Concerns about the patient history

Consider the following four aspects of the patient’s clinical history (pain history, general health, mental health and social history) when seeking GP advice.

Concerns about pain history

Persistent pain often varies in intensity and sometimes location. It is common for patients on opioids for persistent pain to report gradual worsening of their pain over time and their pain may also flare-up from time to time. Sometimes the reason for this may be apparent and often it is not. This is the natural course of persistent pain.

Discuss with a GP when patients report persistent new pain and/or pain-related symptoms that haven’t yet been discussed before. Pain-related symptoms that would be important to discuss with a GP include:

• pain-related breathlessness, nausea, sweating,
• new history of pain at night.

Concerns about general health

Discuss with a GP when patients:

  • don’t look “well” (pale, very frail) without good cause that has/is not being addressed,
  • present with weight loss for no good reason, night sweats, fatigue.

Concerns about mental health

We outlined how to assess risk in patients with low mood in previous sections. In this section, we recap on this risk assessment with a focus on when to seek advice and support from the GP.

There are other instances where you may need to discuss your patient with a GP and these include:

  • New onset or worsening anxiety/ depression
  • Evidence of self-neglect
  • Visual evidence of recent self-harm or an admission of recent self-harm
  • Hallucinations (hearing or seeing things that aren’t there), delusions (fixed, false or irrational beliefs, despite being confronted by the rational facts), excessive paranoia, or an apparent detachment from reality

If a patient reveals there is a current risk of suicide, make a plan to discuss their case with the GP. The urgency of this discussion will depend on the perceived risk:

Concerns about social history

  • Is the patient drinking alcohol and has this increased following a PROMPPT pain review and a change in the opioid medicines to harmful levels (> 14 units / week for adults)?
  • Any other substance misuse that needs addressing?