Recommendations 1–4

  • Nearly 20% of Australians suffer from persistent pain, primarily > 65 years old
  • Pain is a personal experience, occurring when and where the patient states Urgent
  • For acute pain see the Primary Clinical Care Manual
  • Persistent pain not responding to intervention may indicate serious underlying pathology; investigate and refer to Persistent pain services (Resource 1.)

1. What is Persistent pain? 1,3,4

  • An ongoing unpleasant sensory and emotional experience not always related to tissue damage
  • Pain persists because of ongoing neurological system changes. With multidisciplinary treatment these changes can be reversed with time
  • Causes may include:
    • ongoing pathology related to chronic conditions
    • cancer or non-cancer origins
    • an acute originating event that is no longer active
    • no easily recognised pathology
  • May lead to life altering physical and psychosocial consequences including:
    • de-conditioning and changes to posture and psyche
    • poor sleep hygiene
    • altered appetite
    • unhealthy behaviours and thoughts
    • depression and anxiety
    • social exclusion
    • reduced confidence
    • drug dependence
    • risk taking
    • family, colleagues and community disconnection due to stigma

Table 1. Factors influencing a persons perception of pain 1,3,4

Factor

Examples

Altered mood

  • Depression
  • Anxiety
  • Delirium
  • Uncertainty
  • Anger
  • Guilt

Past pain experiences

  • Childhood experiences
  • Parenting
  • Social media
  • Social stigma
  • Fearful events

Symptoms

  • Fatigue from insomnia
  • Persistent nausea from treatment

Culture

  • Language
  • Communication
  • Religion
  • Spirituality
  • Beliefs
  • Community

Response

  • Active
  • Passive

Social

  • Health system
  • Family and family expectations
  • Work and income
  • Friendships and personal relationships

2. Diagnosing persistent pain 1,3,4

  • A patient’s pain needs to be accurately evaluated to provide the best outcomes
Listen to and believe the patient’s description of their pain and the experience and meaning they ascribe to it
  • Thorough assessment and baseline measurements of pain and function ensures treatment responses are monitored and interventions tailored. Assessment includes:
    • the cause, its nature, location, timing and onset
    • the radiation or if it moves about
    • the quality or how the patient describes the pain
    • the severity using a pain scale. See Resource 2.
    • aggravating and relieving factors
    • the impact on the patient
    • factors influencing the person’s perception of pain. See Table 1.
    • diagnosed chronic condition symptoms and disease processes
    • the presence of Red Flags e.g. weight loss, history of malignancy, urinary retention, incontinence, sexual dysfunction, night pain or sweats, IV drug use
    • any abnormal response to stimuli
    • drug related pain
    • cognition. See Cognition and recall.
    • a systems and neurological examination. See Table 2.
  • Terms to describe pain include:
    • allodynia: pain in response to non-painful stimuli e.g. cuddling
    • hyperalgesia: hyper-response to stimuli e.g. pinprick or pressure
    • hyperpathia: increased severity in response to repetitive stimulus e.g. poking

Table 2. Types of pain 1

Type

Description

Nociceptive pain

  • Actual or threatened damage to non-neural tissue
  • Due to activation of sensitive receptors superficially (e.g. skin) or deep tissues (e.g. body organ, bone)

Neuropathic pain

  • Caused by a lesion or disease of the nervous system

Breakthrough pain

  • The pain experienced between regular doses of an analgesic
  • Can be an occasional natural fluctuation
  • Regularity indicates inadequate analgesia and management

Incident pain

  • Incident pain occurs with or is exacerbated by:
    • physical activity
    • an event i.e. wound care
    • coughing

3. Management of persistent pain 1,3,4

  • The goal of managing persistent pain is to improve a patients quality of life by encouraging and supporting them to:
    • be as independent as is feasible and safe
    • participate in leisure and productive activities
    • re-engage in family and community roles
    • return to driving (if appropriate)
    • access the wider community
    • maintain quality relationships with significant others
  • Prior to managing persistent pain review current or previous:
    • pain management strategies
    • dosage, choice and efficacy of medicines
  • Consult Persistent pain management services for treatment and management advice for complex persistent pain patients. See Resource 1.
  1. Support patient self-management 1–4
    • Discuss early warning signs for onset of pain and what to do i.e. enact treatment plan (below)
    • Encourage effective active management strategies (e.g. physical activity, social connection, nutrition) over passive techniques (e.g. analgesics, massage). 66% of people take medicines without active management strategies
    • Engaging our patients to identify barriers to adequate lifestyle modification and clinical adherence and develop goals to overcome those barriers
    • Provide persistent pain resources. See Resource 3.
    • Consult Persistent pain management services who help support patients with self-management techniques. See Resource 1.
  2. Social-emotional support 1–4
    • Altered Social-emotional wellbeing and social isolation is common with persistent pain
    • Maintaining social links improves feelings of worth and belonging and benefits pain reduction
    • Support patient to:
      • join and maintain a local or online pain support group
      • maintain or return to employment
      • volunteer in community group activities
  3. Social, spiritual and cultural support 1
    • Aboriginal and Torres Strait Islander Health Worker should engage and support the patient in the first instance
    • For complex issues refer to a psychologist, social worker, counsellor or other members of the multidisciplinary team
    • For cultural support refer to liaison officer, spiritual or traditional healer
  4. Develop a management plan 1–4
    • Develop a plan (Resource 4.) with patient and significant others by exploring:
      • understanding their pain e.g. recognising onset of pain
      • monitoring their pain. See Resource 5.
      • any unhelpful beliefs
      • implementation of management strategies e.g. exercise, medicines, diet
      • expectations and goals of strategies
      • support people
      • response to interventions to determine if other treatments can be offered
      • what actions to take when pain occurs
      • when to seek medical support
  5. Physical activity 1,3–5
    • Physical activity and sleep is a first-line management strategy for persistent pain
    • It can reverse or halt significant de-conditioning, improve mood and functioning, and reduce the impact and severity of pain
    • Strengthening and flexibility exercises can reduce pain in some conditions e.g. osteoarthritis and long-standing spinal pain
    • Long-term physical activity combined with psychotherapy can improve function, conditioning and quality of life
  6. Psychotherapy 3,4,6
    • Considered a first-line (often primary) pain management strategy e.g. cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT)
    • Associated with improved treatment adherence, function, quality of life and reduced analgesic use, distress and disability
    • All clinicians can provide basic techniques e.g. active listening, reassurance and clarifying intervention goals and expectations. See Engaging our patients.
    • Formal psychotherapy:
      • supports patients to identify and challenge unhelpful thoughts, emotions and behaviours to pain, and replace them with more realistic thoughts
      • requires considerable commitment by the person with pain
      • is facilitated by a social worker, mental health worker or psychologist
    • Unhelpful responses to pain include:
      • a tendency to engage in catastrophic thoughts e.g. “this pain is killing me”
      • over activity on less painful days
      • followed by catastrophic thoughts when pain persists again
    • Patients identify goals to defuse unhelpful thoughts of helplessness by:
      • problem solving
      • moderating activity levels and taking regular breaks
      • alternating activities
      • reducing reliance on analgesics or clinicians to resolve the pain for them
  1. Obstructive sleep apnoea (OSA) 1
    • Improving sleep hygiene reduces nervous system stimulation and pain by:
      • reducing screen time and caffeine intake
      • consistent bedtime routines
      • weight loss
      • CPAP therapy
    • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 6.
  2. Thermotherapy 1
    • Heat and cold packs can reduce pain by changing blood flow and nerve conduction and providing distraction and relaxation
    • Used as an adjunct therapy to active strategies
  3. Massage 1,4
    • Passive movement of soft tissue can be effective for chronic lower back pain
    • Used as an adjunct therapy to active strategies. See Resource 7.
  4. Transcutaneous electrical nerve stimulation (TENS) 1
    • A portable low-voltage hyperstimulation device for chronic localised nociceptive and neuropathic pain. See Table 2.
    • Enables the patient to perform activities while being used
    • Taught to those unresponsive to other therapies by a physiotherapist
    • Used as an adjunct therapy to active strategies
  5. Passive movement 1
    • Reduces pain by improving awareness, control, efficient movement patterns and posture
    • Involves physically moving a patient’s body part:
      • passively by the clinician or
      • actively-assisted by the patient and clinician or
      • actively by the patient independently
    • Used passively initially before progressing to Physical activity and sleep.
  6. Relaxation techniques 1
    • Can help some patients with pain and nausea. See Resource 7.
    • Meditation and self-hypnosis requires frequent practice
    • Applied whenever there is more pain than usual
    • Has the advantage of being applied anytime, anywhere
    • Audio direction can be helpful
  7. Occupational therapy 1
    • A workplace and home assessment is undertaken and a patient’s functional capacity evaluated to:
      • restore a patient’s best level of daily activity and
      • maintain their function
    • Patients can be taught ways to manage daily chores and tasks at home by:
      • task simplification
      • using suitable aids e.g. rails, walkers
      • changing how activities are normally performed
  8. Carer support 1,3
    • Caring for a patient with persistent pain is a source of stress, burden and isolation
    • Assess and address the needs of the carer. See Engaging our patients.
    • Involve carers in all service co-ordination and interventions including education, visiting specialists, and telehealth, telephone or online service provision
    • Provide resources and refer to carer support services so carers can address their own needs. See Resources 8.
    • Refer to respite services so carers can take a break. A refreshed carer enables patients to stay in their home longer. See Resource 9.
  9. Opioid tolerance 7
    • Many patients who take long-term opioids will be opioid-tolerant, that is:
      • the effect of the drug decreases over time and
      • higher doses are needed to obtain the same analgesic effect
    • Treating acute pain aims to provide effective analgesia while minimising tolerance and preventing withdrawal
    • Under-estimating pain treatment in opioid-tolerant patients is common, causes withdrawal and can lead to mistrust of medical care
  10. Opioid dependence 7
    • Opioid dependence is a normal physiological response to long-term opioid use associated with withdrawal symptoms during:
      • sudden reduction
      • cessation
      • drug reversal
    • Withdrawal symptoms include:
      • agitation
      • sweating
      • musculoskeletal pain
      • abdominal cramps
      • diarrhoea
      • nausea and vomiting
      • seizures
      • constant goose bumps
  11. Opioid-use disorder (addiction) 7
    • Opioid addictiondiffers from dependence in that it is associated with:
      • above withdrawal symptoms and
      • compulsive drug seeking and drug-taking behaviours for non-medical effects
    • Seek early advice from Persistent pain management services (Resource 1.) when managing:
      • pregnant women
      • risk of tolerance, physical dependence or withdrawal
      • psychological and behavioural characteristics of addiction
      • poly-drug use e.g. alcohol, benzodiazepines, cannabis
      • use of withdrawal medicines e.g. methadone, buprenorphine, naltrexone
      • signs of drug use e.g. organ impairment, infectious diseases
    • Beware of drug diversion tactics; the unlawful channelling of regulated pharmaceuticals for illicit use. See Resources 10–11.
Contemptuous or disapproving attitudes toward patients with an addiction disorder is unethical, disrespectful and unhelpful. Clinicians should be mindful of their own beliefs and behaviours and treat all patients with care and respect

4. Medicines for persistent pain

  • If the focus of treatment changes to palliation see Palliative care.
  1. Prescribing opioids 8,9
    • Opioids are indicated for the management of severe pain where:
      • other treatment options have failed, are contraindicated, not tolerated or are otherwise inappropriate to provide sufficient management of pain, and
      • the pain is opioid-responsive, and
      • requires daily, continuous, long term treatment
    • Monitor to reduce misuse. See Resource 10.
    • Queensland prescribers are required to check QScript (Resource 11.) before prescribing, dispensing or giving a treatment dose of a monitored medicine
    • Develop an opioid contract (Resource 12.) with the patient to provide:
      • education about the medicine and possible effects
      • a clear agreement about the expectations of the treating clinician
      • agreed goals of the trial (e.g. improved pain and function)
      • a plan to wean and cease opioids if goals are not met

Table 3. Quality use of opioids

  • One clinician should be responsible for prescribing
  • Avoid introducing an opioid at the same time as another drug
  • Start with a low dose and adjust slowly according to response
  • Use lower doses in older people and monitor carefully
  • Avoid the use of immediate-release or parenteral opioids
  • Recommend laxatives at the commencement of treatment as needed
  • Check for potential interactions with all patient medicines, drugs or other substances
  • Avoid using benzodiazepines with opioids due to severe sedation and impaired cognition
  • Avoid using opioids for breakthrough pain
  • Regularly review improvement to patient quality of life and function or whether alteration to medicines is required
  • Cease opioid slowly under supervision. Seek specialist advice if uncertain about the weaning procedure
  • For regulatory requirements and resources for prescribing monitored medicines. See Resource 13.
  1. Cancer related pain 7,11
    • Includes pain related to cancer or cancer related treatments or complications
    • Cancer pain may require a rapid and timely escalation of pharmacological management with attention to the mechanism of pain
    • See Flowchart 1. for cancer pain management

Flowchart 1. Cancer pain management 1,7,11

Cancer pain management

  1. Non-cancer related pain 7,10
    • Includes persistent pain related to e.g. trauma, back strain, osteoarthritis
    • Improving function is the aim of managing persistent non-cancer pain. Medicines will only modify the pain moderately
    • Non-pharmacological options should be employed before starting medicines
    • Neuropathic pain, such as with diabetes or stroke, responds poorly to regular analgesics. Adjuvants can be more effective e.g. antidepressants, antiepileptics
    • Regularly review medicine use to assess if quality of life and function is improving
    • See Flowchart 2. for non-cancer pain management

Flowchart 2. Non-cancer pain management 1,7,10

Non-cancer pain management

Table 4. Analgesics for persistent pain 7,10–12

Simple analgesia

  • Rarely relieves pain completely but can modify its severity. Discontinue if no benefit after an adequate trial
  • Reduce dose in those with liver disease, are malnourished, small in size, or frail aged
  • Use the lowest possible dose of NSAID for the shortest time possible. Continual daily use is not recommended
  • Use NSAIDs with caution in frail aged, those with renal or hepatic impairment, history of peptic ulcer disease, hypertension or heart failure

Paracetamol 1g PO, 4–6 hrly (max. 4 g/day) OR

Paracetamol MR 1.33g PO 8-hrly

Ibuprofen 200–400 mg PO tds OR

Naproxen 250–500 mg PO bd

Opioids

  • Side effects include respiratory depression, OSA, fluid retention, impaired cognition and coordination (i.e. falls and fractures), chronic constipation, nausea and vomiting, fluid retention, oedema, dependency and sedation
  • If an initial trial of an opioid is tolerated but ineffective, trialing another opioid is likely to be ineffective

Tapentadol MR 50mg PO once a day to bd. Can increase every 3 days as necessary (max 300mg/day)

Tramadol MR 50mg PO once a day to bd. Can increase every 3 days (max 400mg/day)

Morphine oral MR 5–10 mg PO once a day to bd. Can increase every 3 days (max. 40 mg/day)

Oxycodone oral MR 5 mg PO once a day to bd. Can increase every 3 days (max. 30 mg/day)

Buprenorphine transdermal patch 5 microgs/hr. Can be increased every 7 days (max. 20 microgs/hr)

Table 5. Adjuvants for persistent neuropathic pain 13–17

  • These medicines have numerous side effects such as fatigue, sedation, dizziness, ataxia, tremor, diplopia, nystagmus, amblyopia, amnesia, abnormal thinking, hypertension, vasodilation, peripheral oedema, dry mouth, weight gain, rash, sweating, flushing, rash, muscle cramp, myalgia, arthralgia, urinary incontinence, dysuria, thrombocytopenia
  • For further specific CMI see the Australian Medicines Handbook

Amitriptyline 10–25 mg PO nocte. Can increase every 7 days (max. 75–100 mg nocte)

Gabapentin 100–300 mg PO nocte. Can increase up to tds every 3–7 days (max. 3.6 g/day)

Pregabalin 25–75 mg PO nocte. Can increase up to bd every 2–3 days (to a max. 300 mg bd)

Duloxetine 30mg PO once a day. Can increase every 7 days to max. 120 mg once a day if tolerated

5. Cycle of care

Cycle of care summary for persistent pain

Action

Dx

Frequency

Blood pressure

12 mthly or as condition indicates

BMI

12 mthly or as condition indicates

Weight

12 mthly or as condition indicates

Pulse rate

12 mthly or as condition indicates

eGFR and ACR

When commencing or altering medicines

Assess falls risk

As patient situation changes

Patient education

Each visit–to ensure co-therapies are being attended

Carer support

Each visit

Lifestyle modification

Each visit

Social-emotional wellbeing

Each visit

Influenza, pneumococcal and covid vaccines

Recommended. See the Australian Immunisation Handbook for schedule

Pain team/specialist/oncologist

As determined by team and specialist

HW/RN

3 mthly

MO/NP

6 mthly

Physiotherapist

At the discretion of the physiotherapist

Occupational therapist

At the discretion of the occupational therapist

6. References

7. Resources

  1. North Queensland Persistent Pain Management Service or Persistent pain management services
  2. Assessment of pain the FLACC pain scale, the Abbey pain scale for non-verbalising people, the Wong Baker FACES Pain rating scale for youth, and the Pain Assessment in Advanced Dementia Scale (PAINAD)
  3. Persistent pain resources
  4. Health management plan and patient resources
  5. The PEG scale for monitoring pain
  6. The Epworth Sleepiness Scale and STOP-Bang questionnaire
  7. Managing your pain resource for patients
  8. Carers Queensland
  9. MyCare respite information
  10. The Prescription Shopping Programme and National Real Time Prescription Monitoring (RTPM)
  11. QScript
  12. Opioid Patient Prescriber Agreement (PPA) or Opioid Treatment Agreement or Drugs of dependence therapy agreement template
  13. Queensland regulatory requirements and resources for prescribing monitored medicines

Last updated: September 2024

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