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Chronic widespread pain

Red flags

  • Hot swollen joints
    • Investigate for inflammatory rheumatological conditions and consider rheumatology referral

The following may lead to more urgent categorisation

  • Severe lifestyle limiting symptoms
  • Escalating analgesic and/or sedative dependence (esp. opioid)

Chronic widespread pain includes:

  • Fibromyalgia
  • Generalised pain from other rheumatological conditions
    • Chronic widespread pain should be considered for referral to Rheumatology for diagnosis and exclusion of other rheumatological conditions

Other important information for referring practitioners

Lifestyle changes

  • Encourage healthy activity within pain limits
    • Consider physio referral
    • Hydrotherapy
    • Desensitisation massage
  • Ensure adequate sleep
  • Check for mood disturbances and relationship difficulties
    • Consider psychology referral for any mood disturbances

Medical Management

See HealthPathways for detailed diagnostic and management pathway for fibromyalgia.

Avoid over-reliance of medication, encourage self-management and set realistic goals for treatment:

  • Target most troublesome symptoms first
  • Start at low dose and titrate
  • Agree on trial period for medication.

Current medications used in fibromyalgia are:

  • amitriptyline:
    • start at 10mg and slowly escalate dose (this may take weeks)
    • max dose 75-100mg
    • consider nortriptyline in older patients (less sedation)
  • tramadol +/- paracetamol:
    • potential synergistic effect
    • no evidence for benefit of other opioids in FM
  • duloxetine:
    • PBS approved for neuropathic pain and major depressive disorder
  • pregabalin:
    • PBS restricted for neuropathic pain refractory to treatment with other drugs
  • gabapentin:
    • not PBS-listed for pain
  • fluoxetine:
    • PBS restricted for use in major depressive disorders/OCD

General content component

WYSIWYG

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • PPMS eReferral form
  • Reason for referral
    • Management plan
    • Specific concerns re medication overuse/dependence
  • History of condition
    • Date of onset and timeline
    • Mechanism of injury (if relevant)
    • Management of condition including treatments trialled and reasons for failure
    • Include relevant specialist letters
  • Current and previous medical conditions
    • Rheumatological conditions where indicated
  • Current medications and previous medications given for pain control
  • List any drug dependency issues e.g. alcohol, cannabis, opioid use, forensic history if relevant
  • Psychological issues
  • Any current medico-legal issues
  • Allergies
  • Relevant examination findings
  • Investigations
    • Rheumatological investigation results
    • Relevant imaging
    • FBC, E/LFT, BS, CRP
    • B12, folate
    • TFTs

Additional referral information (useful for processing the referral)

  • Include other specialists opinions and letters
  • Investigations related to co-morbidities e.g. diabetic control
  • Patient to complete Entry Patient Questionnaire prior to first consultation or at the time of first appointment

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • 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

  • 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

  • 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

  • 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

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

  • 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.)
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