New Chronic Pain Guidelines Published

For the first time in more than a decade, the American Society of Anesthesiologists Task Force on Chronic Pain Management has updated its chronic pain guidelines. Original Article at http://cme.medscape.com/viewarticle/719781

The new recommendations are designed to help clinicians who treat pain. The objectives are to optimize pain control, enhance physical and psychological well-being, and minimize adverse outcomes.

Richard Rosenquist, MD, from the University of Iowa Hospital, Iowa City, led the 12-member task force of anesthesiologists in both private and academic practice from various parts of the United States. The group also worked with members of the American Society of Regional Anesthesia and Pain Medicine.

The new guidelines appear in the April issue of Anesthesiology.

The recommendations apply to patients with chronic noncancer, neuropathic, somatic, or visceral pain. The task force focused on interventional diagnostic procedures including diagnostic joint block, nerve block, and neuraxial opioid trials.

Focus on Interventional Diagnostic Procedures

The team agreed that findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide an individualized treatment plan focused on optimizing the risk-to-benefit ratio. Treatment should progress from a lesser to greater degree of invasiveness.

“Whenever possible,” the task force reports, “direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care.”

The new guidelines advocate for multimodal interventions for patients with chronic pain. The task force suggests that a long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy. In addition, when available, multidisciplinary programs may be used.

The new guidelines detail

• ablative techniques,
• acupuncture,
• blocks,
• botulinum toxin,
• electrical nerve stimulation,
• epidural steroids,
• intrathecal drug therapies,
• minimally invasive spinal procedures,
• pharmacologic management,
• physical therapy,
• psychological treatment, and
• trigger point injections.

The task force defines chronic pain as pain of any etiology not directly related to neoplastic involvement associated with a medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing and adversely affecting the function or well-being of the individual.

Drugs for chronic pain include anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, nonsteroidal anti-inflammatories, opioid therapy, skeletal muscle relaxants, and topical agents. The task force discusses each in detail and recommends strategies for monitoring and managing adverse effects and patient compliance.

The new guidelines cover a range of advances not included in the initial version published in 1997. As a result, the number of pages has more than doubled in the new publication. The complete guidelines are available online.

Financial disclosures for the 12 members of the American Society of Anesthesiologists Task Force on Chronic Pain Management were not provided.

Anesthesiology. 2010;112:810-833.

Clinical Context

Study Highlights

• All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.
• A pain history should include a general medical history with emphasis on the chronology and symptomatology of the presenting complaints; a history of current illness; and a review of previous diagnostic tests, results of previous therapies, and current therapies.
• The causes as well as the effects of pain (eg, the ability to perform activities of daily living, changes in occupational status) and the impacts of previous treatment should be evaluated and documented.
• The psychosocial evaluation should include information about the presence of psychologic symptoms (eg, anxiety, depression, or anger), psychiatric disorders, personality traits or states, history of substance or current medication use or misuse, and coping mechanisms.
• The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation.
• Appropriate diagnostic procedures may be conducted as part of a patient’s evaluation, based on a patient’s clinical presentation.
• The choice of an interventional diagnostic procedure (eg, selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, and provocative discography) should be based on the patient’s specific history and physical examination and anticipated course of treatment.
• Multimodal interventions should be part of a treatment strategy for patients with chronic pain. Also, a long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.
• The following single-modality interventions are often explored and are used in conjunction with multimodal interventions:
  • Ablative techniques are used; however, other treatment modalities should be attempted before consideration of these techniques.
  • Acupuncture may be considered as an adjuvant to conventional therapy in the treatment of nonspecific, noninflammatory low back pain.
  • Intraarticular facet joint injections may be used for the symptomatic relief of facet-mediated pain and sacroiliac joint injections for the symptomatic relief of sacroiliac joint pain.
  • Nerve and nerve root blocks such as celiac plexus blocks, lumbar sympathetic blocks, sympathetic nerve blocks, medial branch blocks, and peripheral somatic nerve blocks may be used.
  • Botulinum toxin may be used as an adjunct for the treatment of piriformis syndrome.
  • Neuromodulation with electrical stimulus, such as subcutaneous peripheral nerve stimulation and spinal cord stimulation, may be used. Shared decision making should include a specific discussion of potential complications associated with spinal cord stimulator placement.
  • Transcutaneous electrical nerve stimulation should be used for pain management in patients with chronic back pain and may be used for other pain conditions.
  • Epidural steroid injections with or without local anesthetics may provide pain relief in selected patients with radicular pain or radiculopathy. Transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before a therapeutic substance is injected.
  • Intrathecal neurolytic blocks should not be performed in the routine treatment of patients with noncancer pain.
  • Intrathecal preservative-free steroid injections may be used for the relief of intractable postherpetic neuralgia nonresponsive to previous therapies. Ziconotide infusion is used in the treatment of a select subset of patients with refractory chronic pain.
  • Intrathecal opioid injection or infusion may be used for patients with neuropathic pain; however, neuraxial opioid trials should be performed before permanent implantation of intrathecal drug delivery systems is considered.
• Minimally invasive spinal procedures (eg, vertebroplasty) may be used for the treatment of pain related to vertebral compression fractures.
• The following pharmacologic treatments can also be used for chronic pain:
  • Anticonvulsants and antidepressants should be used as part of a multimodal strategy for patients with chronic pain.
  • Extended-release oral opioids should be used for neuropathic or back pain patients, as well as transdermal, sublingual, and immediate-release oral opioids.
  • For selected patients, ionotropic N-methyl-D-aspartate receptor antagonists (eg, neuropathic pain), nonsteroidal anti-inflammatory drugs (eg, back pain), and topical agents (eg, peripheral neuropathic pain) may be used, and benzodiazepines and skeletal muscle relaxants may be considered.
  • A strategy for monitoring and managing adverse effects and compliance should be considered for all patients undergoing any long-term pharmacologic therapy.
• Physical or restorative therapy may be used for patients with low back pain and for other chronic pain conditions.
• Cognitive behavioral therapy, biofeedback, or relaxation training as well as supportive psychotherapy, group therapy, or counseling should be considered for patients with chronic pain conditions.

Clinical Implications

• Chronic pain is defined as pain of any cause not directly related to neoplastic involvement, associated with a chronic medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing, and adversely affecting the function or well-being of the individual.
• Chronic pain management usually includes multimodal interventions, pharmacologic management, and cognitive behavioral therapy. A long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.

Tags: Dolore, News