Certain Tests and Treatments for Chronic Pain Should Be Questioned

Not prescribing opioids first or as a long-term therapy for chronic, non-cancer pain and avoiding MRIs, CTs and X-rays for low-back pain are among the tests and treatments identified by the American Society of Anesthesiologists (ASA) that are commonly ordered but not always necessary. The ASA released its second list of five targeted, evidence-based recommendations that address what care is really necessary.

ASA’s list identified the following recommendations:

1. Opioid analgesics should not be prescribed as a first-line therapy to treat chronic pain.
Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.

2. Opioid analgesics shouldn’t be prescribed as long-term therapy to treat chronic pain until the risks are considered and discussed with the patient. Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.

3. Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications. Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Intravenous sedation shouldn’t be used for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks or joint injections should not be used as the default practice. Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false positive responses ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.

5. Irreversible interventions for pain that carry significant costs and/or risks should be avoided. Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.

“As leaders in patient safety, physician anesthesiologists want the most effective tests and treatments for our patients and we want them to be used appropriately,” said ASA President Jane C. K. Fitch, M.D. “ASA has taken the lead in improving patient safety related to anesthesiology and pain medicine. This Choosing Wisely list can make a positive and significant impact on patient care and quality.”

To date, nearly 100 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 250 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss. ASA published its first Choosing Wisely list in October, 2013 regarding anesthesiology.

Source: American Society of Anesthesiologists (ASA)