CHRONIC PAIN PATHWAY



GUIDELINES FOR CLINICIANS FOR MANAGEMENT OF CHRONIC PAIN Health Needs Assessment HNA (18 item) The HNA shares patient chosen priorities for change to be addressed in pain managementIMPROVING PATIENT KNOWLEDGE: PAIN persisting AssessmentClarify patient knowledge / understanding acute and chronic pain Clarify patient knowledge of single or multiple diagnosesInterventionPatient education 1:1 or group based via pain rehabilitation programmeSelf help information : PALS, Public library. Health kiosks, support groups Clinicians sources pain specialist clinicians Internet sourcesResourcesSelf help materials: Understanding Persistent Pain Tasmanian Health Organisation South 2014Explain Pain from livewellwithpain.co.uk Patient ResourcesWeb site informationUnderstanding Pain in Five minutes U tube video PAIN RELIEF AssessmentClarify pain relief problemDefine pain problem/s? neuropathic, nocioceptive Check patient use of medication carefully and assess if misuse, misunderstandings and abusesee drug side effects belowInterventionsDrug treatments: (Check condition specific sheets)WHO ladder for analgesicsCapsaicin, LidocaineTricyclics: amitriptyllineGabapentinoidsOpioidsOther non drug interventionsTENSAcupuncture – consider referral for myofascial painEpiduralsInjection therapyDorsal Column Spinal cord stimulator Pain management or rehabilitation programmesResourcesPain Management Services patient informationPatient procedure information sheets: epidural , TENS , Dorsal column spinal stimulatorThe British Pain Society Guidelines on “Dorsal Column Stimulators” March 2004DRUG SIDE EFFECTSAssessment: General analgesicsCheck other medication taken including illicit drug use such as heroin.Check for drug interactionsCheck pain relief effectiveness using VAS and % reliefCheck: constipation, nausea + vomiting, drowsiness, light-headednessCheck for misuseInterventions for all drugsNo pain relief stop drugEncourage patient to experiment with dose and timing for all analgesicsUse of drug education 1:1 or group based in Pain Management Programme Patient to self report symptoms to Community Pharmacist/GP/Pain teamStop drug if drug interaction, side effect or other problem.ConstipationPatient education via self help information/ 1:1 from specialist/practice nurses/PHCTEncourage use of fruit and fibre rich diet Encourage regular FLUIDS through 24/7Opiods: Routinely use bulk and stimulant laxatives, when prescribing these analgesicsLactulose/Fybogel/Stimulant laxatives Nausea + vomiting:Change analgesicAnti emetics:CyclizineProchlorperazineUse tablet, sublinqual, rectal routes.Moderate/strong opiodsSide effect interventions as aboveCheck for withdrawal or dependence symptoms NSAIDCheck for dyspepsia symptoms contraindicated in peptic ulcerationCheck for drug interactions: aspirin and ibuprofenCheck for asthma /CVD riskInterventionsDiscontinue drugs if severe gastrointestinal symptoms or worsening asthmaConsider safer low risk of gastrointestinal side effects preparation. Check BNFConsider Cox 2 inhibitorDRUG SIDE EFFECTS continued:AntidepressantsAssessment Check pain reliefSleep effectivenessCheck: constipation, drowsiness, light-headednessDry mouthInterventionsSide effect interventions as above for problem identifiedAnticonvulsantsAssessment:Check pain relief effectivenessRashes, sore throatCheck other medication taken Check for drug interactionsInterventionsSide effect interventions as for all drugs.Resources;Patients: Self help information sheets onIndividual drug typesUnderstanding drugs for chronic painManagement of constipationClinicians: Up to date BNF and Clinical Evidence sourcesSLEEP DIFFICULTIESAssessment:Clarification of the type of sleep difficultyWhat is the sleep pattern? Is the problem insomnia or excessive daytime drowsinessIs 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 factorsExclude sleep apnoea via patient.co.uk/ resources for professionalsSleep Difficulties InterventionsInsomniaSleep education via sleep diary and informationPatient problem solving Relaxation via diaphragmatic breathing, progressive muscle relaxation, mental imageryStretches on waking or prior to sleep timeTreat depression / anxiety with appropriate SSRI or Tricyclic antidepressant as local or national guidelines suggest .Improve pain management via analgesia, TCA’s (such Amitriptyline), avoid Benzodiazepines, optimise medication and review and stop if no improvement in sleep or daily living activities/personal goals.Daytime drowsinessMinimise drug side effects by adjusting dose, timingResourcesPatient self help material on use of analgesics and sleep management my.livewellwithpain.co.uk. Use this my.livewellwithpain.co.uk sleep information sheet to access helpful web sitesRelaxation information handouts / tapes – download free relaxation resurcesPHQ9 / GAD7 to assess severity of depression/anxietyReferral to GP for management of depression/anxiety with drugsPsychologist with focus on CBT type therapiesRange of self help resources: The Sleep book Guy MeadowsOvercoming Insomnia Colin Espie ; digital CBT programme on line ? free accessPhysical Role Functioning ProblemsMOBILITY DIFFICULTIESAssessment:Is it pain related? Is it stiffness related?Is it weakness related?Is it balance related?Is it fear relatedCan 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?InterventionsStretchesExercises including trunk / pelvic stability workRegular or daily walkingHydrotherapyStamina building by graded exercise/activities e.g walking, swimming, dancing, exercise bike Use of aids if context is appropriateBalance & Walking Group at Rehabiliation type CentreBiomechanical assessment at HPCResourcesSelf help information: Keeping physically active, goal setting, pacing skillsHealthy eating information and support via Practice Nurse or local health/other resourcesPhysiotherapySelf help groups in community forFibromyalgia group, Back or Spinal pain Lets get active programmes suitable for those with painSwimming pool venues information Access Bus service informationSocial Services for Disability Blue Badge rules and regulations or similarMotability information including details of local disability centre ( for example see )BALANCE DIFFICULTIESAssessment:Is it due to dizziness?Is it due to ear / vertobrobasilar insufficiency (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?InterventionsBalance & Walking Group at ...... locationBiomechanical Assessment at locationCooksey Cawthorne exercises via PhysiotherapyAppropriate aidsResourcesSelf help information: Balance exercise sheetsIncrease physical activity via graded exposurePACING DIFFICULTIESAssessment:Identify the style of pacing, is it overactive / underactive / mixed pattern?InterventionsPatient educationWeekly Activity diaryGoal settingProblem solving skillsRelaxation skillsResourcesSelf help information: How to improve pacing including case history examplesSee Resources sheet in for books and other suggestionsWeekly activity diary to spot patterns of unhelpful pacing and plan making changesWebsite for more information on managing pain with section on pacing for more information on Tai Chi, yoga or specific programmes aimed at supporting balance activityIMPROVING FITNESSAssessment: What is the present level of activity? Patient activity log /diary/app recordWhat were the person’s previous interests / levels of activity?InterventionsEmphasis on graded exercise programme: stretch, strengthen and stamina programme including cardiovascular fitnessGoal setting using SMART- ERLearning Pacing skillsProblem solving skillsHydrotherapy advice sessionAccess local physical exercise programmesResourcesSelf help informationArthritis UK leaflet “Keep Moving”Keeping physically activePublic swimming baths and session timesRange of local physical activity programmes and including Mind or Mental HealthFibromyalgia Support Group or others details locallyEmotional and social role functioning problems (Psychosocial)DEPRESSIONAssessment: check out the followingICD -10 DIAGNOSTIC GUIDELINES FOR DEPRESSION - F321.Depressed mood for two weeks2.Loss of interest3.Fatigue or decreased energy4.Loss of confidence or self-esteem5.Self-reproach or guilt6.Recurrent thoughts of death, suicide or suicidal behaviour7.Diminished concentration or indecisiveness8.Agitation or retardation9.Sleep disturbance (insomnia or hypersomnia)10.Appetite and weight change (increase or decrease)ICD-10Severe depression: eight symptoms including 1&2 or 3Moderate depression: six symptoms including two of 1,2 or 3Mild depression: four symptoms including two of 1&2 or 3Diagnosis and severity of depression including suicidal risk assessment.Interventions: Clarify diagnosis and treatment:GP for drug treatment and access to mental health services/counselling if severe depression and not respondingIAPT or local CBT based therapy services services; Low intensity service input from PWP for brief assessment of needs and access to relevant self helpClinical Health Psychology Service where it can be clarified if the depression is primarily ‘pain’ or ‘life events’ related – and appropriate therapy/referral instigatedSelf help informationfor range of mood resources for depression, anxiety, sleep and anger Help groups National mental health support Mind; Depression and Anxiety Self Help groupsAntidepressantsPatient information resources specifically on Use of antidepressants which increases patient’s more effective use of medicationTricyclic antidepressants: amitriptylline, dothiepin, doxepin, trazodone, Life difficulties e.g. FinancialBenefitsHousing Welfare Rights or Citizens Advice BureauPsychosocial interventionsSocial Services/Community Mental Health TeamResourcesPHQ 9 /GAD 7 for ongoing assessment etcGP prescription for self help resources via libraries for mental health Managing moods self help material as previously listed Managing Mental Health ? local mental resources guide - link into this resource if availableWebsite information sheet to access helpful trusted web sitesANXIETY DISORDERS:AssessmentClarify if fearful of movement with avoidance or safety behaviours Assess if any concerns or fears related to pain or otherwiseCheck bodily symptoms: sweating, palpitations, feeling tense or agitated, chest tightnessCheck: Average daily intake of tea/coffee/colaAverage weekly alcohol intakeAverage drug misuse, prescribed or illegalAssess if excessive use of drugs such as asthma inhalers; salbutamol etcAssess if has panic attacks and related to places, people, activitiesAssess severity of disorder with PHQ questionnaireInterventionsSelf help information for patients to understand their anxiety and how to manage itReferral to GP for treatment or referral to local mental health servicesReferral or self referral IAPT or relevant psychological servicesResourcesGAD 7 questionnaire Overcoming anxiety self help materials help groups information: e.g. Leeds Mind information Website information sheet to access helpful web sites for mental health locally or nationallyPOST TRAUMATIC STRESS DISORDERAssessment Clarify presence of symptoms: nightmares, flashbacks, disturbed sleep patterns, excessively anxious, guilt feelings, hypervigilance.InterventionSelf management resources offered: Referral/self referral to IAPT service / Pyschology Services/ Help for Heroes/Combat Stress etcANGERAssessment Clarify if anger related to pain and its impact on the patient’s life OR other issues in their lives at presentClarify if excess use of alcohol/prescribed drugs /cannabis or other mind altering drugsClarify if patient would like help to address their anger problem.InterventionSelf help Information: Managing Moods: Anger ntw.nhs.uk/pic/selfhelpReferral to IAPT for assessment/intervention related to physical health problemsReferral for drug/alcohol servicesResourcesSelf help information sheets ntw.nhs.uk/pic/selfhelpWebsite information sheet to access helpful web sitesALCOHOL/DRUG MISUSEAssessmentClarify if patient is misusing alcohol: either use the AUDIT questionnaire or ask the patient about their weekly consumption of alcohol:NB Healthy drinking limits: Male <14-21 units/week Female <14units/weekInterventionBlood test; assess impact on liver function; gamma glutamyl transpeptidase levelsClinical examination for hepatomegaly and signs of alcoholic liver diseaseReferral for further management via local drug and alcohol servicesSelf help information: How to cut down on drinking resourcesResourcesSelf help information on how to cut down on drinkingLocal alcohol servicesInformation sheets on local servicesRELATIONSHIP DIFFICULTIESAssessmentAssess if any significant impact on close relationships and if currently would like helpInterventionSelf help information: Relationships and communication AssertivenessAngerReferral to access to primary care based counsellingOffer information on Relate servicesOffer information about other services via local mental health for e.g Leeds / Leeds MindResourcesInformation and referral forms for RelateSelf help information on anger, relationships and communicationMental Health Services guide for LeedsShare about family mediation services if availableSEXUAL DIFFICULTIESAssessmentClarify sexual difficulty if appropriate and possible in the context of the assessmentCommon difficulties are: reduced libido; increased or fear of pain increase; impotence, ejaculation dysfunction, orgasmic problemsInterventionProvide information on Relate service locallyReferral: access to local psychosexual service or RelateResourcesSelf help information: Changing Life Situations; Chronic pain and sex in Overcoming Chronic Pain Cole et al 2005 RobinsonWebsite information CARERS NEEDSAssessment Assess if disability means reliance on a carer for a range of daily living activitiesIdentify if evidence of carer stress or difficulties due to carer health problems or depression eg denial or over-protectiveIdentify if young carers under 18 years involved Intervention Self help information: share information on local support services in Leeds and if Young Carer’s service/support via Dr Barnardo’sResourcesInformation packs on local carer support network including Young Carer SchemesFINANCIAL ISSUESAssessmentIdentify 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?Intervention:Self-help information about help with debt, paying bills, accessing benefitsResourcesInformation with Citizens Advice Bureau details etc.Practical Problem Solving handout Information about where to address Benefit entitlements and relevant trustworthy website in Leeds CONTINUING TO WORKAssessmentIdentify patient’s goal with current workIf on sick leave in current work what is needed to enable them to continue?Less hoursPhased return to workErgonomic assessmentPractical help to improve Access to Work InterventionSelf-help information in local area/communityOffer support either via GP or direct to employer where patient requests such support; usually a written letterEncourage patient to liaise with employer and negotiate appropriately for their needs ? local service to help hereResourcesAccess to Work’ information (Regional Disability Service) so can make contactDisability at Work schemesErgonomic assessment via Physiotherapist or Occupational Therapy referralAssertiveness information sheet TO WORK or STAY IN WORKAssessmentIdentify patient’s goal about returning to workIf on sick leave in current work what is needed to enable them to continue?Less hoursPhased return to workErgonomic assessmentPractical help to improve Access to WorkInterventionProvide current information about help on schemes to return to work or training.Offer support either via GP or direct to employer where patient requests such support; usually a written letterResourcesInformation details:Disability support service‘Access to Work’ informationWorkability schemesDisability Access Technology Advice and training courses informationGo 4 / Connexions for career and/or retraining assessmentLocal Community Education centres or vocational colleges may offer career and/or retraining assessment. ................
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