Download St. Paul`s Hospital COMPLEX PAIN CENTRE Rm. 4B

St. Paul’s Hospital
COMPLEX PAIN CENTRE
Rm. 4B-437, 1081 Burrard Street
Vancouver, BC V6Z 1Y6
TEL: 604-682-2344 EXT. 62896
FAX: 604-806-8782
GENERAL PROGRAM DESCRIPTION
This Interdisciplinary Pain Management Program is for patients requiring treatment of severe pain that
has proven unresponsive to conventional approaches. Emphasis is placed on self-management and
rehabilitation / activation within the context of specialized medical assessment and treatment.
1. All patients will participate in an introductory education session and program orientation.
2. Consultations and visits can include both individual and group sessions, and will be individualized
for each patient.
3. Disciplines involved with pain management in this program include:
 Anesthesiologists trained in interventional techniques

 Psychiatry

 Physical Medicine and Rehabilitation

 Internal Medicine

 Neurosurgery

Psychology
Nursing
Physiotherapy
Occupational Therapy
Social Work
The treatment provided by the Complex Pain Centre is specialized and is not open-ended;
patients will be followed by their family physicians during and following their participation
in the program.
The program is offered to patients within the catchment area of the Vancouver Coastal Health
Authority, with exceptions only for Inpatients and Neuromodulation treatment.
For the purpose of continuity of care, exceptional consideration may also be given to patients
living outside the Vancouver Coastal Health Authority but who maintain a significant, ongoing
clinical relationship with other physicians and programs at St. Paul’s Hospital.
INCLUSION CRITERIA:
 Patient has evidence of acute cancer or neuropathic pain (e.g. Complex Regional Pain Syndrome).
 Patient has evidence of sub-acute or complex pain which is unresponsive to conventional treatments.
 All appropriate investigations have been completed including: spinal pain: bone scan within past
6 months; plain x-ray and CBC
 Patients over 60 years old OR with history of malignancy OR radiculopathy: CT or MRI within
past 18 months
 Chronic headaches: neurological consultation + CT or MRI cervical spine within past 24 months
 Full completion of referral package, including referring physician agreement to remain clinically
involved during and following program and maintaining responsibility for pain-related prescriptions
after program completion.
EXCLUSION CRITERIA:
 Patient cognitively unable to participate in multidisciplinary assessment and treatment program
 Patient is psychiatrically unstable (e.g. active psychosis, severe depression, actively suicidal)
 Patient is actively abusing prescription or recreational drugs and/or unwilling to consider dose
reduction, modification, or streamlining of medication as possible components of treatment
 Referral source’s primary goal is a medical-legal consultation, or to obtain “medical marijuana”
 Patient has an orthopedic condition or injury and is currently awaiting planned surgical treatment
 Patient has an infection or significant communicable disease posing risk to staff and other patients.
 Chronic pelvic pain requiring further diagnostic clarification.
ADDITIONAL RESOURCES:
RACE hotline for GP support: 604-696-2131, or toll-free 1-877-696-2131 Monday to Friday, 8 am to 5 pm
www.painbc.ca
Form No. OP103 (R. Oct 3-12)
www.canadianpaincoalition.ca
www.cirpd.org
St. Paul’s Hospital
COMPLEX PAIN CENTRE
REFERRAL
Rm. 4B-437, 1081 Burrard Street
Vancouver, BC V6Z 1Y6
TEL: 604-682-2344 EXT. 62896 or 604-806-8019
FAX: 604-806-8782
REFERRAL INSTRUCTIONS:
1. Complete ALL PAGES of the Referral form including Patient Pain History. PLEASE PRINT CLEARLY
2. Fax completed referral package to 604-806-8782. We will contact the patient directly to set-up an appointment.
Include the following information as part of the package:  All specialist consult reports and investigations
 A printout of patient’s CURRENT medications
IMPORTANT: If pertinent information is missing, the referral will be returned to you and your patient will not be waitlisted.
New patient
Re-referral
PATIENT NAME:
Gender:
Date of Birth: (dd/mmm/yyyy)
PHN #:
Male
Female
Address:
Phone:
Home:
Cell:
Work:
REFERRING MD:
Phone:
Fax:
Area of Expertise:
GP: (if not referring MD)
Phone:
Fax:
I have read the program description of the St. Paul’s Hospital Complex Pain Centre and acknowledge that it is a time-limited
program. In referring this patient, I agree to accept responsibility for ongoing care once this patient is discharged from the
Complex Pain Centre. I acknowledge that this may include prescribing opioid and other pain-modifying medications.
Signature of Referring MD
Printed Name
PRIMARY REASON FOR REFERRAL: (confirmed or suspected):
Musculoskeletal Pain
Myofascial Pain Syndrome
Chronic Daily Headache
Arthritis (osteo or rheumatoid)
Migraines
Herpetic Neuralgia
Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)
Other:
DURATION OF PAIN:
Less than 6 months
6 to 24 months
Low Back Pain WITH Radiculopathy
Low Back Pain WITHOUT Radiculopathy
Fibromyalgia
Temporomandibular joint pain
Unknown:
More than 24 months
PREVIOUS INVESTIGATIONS AND CONSULTATIONS: (attach all reports)
We expect that all appropriate initial investigations have already been performed by the referring doctor.
Imaging:
Date
Specialist consult reports (including surgical reports)
CT Scan
X-ray
Lab Work
MRI
Bone Scan
Physiotherapy/Occupational Therapy Assessment
Form No. OP103 (R. Oct 3-12)
Page 1 of 3
St. Paul’s Hospital
COMPLEX PAIN CENTRE
REFERRAL
PATIENT PAIN HISTORY
BRIEF PAIN HISTORY: Inciting Event
MVA Date:
ICBC Case:
Yes
Workplace Injury
WorksafeBC (WCB):
No
Yes #
Other Injury:
Post Surgery
Post Illness
Other:
Patient has disabling pain, but with better pain management the patient is likely to return to, or remain at, work.
Which Statement BEST describes the patient:
Emerging Pain Condition: Relatively uncomplicated medication profile; single treatment/therapies ineffective
(Patient would benefit from an assessment, education and possibly specialized treatment)
Debilitating and Complex Pain Condition: Significant behavioral/emotional involvement; complex medication profile/addiction issues.
(Patient requires highly specialized medical intervention/multidisciplinary programming)
PAIN DIAGRAM: Location of Pain
MEDICAL HISTORY:
History of Stroke
Heart Disease
Urological Issues Specify:
Traumatic Brain Injury
COPD/emphysema
Gynecological Issues Specify:
Vision Impairment
Diabetes
Gastrointestinal Issues Specify:
Hearing Impairment
Kidney Disease/Dialysis
History of Cancer Specify:
Hypertension
Liver Disease
Autoimmune Disorder Specify:
Other:
Form No. OP103 (R. Oct 3-12)
Page 2 of 3
St. Paul’s Hospital
COMPLEX PAIN CENTRE
REFERRAL
PATIENT PAIN HISTORY
PSYCHIATRIC HISTORY:
Anxiety Disorder
Mood Disorder PHQ-9
Psychotic Disorder
Personality Disorder
Other:
Psychiatrist currently providing care:
No
Yes
ADDICTION CONCERNS:
No
Yes
Recreational drugs:
No
Yes - specifiy:
Prescription Drugs (e.g. opioids, benzodiazepines)
Details:
PAST TREATMENT HISTORY:
Single Modality Rehabilitation:
Occupational Therapy
Physiotherapy
Chiropractic
Massage therapy
Multidisciplinary Rehabilitation:
Specify Program:
Facility:
Surgery: (specify and provide date)
Previous Psychiatric Admits:
No
Yes - Dates:
Is the patient being followed by a Mental Health Team?
Mental Health Team Name:
Psychiatrist’s name:
Past History
No
No
Yes
Active Issue
Yes - specify:
Alternative Treatments:
Naturopathy
Acupuncture
Other: (specify)
Procedural Treatments:
Epidurals
Sympathetic Blocks
Somatic Nerve Blocks
Psychological Treatments:
Details:
Trigger point injections
Other: (specify)
PREVIOUS MEDICATION TRIALS: (Specify medication name, dosage and reason for discontinuation)
NSAIDs/Acetaminophen:
Anti-depressants:
Opiates:
Anti-convulsants:
Other:
IMPORTANT: Include a printout of patient’s CURRENT medications in the referral package
Form No. OP103 (R. Oct 3-12)
Page 3 of 3