Should I arrange a pain‑management referral for the patient requesting it due to uncontrolled pain?

When to Arrange Pain Management Referral for Patient Request

Yes, arrange a pain management referral when a patient requests it due to uncontrolled pain, particularly if their pain remains ≥3/10 despite current therapy or if specialized interventions are likely to improve pain relief and function. 1, 2

Key Indications for Pain Management Referral

Primary Referral Criteria

The major indication for specialty pain consultation is when pain is likely to be relieved or function improved with physical, cognitive, or interventional modalities delivered by a specialty service provider 1. This applies when:

• Pain intensity remains ≥3/10 on a 0-10 numeric rating scale despite appropriate analgesic therapy 1
• Failure to achieve adequate analgesia without intolerable side effects from current management 1
• Pain likely to benefit from nerve blocks (e.g., celiac plexus block for upper abdominal pain, superior hypogastric plexus block for pelvic pain, peripheral nerve blocks) 1
• Complex pain requiring multidisciplinary management when monotherapy has failed 2

Specific Clinical Scenarios Requiring Referral

Interventional pain procedures are indicated when: 1

• Well-localized pain syndromes amenable to regional blocks
• Intractable pain requiring intraspinal agents, spinal cord stimulation, or neurodestructive procedures
• Bone lesions requiring radiofrequency ablation or vertebroplasty/kyphoplasty

Substance abuse consultation is needed when: 1

• Questions or concerns exist about medication misuse or diversion
• Evaluation for substance use disorder is required
• Assistance with treatment agreements and limit-setting is necessary

Assessment Before Referral

Document Pain Characteristics

Before referring, establish baseline documentation: 1

• Worst pain in last 24 hours using 0-10 numeric rating scale (the key screening question)
• Average pain and pain "right now"
• Pain quality (aching, burning, shooting, stabbing, tingling—helps identify somatic, visceral, or neuropathic origin)
• Interference with daily activities, work, sleep, mood, and quality of life
• Current analgesic regimen and response to therapy

Identify Red Flags

Assess for oncologic emergencies requiring immediate intervention alongside pain management: 1

• Impending spinal cord compression
• Brain, epidural, or leptomeningeal metastases
• Bone fracture or impending fracture of weight-bearing bone
• Infection, obstructed or perforated viscus

Common Pitfalls to Avoid

Do not view pain clinics as "last resorts" for hopeless cases 3. Early referral when pain is uncontrolled prevents:

• Decreased responsiveness to opioid analgesics from undertreated pain 1
• Development of pseudoaddiction (drug-seeking behaviors arising from unrelieved pain) 1
• Increased psychological distress that amplifies pain perception 1

Prepare the patient adequately before referral: 3

• Explain the purpose and expected outcomes of specialty pain management
• Provide comprehensive documentation including medication list, side effects, and what has been tried 1
• Ensure patient understands this is collaborative care, not abandonment

Role of Primary Provider During Specialty Care

Continue active involvement: 1, 3

• Maintain communication with the pain specialist
• Monitor for medication side effects and complications
• Address comorbidities and psychosocial factors
• Provide ongoing support and reassurance that pain management will continue 1

For patients on opioid agonist therapy (methadone/buprenorphine): 1

• Verify and continue usual OAT dose with the patient's addiction treatment provider
• Reassure patient that addiction treatment will continue uninterrupted
• Recognize that daily opioid treatment requirements must be met before attempting additional analgesia

Documentation Requirements

Provide the pain specialist with: 1

• List of each current medication with dosing instructions
• Potential side effects experienced
• Previous pain therapies attempted and responses
• Psychosocial assessment including substance abuse history, psychiatric history, and risk factors for aberrant medication use
• Patient's goals and expectations for pain management