependence and addiction - GOV.UK (www.gov.uk)

Guidance for healthcare professionals on drug driving (publishing.service.gov.uk)

Tapering and stopping | Faculty of Pain Medicine (fpm.ac.uk)


For patients:

Live Well With Pain Home - Live Well with Pain

Pain Café Locations And Times Cornwall Connected by Pain, delivering community pain cafes across Cornwall | Connected by pain | Stronger together | A community supporting each other with persistent pain

Useful patient information leaflets on pain medications, interventions, driving and pain Patient information leaflets | Faculty of Pain Medicine (fpm.ac.uk)

Useful patient information leaflet on taking opioids for pain FPM-OA-taking-opioids.pdf

 

 

Page Review Information

 

Review date

09/05/2024

Next review date

09/05/2027

Clinical editor

Dr Rebecca Hopkins

Contributors

Dr Neil Roberts, Pain Consultant, Royal Cornwall Hospitals Truro