Guidelines for Referring Patients
WHEN TO REFER FOR IPCA PAIN EVALUATION/TREATMENT
(Ie: This Is A Place That Does Evaluation, Diagnostic Work Up, Treatment, And Coordination Of Care, a Place To Send The Patient When Management In The Primary Care Clinic Is Not Working, Before Multiple Specialty Referrals)
- Evaluation (not just end of the line treatment!) of subacute and chronic back pain and sciatica and headaches and neuropathies. Urgent evaluation of persistent (outlasting the immediate acute phase of 1-3 weeks) pain following a nerve injury.
- For help with pharmacotherapy.
- Evaluation of any painful condition where straightforward interventions done at the primary care level – such as medication, physical therapy, and complementary medicine techniques have failed to progress the patient.
- Evaluation of patients with prominent psychosocial barriers to improvement in function and comfort. Addiction disorders will need to be evaluated first, if they exist. Call for referral suggestions. (Refer for multidisciplinary evaluation – both physician and pain psychologist).
- Evaluation of a chronically painful condition (greater than 3 months) for which the cause is not clear. We specialize in diagnosis!
- Evaluation of any clearly understood chronically painful condition for which the range of treatment options are not clear, or local options have been exhausted. (for example, subacute and chronic back pain or neck pain, headache).
- Evaluation for candidacy for specific pain relieving therapy or research programs outlined in the IPCA website (Physician, psychologist, and/or orthopedic medicine evaluation, depending on the nature of the treatment in question).
- manual medicine
- interventional techniques such as IDETT, vertebroplasty, neuromodulation, injections, thermal nucleoplasty
When NOT to refer
- When there is active substance abuse. Chronic pain cannot safely or effectively be treated though an outpatient pain medicine clinic when the patient has an active substance use disorder. This patient should be referred for substance abuse treatment, then perhaps for outpatient pain medicine evaluation.
- When there are severe psychosocial issues (homeless and disorganized, out of control family/social situation, for example) and/or active severe mental health co-morbid factors driving the pain presentation. Appropriate treatment would focus on these psychological factors first and foremost, and thus the medical home must be the mental health clinic; and pharmacotherapy for pain must be provided though a mental health clinic setting. This is analogous to the local effort by some of Tucson’s community health centers’ efforts to deliver primary care services in the mental health clinic, not the primary care office. Since mental health has to be considered first in all medical care and decision making, and since clinic staff need to be well trained in handling mental health crises, primary care and pain care is co-delivered with mental health care. Such services may not be available to your patient, but that does not change the fact that there is no safe and effective alternative.
It may be helpful to think of patients as fitting one of three scenarios, when deciding where to make a referral:
These are patients with straightforward painful pathology and minimal psychosocial comorbidity (a herniated intervertebral disc with sciatica, for example). When these patients are coinsistently referred early to IPCA, we have an opportunity to help our primary care colleagues prevent progression to the chronic pain, difficult patient.
These patients can be treated successfully and safely with disease specific intervention (such as physical therapy, injections and surgery); they are good candidates for the IPCA outpatient acute/subacute pain clinic. Often limited psychological interventions such as relaxation training may also be useful, and a pain clinic with interdisciplinary capability is therefore the most appropriate place to refer. In fact, national pain guidelines advocate the interdisciplinary model of care for these patients, based on the emerging outcomes literature that results are better (Chou R Spine May 2009; Vol 34(10):1066-1077).
Complicated severe chronic illness of any sort, or a patient with significant but not overriding psychosocial factors. For these patients, psychosocial factors play a significant role in producing disabilty from pain, and psychosocial issues can derail disease specific treatment efforts (such as back surgery). These patients are candidates for the Chronic Pain Management program at IPCA. These patients should undergo a multidisciplinary evaluation that includes testing and interview to define psychosocial factors. These patients may benefit from more intensive non-pharmacologic cognitive and/or behavioral therapy to help them learn to manage pain optimally and make good use of interventional pain treatment and pain medications. Mental health problems must be aggressively co-treated. Procedural interventions should be judiciously carried out in an interdisciplinary environment. These patients are candidates for referral to a well integrated interdisciplinary pain clinic.
This group of patients have active substance abuse or severe mental health problems as outlined above in “When Not to Refer.“ These are not good candidates for an outpatient pain program like IPCA, they need to be treated through a mental health clinic setting or in the case of active substance use, referred to a substance abuse program.