Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- mental health emergency with acute suicidality and harm to self / others
- actual or threatened cauda equina syndrome (CES):
- unexplained or unexpected loss of bladder or bowel function
- perianal anaesthesia
- bilateral nerve pain (leg pain below the knees)
- progressive weakness
- clinical signs of spinal nerve root or spinal cord compression with severe/rapidly progressing neurological deficits including myelopathy
- spinal tumour with significant pain and/or neurological deficit
- spinal fracture/trauma with significant deformity, instability, and/or neurological deficit
- clinical suspicion of spinal infections
- high risk of irreversible deficit if not assessed urgently
- concerning features may include:
- age at onset > 50 years
- recent significant trauma
- unexplained weight loss
- history of cancer/malignancy
- history of intravenous drug use
- prolonged corticosteroid use
- features of CES
- severe, worsening pain; especially at night
- fever
- recent serious illness/significant infection
Please contact the on-call registrar to discuss your concerns prior to referral.
For clinical advice, please telephone the relevant specialty service.
Central Adelaide Local Health Network
- The Queen Elizabeth Hospital (08) 8222 6000
Northern Adelaide Local Health Network
- Northern Pain Rehabilitation Service (08) 7321 4133
Southern Adelaide Local Health Network
- Flinders Medical Centre (08) 8204 5511
Inclusions
- persistent pain with:
- significant impact on quality of life where all reasonable investigations have been completed and reasonable management in the primary care sector has been tried with insufficient success
- a primary care physician or specialist is actively involved in the patient’s care
Exclusions
- conditions which have not been previously treated in a primary care setting
- patients who can be well managed in primary care, using appropriate guidelines where necessary
- indefinite referrals
- active work cover claims – consider referral to a private pain physician
- patient has not consented to the referral and is not willing to engage in a multi-disciplinary program with guidance towards self-management
- patients with a cognitive impairment of sufficient severity that would affect the ability to self-manage their condition unless they have a carer, that is willing and able to assist with pain management recommendations
- validation of an opioid prescription (e.g., second opinion for ongoing opioid prescription without intention to wean) - see Statement regarding the use of opioid analgesics in patients with chronic non-cancer
- active substance use disorder — for example, not in remission and unstable – Drug and Alcohol Services South Australia (DASSA)
- management of acute mental health issues requiring urgent or crisis care
- acute or sub-acute non-specific spinal pain, less than 6 months
- previous Pain Management Unit (PMU) patients who:
- have not followed management recommendations unless there are extenuating circumstances or new issues
- have completed the pain management pathway/programs and for whom no new management approaches are available (within previous 24 months).
- for the purpose of a third-party assessment - Return to Work SA, Disability Support, Medico-Legal, NDIS, Workcover/Allianz (except drug trials with prior approval)
- patients undergoing treatment from other specialist services for the same pain problem without mutual awareness/agreement of cross referral by both teams
- request for medicinal cannabis education, trial and endorsement - refer to Faculty of Pain Medicine ANZCA Position Statement on Medicinal Cannabis with particular reference to its use in the management of patients with chronic non-cancer pain and Medicinal Cannabis – Patient access in South Australia
- ketamine infusion for the purpose on continuing a private stand alone off-label therapy or endorsement thereof - refer to Faculty of pain Medicine ANZCA Position Statement on the use of ketamine in the management of chronic and non-chronic cancer pain
- public pain clinics do not routinely offer appointments to patients seeking a second opinion for a condition already seen by the same speciality within the same of another Local Health Network, with the exception of patients who have moved to a new catchment area or patients transferring from paediatric health services due to their age. Such referrals will be considered but are highly unlikely to be accepted. Alternatively, a referral can be made to a private pain specialist.
Triage categories
Category 1 (appointment clinically indicated within 30 days)
- cancer pain where patient’s specialist treating team is requesting persistent pain management support
- patients on a palliative care pathway where the patient’s specialist treating team is persistent pain management support, for example, with an intervention
- 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
- newly diagnosed chronic regional pain syndrome (CRPS) less than 3 months since onset
Category 2 (appointment clinically indicated within 90 days)
- previously diagnosed complex regional pain syndrome (CRPS)
- persistent pain following trauma or surgery, 6 to 12 weeks
- sub-acute pain, defined as lasting 6 to 12 weeks, with risk of functional deterioration
- frequent pain exacerbations occasioning emergency presentations or hospital admissions
- patients for interventional procedure or infusion
- Statewide Spinal Cord Stimulator implantation, Southern Adelaide Local Health Network only
- elderly (75 years and over) pain with multiple comorbidities
Category 3 (appointment clinically indicated within 365 days)
- pain lasting greater than 1 year
- not responding to general physician (GP) management
- requiring diagnostic advice
- requiring medication optimization
- with associated psychological distress
- with associated physical interference
- musculoskeletal conditions - chronic shoulder, hip, knee pain
- visceral pain with clear pathology - inflammatory bowel disease, recalcitrant angina
- pelvic pain
- persistent pain without obvious organic pathology with significant psychosocial factors
- opioid reduction review if the patient is willing to wean and requires support
- <100mg oral morphine equivalent dose (oMED) – Central Adelaide Local Health Network and Northern Adelaide Local Health Network only
- transitional to adult pain service - for teenagers age 17 years onwards who are unlikely to continue with the paediatric service
Considerations prior to referral
Prior to referral to a public specialist outpatient service please consider whether:
- the patient has a regular General Practitioner (GP) or regular GP is aware that the referral has been sent
- all reasonable and appropriate medical investigations have been completed
- reasonable management in the primary care or hospital sector has been tried with insufficient success
- chronic pain is having a significant impact on life and therefore warrants referral to the multidisciplinary specialist chronic pain service
- for example - sleep, self-care, pain necessitating the assistance of others, pain impacting mobility, work attendance, socialisation, recreation, relationships and/or emotional regulation
- chronic pain exacerbations have resulted in extreme distress or repeated hospital presentations/admissions and therefore warrants referral to the multidisciplinary specialist chronic pain service
- current medication management is not providing relief nor leading to improved quality of life -. polypharmacy, and therefore warrants referral to the multidisciplinary specialist chronic pain service
Essential referral information
Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
Clinical details
- medical history, including current medications and past analgesia/medication trialled for pain condition
- specific site of pain:
- spinal pain
- musculoskeletal pain - shoulder, hip, knee, other
- cancer pain - type of cancer
- neuropathic pain - post herpetic neuralgia / peripheral / central neuropathies
- chronic regional pain syndrome (CRPS)
- visceral pain - irritable bowel syndrome (IBS) / inflammatory bowel disease (IBD) / chronic pancreatitis / recalcitrant angina
- pelvic pain/ endometriosis/ interstitial cystitis / bladder pain syndrome
- headache and orofacial pain, temporomandibular joint (TMJ) disorder
- chronic widespread pain
- pain onset, duration and frequency
- associated functional impairment - pain impacting on mobility, work or school attendance, recreation, relationships and/or emotions, sleep, self-care
- associated features - autonomic features, vomiting, photophobia, urinary and bowel frequency
- screening neurological examination
- mental health history - name of treating clinicians and details of past and present treatments, and relevant information regarding trauma history
- psychological stressors - including housing, financial, employment security, social support (formal and informal), interpersonal issues (family violence, custody issues), forensic history
- complex psychosocial influences relating to pain behaviour
- pain exacerbations have resulted in extreme distress or repeated hospital presentations / admissions
- complete past medical history including comorbidities and past surgical history
- current medication list including non-prescription medication, herbs and supplements
- oral morphine equivalent dose (oMED), red flag on ScriptcheckSA - Downloadable opioid
- alcohol and other drugs history, smoking/vaping status, medical and non-medical marijuana, illicit drugs
- list all treatments including maximum dose reached and duration of therapy
- relevant imaging results - plain X-ray, computed tomography (CT) and magnetic resonance imaging (MRI)
- include details of neuroimaging including radiology provider and accession number
- presence of red flags, complete relevant investigations:
- complete blood examination (CBE)
- electrolytes, urea, creatinine (EUC)
- liver function tests (LFTs)
- estimated glomerular filtration rate (eGFR)
- erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- details on current or previous treatments from other specialist or allied health service providers for the same pain problem - physiotherapist, community support
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: computed tomography (CT) / magnetic resonance imaging (MRI) / other if available past 3 years
Headaches / cranial nerve pain
- recent neurology report if available
- previous relevant diagnostic imaging - CT/MRI/other if available past 3 years
Joint pain
- rheumatology report if available
- CRP, EUC, FBE
Neuropathic pain
- results relevant to diagnosing aetiology of peripheral neuropathy
- previous nerve conduction studies where relevant if available
- screening blood test for neuropathy results
- glycated haemoglobin (HbA1c) if diabetic
Chronic visceral pain
- urology and gastroenterology reports if available
Chronic pelvic pain
- obstetric/gynaecological reports if available
- past procedures and treatment outcomes
Malignancy pain
- past procedures and treatment outcomes
- oncology or palliative care reports
Musculoskeletal pain / osteoporosis / chronic high dose opioids:
- vitamin D, ionised calcium, magnesium
- bone mineral density
- testosterone level
- if inflammatory arthropathies include: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) results
Clinical resources
- The Australian Pain Society
- Faculty of Pain Medicine
- International Association for the Study of Pain (IASP) Statement on Opioids
- Prescribing drugs of dependence in general practice guideline
- Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine - Acute Pain Management: Scientific Evidence
- Downloadable opioid calculator
- Australian Association of Musculoskeletal Medicine
- Therapeutic Guidelines (eTG)
Consumer resources
- Reach For The Facts
- NSW Government Agency for Clinical Innovation - Pain Management Network
- Smiling mind mindfulness app
- Headspace
- Chronic Pain Australia
- Pain Australia
- Consumers Health Forum of Australia
- Pelvic Pain Foundation
- EndoZone - Helping you live well with endo
- NSW Government Agency for Clinical Innovation - Pain Management Network: Our Mob indigenous specific resources
- NSW Government Agency for Clinical Innovation - Pain Management Network - Pain and Pacing
- Northern Pain Centre – 12 Quick Tips for Planning Your Day with Chronic Pain
- Protailored Physical Therapy - Nerve Desensitization Techniques
- Therapeutic Goods Administration - Chronic pain management video resource: Brainman
- SleepHealth Foundation - Cognitive Behavioural Therapy for Insomnia (CBT-I)
- Australian Pain Society - Supporting Multidisciplinary Pain Management in Australia
- Pain Australia - Support Groups & Helplines
- This Way Up - Insomnia Program
- Government of Western Australia - painHEALTH
Reason for request
- to establish a diagnosis
- for treatment or intervention
- for advice and management
- for specialist to take over management
- for a specified test/investigation the General Practitioner cannot order
- for other reason (e.g. rapidly accelerating disease progression)
- transfer of care from another tertiary service
- clinical judgement indicates a referral for specialist review is necessary.
Patient demographic details
- 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
Clinical modifiers
- 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
Other relevant information
- 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.
- Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
- Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
- Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
- All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.
Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.
The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.