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Receiving a new referral to specialist pain clinics

Guiding principles

Listed below are some guiding principles when receiving a referral to a chronic pain service.

  1. Referrals to a pain clinic should be triaged/assessed as to their appropriateness, fit with the service model and readiness of the patient to participate in the service model. It may be necessary to provide assessment and referral onto addiction medicine, mental health services or primary care services for example, with support and a suggested management plan.
  2. Referral flows between Tier 2* and 3# services. As a general principle, referred patients should be provided with an assessment and management plan in the centre that is located closest to their place of residence. This would include paediatric services for those consumers living in rural areas. If it is considered that the person is most likely not to benefit from the service type available at the specific centre eg requires high intensity programme or intervention than cannot be provided, requires consultation for implant, requires specific paediatric interventions, then they should be referred to the centre that provides this service within their geographic sector as per the Metropolitan and Rural Service Flow documents attached. The principle underpinning this is that the role of Tier 2 services is to assess, triage and identify potential need to refer to Tier three services when complexity is high or resources insufficient.
  3. High intensity programmes of 60 hours or more are available only at RPAH, RNSH, St George and Lismore. These programmes are suitable for people able to participate in a group setting with high to moderate complexity pain as measured by the eppoc outcome questionnaires. (See Which Program for Which Patient). Referrals should preferentially be made according to NSW Pain Service: Locations.
  4. Implants and stimulators are currently being offered to public patients at RNSH, RPAH, Westmead, Nepean, POWH, and Liverpool. Referrals should preferentially be made according to NSW Pain Service: Locations
  5. The following specialised services are available at the pain clinics listed below.
    • Services for HIV related chronic pain: St Vincent’s Hospital
    • Services for Burns: Concord Hospital
    • Services for Spinal Cord Injury related pain: Greenwich Hospital, Royal North Shore Hospital, Prince of Wales hospital
    • Paediatric pain program: Sydney Children’s Hospital
    • Paediatric day program: The Children’s hospital Westmead.

*Tier 2 services have been defined as those:

  • offering low/medium intensity programmes
  • offering triage/assessment  of high complexity patients with management and referral plan  forwarded to appropriate service
  • not accredited by the Faculty of Pain Medicine as a training facility
  • having a minimum multi- disciplinary staffing complement; nursing, medical. physiotherapy, psychology.

# Tier 3 services are those holding accreditation with the Faculty of Pain Medicine.

Guideline to assist in the classification of adult patient complexity on initial presentation to a service

NB: This information is provided for the purposes of assisting with communication and understanding across the pain network community. It has not been validated and is intended to be  used flexibly.

Domain
Low
Moderate
High
Pain Intensity
<5 on BPI
 5-8 on BPI intensity
>8 on BPI intensity
Pain Interference
<5 on BPI interference 
5-8 on BPI interference
>8 on BPI interference
Depression
<13 on DASS
14-20 on DASS
>20 on DASS
Pain Self-efficacy
>35 on PSEQ
20-35 on PSEQ
<20 on PSEQ
Catastrophising
<20 on PCS 20-30 on PCS
>30 on PCS
Reliance on medication
Simple analgesics, NSAIDs, antidepressants, anxiolytics, low level anticonvulsants, sleeping tablets, occasional opioid use (eg Panadeine Forte 1-2 daily, 1 Endone prn)
As for low, plus low to moderate regular opioid use : 20-50 morphine equivalent daily or 6-8 Panadeine Forte
As for moderate plus higher level regular opioid use- >50mg morphine equivalent
Employment
Able to work with pain

No current employment or difficulty maintaining employment due to pain (reduced hours, modified/light duties)
No current employment due to pain
Mental Health
No other relevant psychiatric diagnosis
May have other psychiatric diagnosis (eg eating disorder, bipolar) but stable and well managed (stable medication regime /appropriate mental health care)
Has other psychiatric diagnosis and not well managed (not on stable medication regime/not under appropriate mental health care)
Willingness to change
Understands importance of active self management and willing to practice/learn; keen to reduce reliance on medication and other passive strategies
Open to active self management but also still seeking 'cure'/ medical intervention and/or stronger medications
Only interested in cure/ medical intervention. Not open to active self- management approach
Co-morbidity
No co-morbid condition
>1 co-morbidity
>2 co-morbidities

OPIOID CONVERSION to oral MORPHINE EQUIVALENT DAILY DOSE (oMEDD)

Toolkit for comparison of opioid regimens by estimation of oMEDD



CONVERSION FACTOR
PROPRIETARY NAMES

From: 
To: oMEDD (mg/day)

ORAL PREPARATIONS



Swallowed



morphine
mg/day
1
Ordine, Sevredol, Anamorph, MS Contin, Kapanol
oxycodone
mg/day
1.5
Endone, OxyNorm (o), OxyContin, Targin
hydromorphone
mg/day
5
Dilaudid, Jurnista
codeine
mg/day
0.13
Panadeine, Panadeine Forte, Mersyndol, Aspalgin, Codalgin, Nurofen Plus, others
dextropropoxyphene
mg/day
0.1
Capadex, DiGesic, Doloxene, Paradex
tramadol
mg/day
0.2
Tramal, Durotram-XR, Zydol, generic
tapentadol
mg/day
0.4
Palexia-SR
Sublingual



buprenorphine (s/l)
mg/day
40
Temgesic, Subutex, Suboxone
TRANSDERMAL PREPARATIONS



buprenorphine
mcg/hr
2
Norspan
fentanyl
mcg/hr 
3
Durogesic, generic
PARENTERAL PREPARATIONS



morphine (sc, iv)
mg/day
3
morphine sulphate, morphine tartrate FI
oxycodone (sc, iv)
mg/day
3
OxyNorm FI
hydromorphone (sc,iv)
mg/day
15
Dilaudid FI, Dilaudid-HP
codeine (sc, iv)
mg/day
0.25
codeine phosphate FI
pethidine (iv, im)
mg/day
0.4
pethidine injection
fentanyl (iv,im,sc)
mcg/day
0.2
fentanyl citrate FI (DBL, AstraZeneca, Sublimaze)
sufentanil (iv, sc)
mcg/day
2

RECTAL PREPARATION



oxycodone (pr)
mg/day
1.5
Proladone (highly variable absorption)
Faculty of Pain Medicine ANZCA, September 2014



Service Flows

Map of NSW Pain servic locations

NSW Pain Services: Locations (pdf)

Children's Services

Local Health DistrictTier 21 ServiceTier 32 Service

Central Coast

Far West (north)

Mid North Coast

Nepean Blue Mountains

Northern NSW

Northern Sydney

South Eastern Sydney

South Western Sydney

Sydney

Western NSW

Western Sydney

Gosford*

Lismore*

Port Macquarie*

The Children’s Hospital Westmead

Far West (south)

Illawarra Shoalhaven

Murrumbidgee

Southern NSW

Orange*

Port Kembla*

Sydney Children’s Hospital
Hunter New England

John Hunter Children's Services

Tamworth*

The Children’s Hospital Westmead

Notes

1. Multidisciplinary pain clinic
2. Multidisciplinary pain clinic accredited with the Faculty of Pain Medicine
* Adult regional pain clinics

Adult Service Flows

Local Health DistrictTier 2 ServiceTier 3 Service
Metropolitan Service Flows
Central CoastGosford

Royal North Shore

John Hunter Hosptial

Illawarra Shoalhaven

Port Kembla

St George

Prince of Wales

St Vincent’s

Nepean Blue Mountains Nepean
Northern SydneyGreenwichRoyal North Shore
South Eastern Sydney

Port Kembla

St George

Prince of Wales

St Vincent’s

South Western Sydney Liverpool
Sydney 

Concord

Royal Prince Alfred

Western Sydney Westmead
Rural Service Flows

Far West

Orange

Nepean

Royal Prince Alfred

Westmead

Hunter New EnglandTamworthJohn Hunter Hospital
Mid North CoastPort MacquarieRoyal North Shore
Murrumbidgee 

Concord

Liverpool

St Vincent’s
Northern NSWLismoreRoyal North Shore
Southern NSW

Port Kembla

St George

Prince of Wales

Western NSW

Orange

Nepean

Royal Prince Alfred

Westmead

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