New Chronic Pain Guidelines Published CME
Cilj novih smjernica za liječenje kronične boli je optimizirati kontrolu boli, poboljšati funkcionalnost bolesnika, njegovo fizičko i psihičko osjećanje, poboljšati kvalitetu života i minimizirati neželjene posljedice. One se odnose na bolesnike s kroničnom ne-karcinomskom boli, somatskom boli i visceralnim bolnim sindromima.
April 6, 2010 ( Updated with commentary April 20, 2010 ) — 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.
“The major change with this guideline is the fact that the guideline is developed from the perspective of interventions used to treat chronic pain,” lead study author Richard Rosenquist, MD, from the University of Iowa Hospital, Iowa City, said in an interview. “Instead of looking at how to treat a given diagnosis, such as low back pain, the guideline examines the evidence to support the use of a broad range of interventions to treat chronic pain.”
The objectives are to optimize pain control, enhance physical and psychological well-being, and minimize adverse outcomes.
The new guidelines appear in the April issue of Anesthesiology.
The 12-member task force consists 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,
- botulinum toxin,
- electrical nerve stimulation,
- epidural steroids,
- intrathecal drug therapies,
- inimally invasive spinal procedures,
- pharmacologic management,
- physical therapy,
- psychological treatment, and
- trigger point injections.
The task force defines chronic pain as pain of any cause 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.
Asked by Medscape Neurology to comment, Roger Chou, MD, lead author of the American Pain Society and American Academy of Pain Medicine opioids guidelines, raised concerns that the approach is so broad, covering all interventions for any type of chronic pain, that it might be difficult to apply in clinical practice.
Guidelines Too Broad?
“The guideline has to cover so many areas that it is difficult to understand the nuances of how to use the different interventions or provide detail on how to individualize their use to specific patients and situations,” said Dr. Chou from the Oregon Health and Science University in Portland.
Dr. Chou also raises concerns about task force reliance on observational studies recommending interventions — even when randomized controlled trials are available that show no benefit.
“For example, the vertebroplasty recommendation,” Dr. Chou said. “It is difficult to justify using observational studies to trump well-done randomized controlled trials.”
He suggests the recommendations do not take into account the magnitude of clinical benefit or the presence and degree of inconsistency among studies.
“If you have well-done randomized controlled trials that come up with different results, that means you can’t even replicate results in highly controlled conditions,” Dr. Chou said. “Why would we think we can reproduce the results in the far messier world of clinical practice?”
He added, “Any statistical heterogeneity is buried in the appendix tables showing the results of the meta-analyses, and there isn’t enough detail to determine whether pooling was appropriate in the first place or even which studies were pooled.”
There are situations, he says, like radiofrequency ablation, where some trials found no benefit and others found some benefit. “And the overall benefit is not large even in the positive trials yet the recommendation is ‘strong’ to do it.”
Dr. Chou said the task force’s decision to survey members and consultants and include these opinions when making recommendations introduces the possibility of stakeholder bias.
Debating the Recommendations
“There is obvious financial self-interest for pain specialists to want recommendations that support use of procedures that they perform,” Dr. Chou said. “It is also doubtful that many of the surveyed folks were well versed in the evidence and the issues in interpretation of the evidence. Rather, many were probably voting by their gut reaction or simply according to how they already practice. This process seems more consistent with a popularity contest than an evidence-based process,” he said.
Dr. Rosenquist counters that the American Society of Anesthesiologists guideline process is extremely rigorous and incorporates a number of steps that are not used by other groups.
He acknowledges the new guidelines are generally supportive of interventional procedures and are not entirely congruent with other recent guidelines. The process varies among groups, he said, and this will have an impact on recommendations.
The task force is evaluating external response and is planning to update the guidelines again in 5 years. This latest version covers a range of advances not included in the first guidelines 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 American Society of Anesthesiologists task force were not provided. Dr. Chou has disclosed no relevant financial relationships.
Chronic pain is a common phenomenon seen in a variety of settings. 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. It is important to address and manage chronic pain and to be aware of resources available for patients.
The purpose of these guidelines for chronic pain management is to optimize pain control, enhance functional abilities and physical and psychologic well-being, enhance quality of life, and minimize adverse outcomes. The guidelines apply to patients with chronic noncancer neuropathic, somatic, or visceral pain syndromes.
- 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.
- 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.