REFREC019
PAIN MANAGEMENT REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Pain management problems are
addressed under the following
headings:
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Acute back pain
Cancer pain
Headache
Persistent pain
Shingles
Last updated February 2006
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REFREC019
Diagnosis / Symptomatology
Acute Back Pain
Evaluation
History and physical examination.
Exclude rare serious conditions
requiring urgent
investigation/interventions (‘Red
Flags’):
 Infection (Discitis,
Osteomyelitis) (.5%)
 Fracture (Osteoporosis!) (3%)
 Tumour (1%)
 Cauda Equina
Syndrome/widespread bilateral
motor weakness
Realise that majority (95%) of low back
pain is non-specific; in these cases do
not perform routine plain X-rays or
other investigations.
 Common findings in patients
with low back pain also occur
in asymptomatic people and
may not be cause of pain!
A specific patho-anatomic diagnosis is
not necessary; differentiation between
somatic referred pain and radicular
pain might be useful.
Consider early in evaluation
psychosocial and occupational risk
factors for pain becoming chronic
(‘Yellow Flags’)
 Prior history of low back pain.
 Poor physical fitness/general
health.
 Smoking.
 Psychological
distress/depression.
 Disproportionate pain
behaviour.
Last updated February 2006
Management Options
Referral Guidelines
Provide effective communication along
the lines of: ‘Back pain is not a
disease, but a common bodily
symptom and activity intolerance’.
 Avoid alarming diagnostic
labels (‘disc out of place,
trapped nerve’).
 Use neutral terms (‘symptom
of physical dysfunction, out of
condition’).
 Address natural history of early
recovery, but possibility of
recurrence and persistent mild
symptoms.
Refer Category 2 for acute back pain
episodes exceeding 3 months duration
without improvement and persistent
significant functional
impairment/disability.
Develop management plan with patient
 Advice to stay active.
 Advice to avoid bed rest.
 Advice to return early to work,
even if only light duties.
 Use of short course of
manipulation.
 Advice to use heat wraps.
 Use of analgesics as required
(paracetamol, NSAIDs,
tramadol, opioids [only shortterm]) to facilitate above
treatment goals.
Consider comedication with low dose
tricyclics and/or in particular in
radicular pain anticonvulsants.
Review carefully if symptoms persist
and disability develops – be aware of
the relevance of ‘yellow flags’ for the
progression from acute to chronic pain,
while clinical factors are only weak
predictors.
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REFREC019
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Last updated February 2006
Low job satisfaction.
Personal problems.
Medicolegal proceedings.
If persistence beyond 6 weeks
 Initiate incremental aerobic
exercise and fitness
programme.
 Apply behavioural medicine
principles.
 Liaise with workplace.
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REFREC019
Diagnosis / Symptomatology
Cancer Pain
Evaluation
History and physical examination.
Assess type, severity and localisation
of pain
 consider occurrence of
multiple pains of various
origins in many cancer
patients.
 consider relevance of
symptoms other than pain in
cancer patients.
Assess physical, but also functional,
psychosocial and spiritual dimensions
of pain
 include assessment of anxiety,
depression, beliefs of patient.
 pay attention to cultural, ethnic
and linguistic factors of pain
experience.
Management Options
Referral Guidelines
Follow principles of WHO analgesic
ladder
 start at step appropriate for
pain severity.
 adjust use of analgesics to
alteration of pain type/severity.
 change step, not within step, if
pain severity increases.
 try opioids in all patients with
moderate to severe pain
regardless of aetiology of pain.
 do not delay initiation of
opioids due to unfounded fears
and reassure patients and
relatives about their fears.
 prescribe analgesia for
continuous pain on regular
basis, not PRN.
 prescribe all patients on
regular opioids breakthrough
analgesia at 1/6th of daily dose.
 titrate opioid doses to
maximum effect and minimum
side effects.
 while using opioids offer
laxatives and antiemetics as
needed.
 change strong opioid if
intolerable side effects.
 use oral route whenever
possible, subcutaneous only if
oral route unavailable.
 consider adjuvant analgesics
in defined pain states, eg
neuropathic pain: tricyclics,
anticonvulsants.
Consider involvement of palliative care
services and hospices as well as
oncology and radiotherapy services
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Last updated February 2006
Refer Category 1 for any of the
following:
 lack of access to above
services.
 need for pain specialist
assessment in unresponsive
pain.

need for interventional pain
management techniques
established.
consider pain relieving anticancer therapy and
radiotherapy in defined
situations.
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REFREC019
Diagnosis / Symptomatology
Headache
Evaluation
History and physical examination
Assess nature and speed of onset,
duration, frequency, severity and
quality, location,
alleviating/exacerbating factors,
response to analgesics, history and
pattern of previous headaches, change
from previous headaches, family
history, associated symptoms and
neurology, current medications
(including frequency and dosing of
analgesics), past medical history,
depression.
Management Options
Follow options outlined in neurology
referral recommendations.
Referral Guidelines
Consider referral to neurology services
along neurology referral
recommendations.
Refer Category 3 for persistent
headaches with impairment of function
and/or quality of life or disability and
pain unresponsive to treatment.
Perform neurologic examination,
mental status, head, neck, eye
examination.
Exclude rare serious conditions
requiring urgent
investigation/intervention:
 Intracranial haemorrhage
 Intracranial tumour
 Intracranial infection
 Increased intracranial pressure
 Acute glaucoma
Exclude other pathology causing
headaches:
 Sinusitis
 Dental pathology
 Ocular pathology
 Vasculitis
Establish diagnosis along the criteria of
the International Headache Society
(IHS).
Last updated February 2006
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REFREC019
Diagnosis / Symptomatology
Persistent Pain
(not further specified)
Evaluation
History and physical examination.
Exclude pain as a symptom of
treatable underlying diagnosis by
appropriate diagnostic measures,
investigations and specialist referrals
as required.
Attempt to establish a diagnostic
category:
 Nociceptive pain
 Neuropathic pain
Identify ‘pathological’ pain, not to be
misunderstood as in general of
psychological/psychiatric origin, but
often as a result of peripheral and
central sensitisation.
Examples of such ‘pathological’ pain
states are
 Phantom limb pain
 Fibromyalgia
 Most chronic back pain
 Many visceral pain conditions
such as irritable bowel
syndrome, interstitial cystitis,
loin pain haematuria
syndrome
Last updated February 2006
Management Options
Explanation of symptoms and
syndromes, often perceived as bizarre
and ‘inappropriate’ by patients,
relevant others and even health care
professionals.
Referral Guidelines
Refer Category 3.
Refer Category 2 in selected special
circumstances outlined by referrer.
Development of a management plan
together with patient, which considers
the biopsychosocial model of chronic
pain and follows principles of
behavioural medicine.
In nociceptive pain (eg osteoarthritis)
use of appropriate analgesics including
regular paracetamol, NSAIDs,
tramadol and even opioids should be
tried, but only continued if resulting in
significant pain relief and/or more
importantly improvement of function.
In neuropathic pain (eg diabetic
polyneuropathy) use of tricyclics,
anticonvulsants, tramadol and even
opioids should be tried, but only
continued if resulting in significant pain
relief and/or more importantly
improvement of function.
In ‘pathological’ pain states analgesics
are usually ineffective and initiation of
opioids potentially harmful; again
anticonvulsants and tricyclics can be
tried as modifying sensitisation
processes. Emphasis here should lie
on physical activation and aerobic
fitness programmes, cognitivebehavioural approaches and
reintegration into work force.
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REFREC019
Diagnosis / Symptomatology
Shingles
Postherpetic Neuralgia (PHN)
Evaluation
History and physical examination.
Early diagnosis is encouraged;
prodromal pain before the rash appears
is possible.
Increased risk of PHN development in
 advancing age (> 50 years)
 severe pain with rash
 prodromal pain
Management Options
Antiviral therapy for all patients with
shingles within 72 hours of rash onset
 valaciclovir preferred agent as
increased pain resolution
Aggressive and effective acute pain
management utilising titration with
non-opioids (paracetamol), NSAIDs,
tramadol and opioids.
Additional systemic steroid use
confers slight benefit on acute pain
and quality of life with no effect on
long-term pain and could be
considered.
Referral Guidelines
Refer Category 1 for any of the
following as early treatment prevents
PHN:
 acute shingles with pain
unresponsive to treatment
 early development of severe
neuropathic pain after rash
has healed
Refer Category 3 for established PHN
with impairment of function and/or
quality of life or disability and pain
unresponsive to treatment.
Initiation of low dose amitriptyline (525 mg nocte) at first diagnosis for 3
months reduces PHN rate by 50%.
In established PHN (>12 months)
treatment success is limited, but
tricyclics, anticonvulsants, tramadol
and opioids should be tried.
Last updated February 2006
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