Chronic Pain Pathway - Leeds

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1. Background Information / Scope of Pathway

Quick info:
Chronic Pain is described as pain persisting more than six months or persistent pain irrespective of the number of sites/s
Chronic pain is different to short acting 'acute' pain and often doesn't respond to usual treatments.
This is because the problem is with the pain system itself, rather than being related to a specific problem in the body.

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2.  Information Resources for Patients and Carers

Quick info:
Leeds Chronic Pain Pathway PIL
Pain Sense PIL
Leeds Community Pain Service PIL

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3.  Development and updates to this pathway

Quick info:
Developed January 2015
Updated July 2015
To be reviewed January 2017
Reviewed March 2019
Reviewed and approved by NHS Leeds CCG Clinical Content Assurance Group – April 2019

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4. Referral Information

Quick info:
Community Chronic Pain Management Telephone Assessment Service (TAS) referral form

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5. Patient Presents with Chronic Pain

Quick info:
Chronic (persistent) Pain is described as pain persisting more than six months or persistent pain irrespective of the number of sites/s

Chronic pain is different to short acting 'acute' pain and often doesn't respond to usual treatments.

This is because the problem is with the pain system itself, rather than being related to a specific problem in the body.

We know many people just manage their lives with chronic pain with no large amount of impact on their health function. There is no need to address this group except to encourage physical activity, healthy eating and smoking cessation, Vitamin D awareness in some ethnic and other relevant groups.

Identify those with chronic pain 6 months or longer who struggle to manage pain symptoms and their impact on sleep, physical activities, mood, social role including work and have reducing or low confidence levels to self manage/cope.

Identification questions:

Question One
During the past month, has it often been too painful to do many of your day to day activities (interference by pain itself)

Question Two
During the past month, has your pain been bad enough to often make you feel worried or low in mood.
(Impact of pain on moods)

If yes to Question 1 and/or Question 2 then referral should be made to Community Chronic Pain Service.

Consider review of medication using the Leeds Analgesia Pathway for Chronic Pain

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6.  Scene Setting

Quick info:
GP satisfies themselves this is a chronic pain issue and the patient has been fully investigated to ensure that there is no serious destructive process, or the pain is amenable to curative treatment.

Scene Setting. This will include:

  • Patient understanding that chronic pain is unlikely to be cured
  • With support chronic pain can be managed and reduced
  • The essential starting point is completion of self-assessments
  • Next step is to jointly develop management plan
  • Supported self-management approach

The patient should be advised to expect the following areas to be assessed:
Medicines management:

Mood and Sleep (remember to consider sleep apnoea)

Impact on physical, social and work ability

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7.  Refer to Community Chronic Pain Provider Telephone Assessment Service (TAS)

Quick info:
Patients should be referred via DART MSK form (S1) or EMIS MSK template.

Patient Information:
Leeds Chronic Pain Pathway PIL
Pain Sense PIL

The community chronic pain provider will be responsible for briefing the patients on the key aspects of the pathway, issuing the self assessment tools and encouraging their use, and booking the patient into the appropriate clinic.

Self assessment tools incude:

  • body pain chart
  • the health needs assessment (HNA)
  • the self-confidence to deal with pain (pain self-efficacy PSEQ)
  • DOLO test (assesses pain experience, physical activities, sleep, mood, energy, work).

Appropriate booking will be made by the community provider dependent on score from self-assessment tools.

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11. Conduct Assessment

Quick info:
Completed tools will be reviewed (digital version will report directly into patient record within clinical system)

  • body pain chart
  • the health needs assessment (HNA)
  • the self-confidence to deal with pain (pain self-efficacy PSEQ)
  • DOLO test (assesses pain experience, physical activities, sleep, mood, energy, work).

This primary care delivered approach should meet the needs of 75% of chronic pain patients. The focus of approach is self-management and to enable patient access to a broad range of resources including the pain toolkit options.

Interpretation of Tools:

Body Chart will share patient pain areas and other symptoms. It will confirm current diagnosis or if not diagnostic clarification to be pursued.

Health Needs Assessment (HNA) tool provides patient summary of their needs due to the impact of pain. It prioritises three most important needs to start self management and pain management focus.

HNA informs clinicians on the severity and impact of pain on health function by the greater the number of areas ticked, so more ticks greater the impact.

The range of impact; physical, emotional, life / work / social. The greater the range of areas, the more severe the impact is on health.

Self Efficacy tool: self confidence to cope with aspects of life despite pain. Patient self completes and score out of 60

Score levels:
40-60/60 = high level of confidence to cope
16-39/60 = moderate level of confidence to cope
0-15/60 = low level of confidence to cope

High level of confidence means the person has minimal level of impact on health due to pain. Management needs focus around:

  • Self management skills/ resources like Pain Toolkit or other,
  • Medicines management with annual review
  • Primary prevention strategies such as smoking cessation, keeping physically active, healthy eating and vitamin D assessment.

Self management resources offered should include; Expert Patient Programme, Leeds Mind and Lets Get Active Leeds

Moderate level of confidence means the person has impact of pain on possible areas;

  • Increasing physical disability or impairment
  • Increasing mood difficulties that interfere with day to day life
  • Affecting work, social or life role.

The same support on self management and pain management as with high level of confidence.
In addition assess for emerging or persisting moods such as depression and anxiety, anger and manage actively.
At intervals use the tools to reassess progress in self confidence and improved health function. If patients confidence to cope or physical or emotional health function is not increasing or worsening referral to Tier 2 service for assessment is indicated.

Low level of confidence means the individual is severely affected by the pain symptoms and is seriously to struggle to cope with all aspects of life. They often have other long term health conditions like, sleep apnoea, diabetes, overweight or obesity, carers with pain problems, depression and anxiety.

These patients need support and consistent guidance on self management, “control not cure” referral to Tier 2 services is indicated (see referral guidance in "Agree Management Plan")

DOLO Test
This tool measures and displays to the patient and their clinician the impact on 8 areas;
Pain, sleep, energy, mood (spirits), social activities, work, physical activities light and heavy.
It is score out of a total score of 800

Score levels mean:
600 = severeto verysevere impact Tier 3 indicated
400-600 = moderate to severe impact Tier 2 indicated
200-400 = mild impact Tier 1 manage with primary care maximising range of local self management support/tools/pain toolkit
0-200 = minimal to no impact

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10. Agree Management Plan

Quick info:
Patient and practitioner to agree where to start with management plan, based on identified 3 needs from the Health Needs Assessment. Negotiate plan and agree action plan (i.e. who will do what) based on options available within

Tier 1

  • Medicine Management
  • Physical
  • Mental
  • Social

There should be a clear distinction between what the practitioner will do and what the patient will do.

This primary care delivered approach should meet the needs of 75% of persistent pain patients.

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13. Significant Needs or Scores Highly On Questionnaires

Assessment indicates that the patient has significant needs and requires input from specialist MDT

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15. Medicine Management

Quick info:
Consider review of medication using Leeds Analgesia for Chronic Pain Pathway
SIDE EFFECTS OR OTHER PROBLEMS WITH CURRENT PAIN MEDICATION:

GP Assessment:
General analgesics

  • Check other medication taken including illicit drug use such as heroin, cocaine, tramadol, benzodiazepine, gabapentin, pregabalin etc.
  • Check for drug interactions
  • Check pain relief effectiveness using VAS and % relief
  • Check constipation, nausea & vomiting, drowsiness, light-headedness
  • Check for misuse and compliance with instructions (i.e. under or over use.)

Interventions:
For all drugs – No pain relief, stop drug

  • Encourage patient to experiment with dose and timing (in line with licensed recommendations re frequency) for all analgesics other than sustained release products
  • Use of drug education 1:1
  • Patient to self-report symptoms to GP
  • Stop drug if a contraindication is present or side effects cannot be adequately managed.

Constipation

  • Patient education via self-help information / 1:1 from specialist nurses
  • Encourage fluids and dietary fibre.
  • Opioids: Routinely use bulk, osmotic and stimulant laxatives, when prescribing these analgesics (Lactulose/Fybogel/Manevac/Laxido Stimulant laxatives)

Nausea & Vomiting

  • Consider change in analgesia or adjust timing/dose
  • Anti-emetics (cyclizine, prochlorperazine) - caution due to abuse potential and safety concerns with long term use
  • Use oral route tablet, sublingual, rectal routes

Moderate / Strong Opioids
Side effect interventions as above including sedation, confusion, hallucinations, mood changes and postural hypotension.
Check for withdrawal or dependence symptoms

NSAID
Check for dyspepsia symptoms contraindication in peptic ulceration. Consider gastro protection therapy.
Check for drug interactions: aspirin and ibuprofen including OTC products
Check for cautions and contra-indications
Check if causes exacerbation of asthma symptoms / CVD risk
Check for CKD / AKI
Consider effect on blood pressure

  • Discontinue drugs if severe gastrointestinal symptoms, worsening asthma or anemia which may be secondary to GI bleed
  • Consider preparations of lower risk of gastrointestinal side effects.
  • Consider adding PPI
  • Consider Cox 2 inhibitor

Antidepressants

  • Check pain relief (not all antidepressants are effective adjuncts to pain relief)
  • Sleep effectiveness
  • Check: constipation, drowsiness, light-headedness
  • Dry mouth
  • Consider risk of self-harm / suicide attempts in particular with tricyclic antidepressants

Anticonvulsants

  • Check pain relief effectiveness
  • Rashes, sore throat
  • Check other medication taken
  • Check for drug interactions
  • Consider the abuse potential and street value of gabapentin and pregabalin

PAIN SYMPTOMS OR PAIN RELIEF:
GP Assessment use STEPS:

  • Clarify pain relief problems
  • Define pain problems
  • neuropathic, nociceptive
  • Check patient use of medication carefully and assess for misuse, misunderstandings and abuse

Interventions:

  • Drug treatments:
  • WHO ladder for analgesics
  • Capsaicin
  • Tricyclics; amitriptyline
  • Anticonvulsants
  • Other non-drug interventions:
  • TENS
  • Acupuncture
  • Epidurals
  • Injection therapy
  • Dorsal column spinal cord stimulator
  • Pain rehabilitation programme

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16. Psychological

Quick info:
UNDERSTANDING WHY PERSISTENT PAIN OCCURS

Assessment:

  • Clarify patient knowledge of acute and persistent pain
  • Clarify patient knowledge of single or multiple diagnoses

Interventions:

  • Patient education 1:1 or group based

Resources:

AN UNHELPFUL CYCLE OF ACTIVITY OF LESS PAIN, SO DO TOO MUCH, SO MORE PAIN, SO REST MORE OFTEN OR FOR LONGER (PACING DIFFICULTIES)

Assessment – consider use of Pain Toolkit page 2:

  • Identify the style of pacing; is it overactive / underactive / mixed pattern?

Interventions:

  • Patient education
  • Weekly activity diary
  • Goal setting
  • Problem solving skills
  • Relaxation skills

Resources:

  • Pain Management Plan app
    Paintoolkit
  • Weekly activity diary to spot patterns of unhelpful pacing and make changes

MANAGING MOOD CHANGES OF DEPRESSION, ANGER, ANXIETY OR WORRY
DEPRESSION

Assessment: check the following

ICD -10 DIAGNOSTIC GUIDELINES FOR DEPRESSION - F32

  1. Depressed mood for two weeks
  2. Loss of interest
  3. Fatigue or decreased energy
  4. Loss of confidence or self-esteem
  5. Self-reproach or guilt
  6. Recurrent thoughts of death, suicide or suicidal behaviour
  7. Diminished concentration or indecisiveness
  8. Agitation or retardation
  9. Sleep disturbance (insomnia or hypersomnia)
  10. Appetite and weight change (increase or decrease)

ICD-10
Severe depression: eight symptoms including 1&2 or 3
Moderate depression: six symptoms including two of 1,2 or 3
Mild depression: four symptoms including two of 1&2 or 3
Diagnosis and severity of depression including suicidal risk assessment.

ANXIETY DISORDERS
Assessment:

  • Clarify if fearful of movement with avoidance or safety behaviours
  • Assess if any concerns or fears related to pain or otherwise
  • Check bodily symptoms: sweating, palpitations, feeling tense or agitated, chest tightness
  • Check: Average daily intake of tea/coffee/cola
  • Average weekly alcohol intake
  • Average drug misuse, prescribed or illegal
  • Assess if excessive use of drugs such as asthma inhalers; salbutamol etc
  • Assess if has panic attacks and related to places, people, activities
  • Assess severity of disorder with PHQ questionnaire

POST TRAUMATIC STRESS DISORDER
Assessment:
Clarify presence of symptoms: nightmares, flashbacks, disturbed sleep patterns, excessively anxious, guilt feelings, hypervigilance.

ANGER
Assessment:

  • Clarify if anger related to pain and its impact on the patient’s life OR other issues in their lives at present
  • Clarify if excess use of alcohol/prescribed drugs /cannabis or other mind altering drugs
  • Clarify if patient would like help to address their anger problem.

Interventions and resources:
Clarify diagnosis and treatment:

TIREDNESS OR LACK OF ENERGY
Assessment:

  • Consider bloods etc.
  • Medicines Review

Resources:

  • Pain Management Plan app
  • www.paintoolkithttp://www.paintoolkit.org/
  • Weekly activity diary to spot patterns of unhelpful pacing and make changes

SEXUAL DIFFICULTIES
Assessment:

  • Clarify sexual difficulty if appropriate and possible in the context of the assessment
  • Common difficulties are: reduced libido; increased fear of pain increase; impotence; ejaculation dysfunction

Interventions:

  • Offer information on Relate services -
  • Referral to psychosexual counselling
  • Referral to Erectile Dysfunction clinic

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17. Physical

Quick info:
WALKING OR MOVING ABOUT, LACK OF FITNESS AND STAMINA

Assessment:

  • Is it pain related? Is it stiffness related?
  • Is it weakness related?
  • Is it balance related?
  • Is it fear related
  • Can the patient walk independently?
  • Does the patient need aids?
  • Does the patient use a wheelchair / scooter?
  • For how far / how long can the patient walk?
  • Can the patient manage stairs / slopes / hills?
  • Can the patient roll over in bed?
  • Can the patient get in / out of bed / chair?
  • Are activities of daily living affected?
  • Is it a drug side effect?

Interventions:

  • Stretches
  • Exercises including trunk / pelvic stability work
  • Regular or daily walking
  • Hydrotherapy
  • Stamina building by graded exercise/activities e.g walking, swimming, dancing, exercise bike
  • Use of aids if context is appropriate
  • GP in house walking club
  • Refer for Physiotherapy if patient is suffering from a MSK condition that will respond to physio
  • Tai Chi, Yoga and Pilates

Resources:

LACK OF FITNESS AND STAMINA

Assessment:

  • What is the present level of activity?
  • What were the patient’s previous interests / levels of activity?

Interventions:

  • Emphasis on graded exercise programme: stretch, strengthen and stamina programme including cardiovascular fitness
  • Goal setting
  • Learning Pacing skills
  • Problem solving skills
  • Hydrotherapy advice session
  • Access local physical exercise programmes

Resources:

BALANCE OR RECURRENT FALLS

Assessment:

  • Is it due to dizziness?
  • Is it due to ear / VBI problems?
  • Is it due to drop attacks?
  • Is it due to weakness?
  • Is it due to gait?
  • Is it due to a neurological condition affecting proprioception?
  • Is it fear related?
  • Is it due to BP?
  • Is it due to vision?
  • Is it due to drugs?
  • Is it due to alcohol?

Interventions:

  • Falls Team

Resources:

  • Advice on Falls Patient Information leaflet (LCH)
  • Tai Chi, Yoga and Pilates
  • The Leeds Directory

DISTURBED SLEEP

Assessment:
Clarification of the type of sleep difficulty

  • What is the sleep pattern?
  • Is the problem insomnia or excessive daytime drowsiness
  • Is it not enough / too much sleep?
  • Is there daytime napping?
  • Where does the patient sleep?
  • Is it pain related?
  • Is it linked with depression anxiety or psychological disorders?
  • What is the daily caffeine intake?
  • Is it drugs related prescribed or illegal?
  • Is it related to excessive or inappropriate alcohol?
  • What are the activity levels through the day?
  • Identify any environmental factors
  • Exclude sleep apnoea

Interventions:

  • GP Review – consider trial of low dose TCA amitriptyline or nortriptyline for 8 weeks, especially if neuropathic pain component.
    Improve pain management via analgesia, TCA’s (such Amitriptyline), avoid Benzodiazepines, optimise medication.
  • Insomnia
  • Sleep education (using sleep diary)
  • Patient problem solving
  • Relaxation via diaphragmatic breathing, progressive muscle relaxation, mental imagery
  • Stretches on waking or prior to sleep time

Resources:

TIREDNESS OR LACK OF ENERGY

Assessment:

  • Consider bloods etc.
  • Medicines Review

Resources:

SEXUAL DIFFICULTIES

Assessment:

  • Clarify sexual difficulty if appropriate and possible in the context of the assessment
  • Common difficulties are: reduced libido; increased fear of pain increase; impotence; ejaculation dysfunction

Interventions:

  • Offer information on Relate-
  • Referral to psychosexual counselling
  • Referral to Erectile Dysfunction clinic

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18. Social

Quick info:
EATING THE RIGHT SORTS OF FOODS, WEIGHT CHANGES
Options for signposting:

  • Mediterranean Diet patient.co.uk
  • Leeds Lets Change - healthy eating website
  • Nutrition & dietetic service (LCH)

RELATIONSHIP DIFFICULTIES; WITH PARTNER, FAMILY, WORK ETC.

Assessment:

  • Assess if pain has any significant impact on close relationships

Interventions:

CONCERNS ABOUT YOUR CARER/PARTNER, THEIR HEALTH OR OTHER PROBLEMS

Assessment:

  • Assess if disability means reliance on a carer for a range of daily living activities
  • Identify if evidence of carer stress or difficulties due to carer health problems or depression eg denial or over-protective
  • Identify if young carers under 18 years involved

Resources:

  • Barnardo’s Young Carers Willow Service
  • Carers Leeds
  • Respite breaks - call Adult Social Care to arrange an assessment Tel: 0113 2224401

REMAINING IN WORK OR RETURNING TO WORK AND/OR TRAINING
Assessment:

  • Identify patient’s goal with current work or returning to work
  • If on sick leave in current work what is needed to enable them to continue?
  • Less hours
  • Phased return to work
  • Ergonomic assessment
  • Practical help to improve Access to Work

Intervention:

  • Offer support either via GP or direct to employer where patient requests such support; usually a written letter
  • Encourage patient to liaise with employer and negotiate appropriately for their needs

Resources:

FINANCIAL OR MONEY DIFFICULTIES

Assessment: ·

  • Identify if financial issues are a significant worry at present?
  • Are they able to deal with these worries?
  • Are they aware of help or resources available?

Resources:
Citizens Advice Bureau
www.leedscab.org.uk
Tel: 0844 4774788

National Debtline - provides free, confidential and independent advice on how to deal with debt problems
www.nationaldebtline.co.uk
Tel: 0808 8084000

How to access benefit entitlements - click here

CURRENT LEGAL CLAIM LINKED WITH THE PAIN PROBLEM
Citizens Advice Bureau
www.leedscab.org.uk
Tel: 0844 4774788

OTHER DIFFICULTIES e.g. CONCERNS ABOUT HOUSING, HOBBIES, LEISURE OR SOCIAL EVENTS)
Leeds Directory - see Map of Medicine pathway
Care & Repair - see Leeds Directory Map of Medicine pathway
Social care assessments - Older people, adults with a disability of any kind, and carers are entitled to ask the council for an assessment of their needs to see if they are entitled to any help. Contact Adult Social Care to discuss your needs.
Tel: 0113 2224401

ASIST (Actively Seeking Independent Support) for help with spending personal budget or finding a personal assistant.
Tel: 0113 2143599

Leeds Mental Health Online Directory - click here

Information about mental wellbeing services in Leeds - https://www.leeds.gov.uk/docs/How Are You Feeling 2013.pdf (including):

  • NHS Primary Care Mental Health Service
  • The Market Place (for young people aged 13-23)
  • Leeds Counselling
  • Women’s Counselling and Therapy Service
  • Relate
  • Leeds Mind Counselling / Peer support

WorkPlace Leeds – Mental Health Employment and Community Support Directory - click here

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20. Review of Management Plan

Quick info:
Review DOLO Test and Self Efficacy test at this point.

The review will be conducted by the practitioner involved in the development of the management plan wherever possible.

Regular use of self efficacy and DOLO test can help track change in confidence to cope and health function. If self efficacy score is increasing and DOLO test is reducing then the pain management approaches are being effective.

If self efficacy is reducing and DOLO test is increasing and patient is more distressed and disabled then referral to Tier 2 community based pain service is indicated.

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22. Improved Return to Primary Care

Quick info:
Discharge back to primary care will include an agreed written maintenance plan.

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23. Person Centred Health Needs Review by MDT

Quick info:
Entry Criteria
Evidence of not coping

  • Distress (depression, anger, anxiety)
  • Seeking to access more drugs, or misuse of drugs

Method

  • Face to face with multidisciplinary team (Team content to vary depending on complexity)
  • Assessment of:
  • Pain
  • Physical Function
  • Emotional Function
  • Social Function

Outcomes

  • Remain in Tier 2 service
  • Referral for specialist intervention - abdominal pain, pelvic pain, CRPS, complex psychological therapies etc.

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24. Referral for Specialist Intervention

Quick info:
Abdominal Pain, Pelvic Pain, CRPS, complex psychological therapies etc.

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25. Tier 2 - Personal Pain Management Plans

Quick info:
Elements Include

  • Pain symptoms managed within the team (primarily drugs, to be prescribed by GP)
  • Physical Function - comprising physical activity programme
  • physiotherapy for specific affected areas
  • general programme for fitness and stamina / balance
    To be delivered in house
  • Emotional and Physical Function
  • CBT, face to face or group based, included within "pain plan"
    To be delivered in house or by integrating elements of existing IAPT services
  • Social Function
  • Programmes to stay in work or return to work
    Out with this service - signpost or refer to other services

Outcomes

  • Discharge to GP, with patients having a personal sustainability plan. Patients annual review to continue
  • Possible escalation to Tier 3

This community care delivered approach should meet the needs of 85% of the patients undergoing Person Centred HNA

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26. Tier 3 - High Intensity Programmes

Quick info:

Entry Criteria
Severe impact, pain has caused severe, serious disability. Typically patients will be immobile, wheelchair bound. Perhaps have 1 good day in 10. Zero quality of life.

Entry to these services is restricted to patients referred by the community chronic pain management providers.

Outcomes
Discharge to GP, with patients having a personal sustainability plan. Patient's annual review to continue.

This specialist service should meet the needs of 15% of patients undergoing Person Centred HNA, 2/3rd through pain medicine 1/3rd through pain management planning

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27. Return to Primary Care

Quick info:
Discharge back to primary care will include an agreed written maintenance plan.

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Leeds Health Pathways