History and Examination

• Duration of chronic pain symptoms
• History of treatments trialled including pharmacological and non-pharmacological with outcomes and dosage
• Current medication
• Past medical history
• Psychosocial history including history of anxiety and depression and any treatments previously undergone for this
• Evaluation of suicide risk assessment where appropriate
• Visual Analogue Scale

Please consider the following investigations to exclude other diagnoses, for example (but not limited to):

• Blood tests:
  • Full Blood Count (FBC)
  • Renal Function Test (RFT)
  • Liver Function Test (LFT)
  • Bone Profile
  • Thyroid Function Test (TFT)
  • C-reactive protein (CRP) or Plasma Viscosity (PV)
  • HbA1c
  • Creatine kinase (CK)

• Urine Dipstick (protein, blood and glucose)

• Additional tests - only if clinically indicated:
  • Haematinics (ferritin, B12, folate)
  • Vitamin D (if at risk of deficiency)
  • Coeliac screen
  • Serology (if risk of infection - consider: hepatitis, EBV, HIV, CMV)
  • Myeloma screen (if patient aged over 60yrs)
  • Cancer screening tests
  • Imaging
  • Autoimmune (Blood Tests for Rheumatology Conditions)
    • (N.B. In suspected cases of FMS there is no indication for auto antibody testing e.g. ANA. These tests should only be done when patient have specific CTD symptoms (e.g. Raynaud’s, sicca symptoms etc)

Please see Central sensitivity syndrome / Fibromyalgia - South & West and Investigations | Diagnosis | Chronic pain | CKS | NICE for further details.

Urgent Referrals

Patients with the following should be referred urgently and don’t need to meet the referral criteria:

• Cancer pain
• Trigeminal Neuralgia
• Complex regional Pain Syndrome (CRPS) consistent with Budapest Criteria

Royal College of Physicians - Complex regional pain syndrome in adults - see Appendix 4

Please note we only accept urgent referrals for the three above conditions

Out of scope for the pain management clinic – patients with:

• Severe mental illness
• Suicide risk
• Substantial unexplained weight loss
• Symptoms or signs of inflammatory joint disease or connective tissue disease
• Clinically significant lymphadenopathy

• Try reasonable analgesia and if neuropathic pain, anti-neuropathic analgesia as per local guidelines.
  
  North and East Devon Formulary
  Chronic Non-Malignant Pain
  Neuropathic Pain
  South and West Devon Formulary
  Chronic Non-Malignant Pain
  Neuropathic Pain

• Appropriate supportive therapy i.e., occupational therapy, physiotherapy and psychological support as available for current presentation.
  
  Prior to referral, please consider the following:
  • Referral to Pain Management recommended by another specialty
    • Please give consideration to whether simple measures have initially been trialled e.g., trial of analgesics, physiotherapy.
    • Other specialties may not have access to full information regarding previous pain management input.

• Patient has been seen by Pain Management in last 18 months
  • Please consider whether re-referral is likely to change outcome

• Patient has completed Pain Management Programme, Body reprogramming course, or ACT programme.
  • It is unlikely we can offer much further for their condition
  • Re-referral to discuss analgesic reduction or a top up of skills learnt might be beneficial. In this case, please provide details and what you hope to achieve by referral.

• Patient only wants an intervention such as an injection
  • Please consider whether a radiology referral may be appropriate. Although injections may help some individuals this will only have a short lived and/or limited effect and should be part of a multidisciplinary approach. A decision on an intervention will only be made after assessment.  We  rarely provide repeat courses of injections. We are unable to provide acupuncture.

Please do not refer patients who are unwilling to attend the Pain Clinic or who are not willing to engage in rehabilitation strategies.

Urgent Referrals

Patients with the following should be referred urgently and don’t need to meet the referral criteria:

• Cancer pain
• Trigeminal Neuralgia
• Complex regional Pain Syndrome (CRPS) consistent with Budapest Criteria
  • Royal College of Physicians - Complex regional pain syndrome in adults - see Appendix 4Please note we only accept urgent referrals for the three above conditions

Please note we only accept urgent referrals for the three above conditions

We realise the significant pressures that referrers are under and will endeavour to see patients as efficiently as possible. In order to manage our resources most effectively we may return referrals that we feel are unlikely to benefit from our advice or management options. On this basis, we ask that referrers ensure that referrals meet the clinical referral guideline criteria.

Referral Criteria

• Patients aged 18 years of age or over

AND

• Pain present longer than 6 months (despite primary care management) (Unless cancer pain, CRPS or Trigeminal Neuralgia – these referrals can be expedited)

AND

• VAS 6/10 or greater 

AND

• No underlying reversible pathology (unless discussed with and agreed by pain consultant or ACP staff)

AND

• Not awaiting further investigations or opinion from other specialties regarding underlying cause of or treatment for pain

Please note:  Referrals not containing sufficient information with reference to the above referral criteria may be returned to the referrer. We only accept urgent referrals for cancer pain, trigeminal neuralgia and CRPS.

Please provide the following information in the referral: 

• Details of the pain problem, including longevity 
• Blood test results to exclude inflammatory condition where appropriate (please see Central sensitivity syndrome / Fibromyalgia (devonformularyguidance.nhs.uk) for details) 
• Treatment trialled including pharmacological and non-pharmacological. It would be helpful to know what the outcome of previous trials of pain medication has been along with maximum doses reached. 
• Current medication 
• Past medical history 
• Psychosocial history including history of anxiety and depression and any treatments previously undergone for this 
• Evaluation of suicide risk assessment where appropriate

Out of scope

• Patients under the age of 18
• Patients with:
• Severe mental illness or poorly controlled mental health
• Suicide risk
• Significant illicit drug misuse (drug dependency team can liaise with the pain team)
• Psychosocial background too unstable to currently engage with Pain Clinic
• Substantial unexplained weight loss
• Symptoms or signs of inflammatory joint disease or connective tissue disease
• Clinically significant lymphadenopathy
• Patients who:
  • have been seen in the pain clinic in the last 18 months
  • have completed a Pain Management Programme in the last 2 years
  • only want an injection
  • are unwilling to attend the Pain Clinic
  • are not willing to engage in rehabilitation strategies

Referral Instructions

e-Referral Service Selection

• Specialty: Pain Management
• Clinic Type: Pain Management
• Service: DRSS-Western-Pain Management-Devon ICB-15N

Referral Form

DRSS Referral Form

GP Information

British Pain Society - Outcome measures 2019 - please see p9 for Visual Analogue Scale

Royal College of Physicians - Complex regional pain syndrome in adults - see Appendix 4 for Budapest Criteria (p55)

Patient Information

MyHealth Devon – Pain Management

Pathway Group

This guideline has been signed off by the Pain management team on behalf of NHS Devon.

Publication date: February 2017

Updated: February 2024