Persistent (Chronic) pain

Overview

Persistent pain is pain that lasts longer than three months. Sometimes the cause of the pain is apparent but often there is no evidence of tissue damage. Persistent pain can significantly interfere with quality of life and can be made worse by the anxiety, stress and anger that often accompany the pain.

Pain can affect just about every aspect of people's lives. It can affect:

• the way people move
• how much they do
• how far they go
• how able they are to take part in activities
• how confident and optimistic they feel.
• relationships with others
• how well they sleep or concentrate
• how much they enjoy life.
• As time goes on the effects of pain become more complicated.

Pain management is not trying to cure pain, but aims to explain and reduce the effects above by giving people information and helping them develop coping skills that improve their ability to manage pain.

In the first instance, self-management can help people develop coping skills that improve their ability to manage pain. General resources on pain management are under the resources section at the bottom of this page. Please share with patients. The leaflets can also be found on the CCG website so links can be sent to patients.

For more specific Remedy pages that may be helpful please see :

• Fibromyalgia
• Back pain/spinal pathway
• Chronic headache and migraine
• Persistent pelvic pain (women)
• Trigeminal neuralgia
• Knee pain
• Hip and knee pain  (self management - including 'Escape pain' course)
• Spinal Cord Stimulation Service - for neuropathic pain

Who to refer

Fibromyalgia : If Fibromyalgia is suspected then please go to the Fibromyalgia page for advise on diagnosis and self-care. If you still need to refer for management, refer via the Pain clinic - see below.

Back Pain For advice and guidance refer to the Back Pain page of Remedy. Pain service run Back Pack (referral criteria for BackPack): this is a 5 week group programme, run by a physiotherapist and psychologist, particularly appropriate for chronic/recurrent back pain with high psychosocial risk factors (which can be measured by tools such as StartBack). Please give this patient info leaflet before referral to help you both decide if they would benefit from a referral.

Pain Clinic 

(this is subject to the Referral to Secondary Care Pain Services Clinics For Assessment And Treatment Criteria Based Access Policy. See pain clinic referral criteria for clinicians). Provided at Southmead and BRI hospitals. For chronic pain (including CRPS, severe neuropathic pain and fibromyalgia) where conservative management has failed (including self-help, physiotherapy, analgesia) AND where patients are prepared to accept a holistic biopsychosocial approach, and where surgery is inappropriate.

Patients who are not prepared to accept a chronic pain diagnosis, and who are not prepared to engage in a holistic biopsychosocial assessment, will gain little benefit from a referral to the pain service. In order to facilitate a referral, please consider giving the patient the following information: ask the patient to read this Pain Clinic Patient Information Leaflet and to fill in and sign this patient pain questionnaire,. This will help you demonstrate that the patient has met the referral criteria and help you both decide if you feel the patient would benefit from referral (this form can be sent with the referral).  Here is also a link to pain clinic FAQs which can be shared with patients. 

You must use the chronic pain referral proforma accepted by both UHB and NBT. In order to help you, we would strongly recommend you use this pain patient questionnaire will help you gather the necessary information and help with patient engagement to meet the criteria. Please send a copy of the completed questionnaire with your referral and reference the referral proforma to this questionnaire.

Referrals to Bath RUH require this mandatory form to be included and so this service will not be offered unless the form is completed and this service is specifically requested in your referral.

Re-referrals

Patients who have been seen in a Pain Clinic before can be re-referred. The triaging pain clinician will decide if the re-referral is appropriate. It is helpful if information can be given in the referral about why the patient wants to return to Pain Clinic. Patients who have been through a Pain Management Programme might be accepted for re referral if they need a ‘top-up’ on their pain management skills or if their circumstances have changed.

Red Flags

Red Flags from patient history or examination (risk is proportional to the number of red flags)

• Possible fracture
• major trauma
• minor trauma in elderly or osteoporotic
• Evidence of neurological deficit (in legs or perineum in the case of low back pain)
• Possible tumour or infection
• New onset Age <20 or >50 years old
• History of cancer
• Constitutional symptoms (fever, chills, weight loss)Recent bacterial infection - IV drug use, Immunosupression
• Pain worsening at night or when supine
• Possibly significant neurological deficit
• severe or progressive sensory alteration or weakness
• Bladder or bowel dysfunction

Yellow Flags (biopsychosocial issues related to chronic pain)

Prescribers should be aware of the existence of ‘Yellow flags’ early in the management of chronic pain. Identification (and subsequent management) of yellow flags will improve the overall management of pain.

The factors which highlight the patient’s risk of chronicity can be identified using the ‘yellow flags’ system:

• Attitudes - towards the current problem. Does the patient feel that with appropriate help and self management they will return to normal activities?
• Beliefs - The most common misguided belief is that the patient feels they have something serious causing their problem – usually cancer. ‘Faulty’ beliefs can lead to catastrophisation
• Compensation - Is the patient awaiting payment for an accident/injury at work/RTA?
• Diagnosis - or more importantly Iatrogenesis. Inappropriate communication can lead to patients misunderstanding what is meant, the most common examples being ‘your disc has popped out’ or ‘your spine is crumbling’
• Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxiety are at a high risk of developing chronic pain
• Family - It is known that family dynamics can increase the risk of chronicity. The two most frequent problems are an over caring or an under-supportive environment.

Before referral

Before referral, referrers should  try to help patients manage their chronic pain including:

Self-help

• Self help information for patients with persistent pain - please give all patients this leaflet which has information about self-help strategies and available resources.
• Persistent Pain - Strategies for keeping mobile - this document gives patients advice about how to keep active and mobile.
• Useful information to help patients get active  - this leaflet has advice about local and organisations that can support an active lifestyle.

All these documents are stored on the BNSSG ICB website so that web links can be provided to the patient where facilities exist. 

Psychological Support

NHS Talking Therapies (VItaHealth) accept referrals of patients with chronic pain and offer on line and some face to face groups for patients - see Services section below or the Talking Therapies page.

Analgesia

An appropriate trial of analgesia in primary care should be considered. See the formulary for BNSSG Chronic Pain Guidelines 2022 for further advice.

Advice and Guidance

There is currently no formal advice and guidance service on eRS for local pain clinics.

Spinal Cord Stimulation

For patients with neuropathic pain of the lower limbs not responding to management in primary care then consider referral for Spinal Cord Stimulation (referral criteria and exclusions apply).

See the Spinal Cord Stimulation Service page for details.

Resources

Pain Scale (VAS)

• Pain scales in multiple languages | British Pain Society

Services

• Pain clinic - NBT

• Pain Clinic - UHBW

• Pain Clinic - RUH Bath

• Arts on Referral for Chronic Pain - NBT

• NHS Talking Therapies - Living Well with Chronic pain

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.