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Persistent Pain – Adult

Red flags

If any of the following are present or suspected, refer the patient to the emergency department (via ambulance if necessary).

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

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

  • Cancer pain where the patient’s specialist treating team is requesting 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 pain 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 days is desirable

  • 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

Category 3

Appointment within 365 days is desirable

  • 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

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

  • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

  • Refer to HealthPathways for assessment and management information if available
  • Please consider phoning your local PPMS for advice regarding medication optimisation or opioid deprescribing.  Please consider the regulatory requirements for opioid prescribing and seek advice from the S8 enquiry service at Medicines Regulation and Quality (MRQ).
  • Note that CPC has been developed for Peripheral neuropathy within the Neurology CPC

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

  • The patient should:
    • have persistent pain with disability and/or psychosocial issues relating to pain
    • 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

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • 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
  • Medicines Regulation and Quality (MRQ) (formally DDU) approval details and MRQ prescription history (if available)
  • 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

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)

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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