In this week’s Medicare Locals Newsletter was a brief note about referrals to the Royal Adelaide Hospital Pain unit.
Referrals now have to be made on their proforma which I can appreciate would ensure that all the required information has been submitted. But I think I can write a better letter freehand. The space left to write some information is exceedingly small.
What really surprised me were the stated waiting times. Well it didn’t come as a real surprise, but it was illuminating to see the triage system documented
Category 1 – Wait time 1-2 days.
- Refractory cancer pain
Category 2 – Wait time 6 -8 weeks.
- Early neuropathic pain or complex regional pain syndrome (CRPS) < 3 months since onset.
- Patients in whom an interventional procedure may be indicated
- Children whose pain interferes with school attendance
- Pain interfering with sleep or self-care
Category 3 – Wait time 3- 4 months
- Pain < 1 year not responding to GP management; frequent pain exacerbations occasioning Emergency Dept. presentations
- or hospital admissions, neuropathic pain, persistent pain following trauma or surgery, pain associated with marked physical
- interference or emotional distress, children and elderly
Category 4 –Wait time 12 – 24 months
- Pain > 1 year not responding to GP management, diagnostic advice, medication optimization, psychological distress,
- physical interference. These patients will undergo Multidisciplinary assessment.
Okay now for some personal observations on the waiting time.
If I had refractory cancer pain then please, please just start the morphine and midazolam infusion and crank it up until I am not in pain anymore.
Thankyou and good night…..
I think if I had a child who was in so much pain that they couldn’t attend school then a TWO month wait is TWO months TOO long.
I recently helped two patients with a Complex Regional Pain Syndrome. I have to admit this is not a pain I have a lot of experience with. For those who need a refresher, a summary from a Lancet paper (The Lancet Neurology, Volume 10, Issue 7, Pages 637-648) describes what may happen
- Typically, patients with CRPS present after minor or moderate tissue injury (eg, a wrist fracture). In the acute phase, the injured limb is usually extremely painful, red, warm (although sometimes it quickly becomes cold) and swollen. Other features, which are also conﬁned to the injured limb but not conﬁned to the distribution of a speciﬁc nerve or nerve root, include allodynia (whereby usually non-painful stimuli evoke pain) and hyperalgesia (whereby painful stimuli evoke more intense pain than usual), changes in sweating, changes in hair and nail growth, and muscle weakness. In particular, mechanical and thermal hyperalgesia are frequently present in CRPS.
- Pain persists beyond the normal time expected for tissue healing.
Uptodate (which I find is very useful for many things) suggests
- “A multidisciplinary approach is suggested in a guideline for management of CRPS developed by a consensus of experts. Clinical experience suggests that treatment is more effective when begun in stage 1, as soon as the diagnosis is established and before radiographic changes appear. However, it is uncertain whether immediate referral to a specialist in pain management results in superior outcomes compared with referral to physical or occupational therapy for protective and assisted mobilization of the affected limb within pain limits, supplemented by conservative pharmacologic interventions, to be followed by referral to an expert in pain management if the patient does not improve. On the other hand, early referral to an intervention pain specialist for appropriate nerve block can reduce pain and can enable CRPS patients to tolerate aggressive physical therapy.”
As a remote GP without immediate access to pain specialists, occupational therapists, psychiatry and physiotherapy this makes optimal management of a patient with suspected CRPS difficult. Waiting up to 8 weeks to get someone seen at a referral centre for a condition where early recognition and management prevents maladaptive changes, makes it even more difficult for my patient.
Prevention of complex regional pain syndrome would be better. There is evidence that early mobilisation and vitamin C (500mg/daily) may be useful particular for distal wrist fractures ( Zollinger etal J Bone Joint Surg Am. 2007;89:1424-1431) and possibly after foot and ankle surgery (Bessea et al, Foot and Ankle Surgery 15 (2009) 179–182).
Maybe the expression should be an “orange a day keeps the doctor at away”!
Even if I get admitted to hospital and become a category three patient I will have to wait up to 4 months to be seen! Do I wait in hospital, the car park or go home?
Finally, for those poor sods in category four who are still in pain after a year of the best a GP can throw at them, well they get the rawest deal – they have to wait up to 2 years to be seen! Maybe it should be be “Category forgotten“. Surely they should be seen before those who have pain less than 12 months? And what if I am waiting as a category three less than 12 months and then become a category four because my pain has gone on for more than 12 months now. Do I go to the back of the queue?
Seems to me as a country GP that some health dollars need to be used to reduce this waiting list. I wonder whether the number of people with chronic pain waiting to see a pain specialist is on public record or would that be too embarrassing for the SA Health Minister ?
Is it this as bad in other jurisdictions????