Quick Steps to Manage Chronic Pain in Primary Care: click here to see management principles
Where pain persists for longer than 3 months, follow these 8 QUICK STEPS to develop a plan:
Does history and examination suggest an underlying red flag condition?
Red Flags
Clinical indicators of possible serious underlying conditions requiring further medical intervention
What to do
- 1 or more red flags indicates urgent referral to appropriate provider
Red Flags - PDF File 666.2 KB
Actions
Red Flag
The presence of a red flag is cause for concern.
Full investigation and referral on for immediate management is the priority.
The pain plan is not the main priority while red flags are investigated.
Actions
Begin by recording a baseline risk of progression, pain intensity or functional impact assessment (OMPSQ-10, PEG / BPI)
Brief Pain Inventory (BPI) or PEG Pain Screening Tool
Assesses pain severity and interference. Validated screening and monitoring tool
When to use
- Initial Assessment
- Patient reviews and monitoring
What to do
- Median interference score of 6.6 at initial assessment indicates moderate disability.
- Develop a Pain Management Plan with ongoing review and refer where appropriate.
- PEG - Add three responses to questions then divide by three to get score out of 10. Most useful in tracking changes over time.
Brief Pain Inventory - PDF File 339.8 KB
PEG Pain Screening Tool - PDF File 1.3 MB
Development and Initial Validation of the PEG - PDF File 170.8 KB
OMPSQ10 short form and OMPSQ10 musculoskeletal pain questionnaire (ÖMPQ)
Predictor of long-term disability and failure to return to work
When to use
- Early phase of assessment (eg 4-12 weeks)
- Workers compensation
- Predictor of long term disability
What to doLow risk OMPSQ 10
- OMSPQ-10 - Cut-off score of >50/100 predicts an increased risk of disability.
- ÖMPQ - a cut-off score of 130 correctly predicts increase risk of disability.
- Develop a Pain Management Plan with ongoing review and refer where appropriate
OMPSQ10 short form - PDF File 49.3 KB
OMPSQ10 musculoskeletal pain questionnaire - PDF File 147.7 KB
- High risk OMPSQ 10 (>50), predicts increased risk of disability.
- For BPI interference score >5 – clarify high scoring questions with patient.
Consider Mental Health or pain clinic referral - Low risk OMPSQ 10 (=50) continue GP management
- Median interference score of 6.6 on BPI at initial assessment indicates moderate disability.
OMPSQ10 short form and OMPSQ10 musculoskeletal pain questionnaire (ÖMPQ)
Predictor of long-term disability and failure to return to work
When to use
- Early phase of assessment (eg 4-12 weeks)
- Workers compensation
- Predictor of long term disability
What to do
- OMSPQ10 - Cut-off score of >50/100 predicts an increased risk of disability.
- ÖMPQ - a cut-off score of 130 correctly predicts increase risk of disability.
- Develop a Pain Management Plan with ongoing review and refer where appropriate
OMPSQ10 short form - PDF File 49.3 KB
OMPSQ10 musculoskeletal pain questionnaire - PDF File 147.7 KB
Kessler 10 (K10)
Measure of anxiety and depression
When to use
- Psychological distress.
What to do
- Scores > 19 indicate need for psychological or mental health plan or referral with ongoing review or Pain Management Plan.
Kessler 10 and scoring - PDF File 50.1 KB
Actions
- Complete GP Plan
- Refer patient to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/introduction-to-pain
- Refer patient to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-thoughts and resources, completing the health plan
- Consider Mental Health plan
- Refer to psychologist
- Maintains some normal activities despite pain (at home or work)
- Uses non-drug ways of self-calming (e.g. relaxation, gentle exercise)
- Takes an active problem solving approach to managing pain
- Minimises alarmist thinking
- Minimises avoidant behaviours
Actions
Partially engaged
Encourage person to go to:
- http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/introduction-to-pain, completing the health plan
- http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-thoughts and view attached resources, completing the health plan
Actions
- Opiod Management Quick Steps
- Complete GP Plan
- refer patient to psychologist for support
- encourage person to go to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/introduction-to-pain, completing the health plan
- http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-thoughts and view attached resources, completing the health plan
View the Flowchart
Actions
Refer patient to:
- http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/introduction-to-pain, completing the health plan
- http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-role-of-medications and resources, completing the health plan
- Dose >40mg Morphine Equivalent per day
- Treatment duration > 90 days
- Opioid Risk Tool > 3
- Side effects from Over the Counter and other medications evident
Actions
- Complete GP Plan
- Refer to physio for conditioning
- Refer patient to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-physical-activity and resources, completing the health plan
Actions
- Complete GP Plan
- Consider referral to psychologist for sleep hygiene strategies
- Refer patient to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-and-sleep and resources, completing health plan
- Consider sleep studies
Actions
- Complete GP Plan
- Consider referral to dietician
- Refer patient to http://www.aci.health.nsw.gov.au/chronic-pain/for-everyone/pain-lifestyle-and-nutrition and resources, completing health plan
Complete GP Plan
- Complete the GP plan using the boxes marked in RED as a prompt.
- Set goals with the patient in each of the marked domains over a few consultations.
- Monitor progress against each goal and baseline measures.
- Use function rather than pain as a guide to indicate progress.
When to consider referral to / or phone consultation
with a pain specialist or clinic
- Complex Regional Pain Syndrome
- Neuropathic pain not responding to current treatment.
- Pain persisting beyond 3-6 months, and lack of response to current treatment: including:
- Declining physical function
- Increasing psychological distress: K10>19, OMPSQ10>50, BPI interference score >5
- Excessive health care utilisation and or multiple medications for pain
- Difficulty weaning chronic opioid therapy
- NB:
- Opioid Morphine Equivalent Dose >40mg = moderate risk of harm
- Opioid Morphine Equivalent Dose>100mg = high risk of harm
- Opioid use >90 days = reduced likelihood of benefit
- Step 1
Does history and examination suggest an underlying red flag condition? - Step 2
Is psychological distress high? - Step 3
Is the patient actively engaged in self management? - Step 4
Are medications effective in managing pain and improving function? - Step 5
Are there indicators of medication risk? - Step 6
Are key physical activities declining due to pain and distress eg work, standing, walking? - Step 7
Is sleep affected? - Step 8
Could nutrition be improved?
