Top 5 Pain Interventions to Avoid

In the latest response to the call from the American Board of Internal Medicine (ABIM) Foundation for recommendations on the most overused interventions, the American Society of Anesthesiologists (ASA) has issued its list of top 5 tests and therapies that are of questionable usefulness in the field of pain medicine.

Launched in 2012, the ABIM’s “Choosing Wisely” campaign challenges medical associations to develop a list of 5 interventions or tests that are commonly performed but don’t always have much evidence behind them. To date, lists have been developed by the American Academy of Dermatologists, the American Academy of Family Physicians (AAFP), the American Headache Society, and the American College of Chest Physicians along with the American Thoracic Society, among others.
In October 2013, the ASA published its first Choosing Wisely list relating to anesthesiology practices. Now, it has released a list of recommendations related to pain management. The American Pain Society (APS) has also endorsed this list on pain medicine.

“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, MD, in a press release. “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.”

The new list includes the following recommendations for doctors:

1. Don’t prescribe opioid analgesics as first-line therapy to treat chronic noncancer pain. Consider multimodal therapy, including nondrug treatments, such as behavioral and physical therapies, before pharmacologic intervention. If drug therapy appears indicated, try nonopioid medication, such as nonsteroidal anti-inflammatory drugs, or anticonvulsants, before starting opioids.

2. Don’t prescribe opioid analgesics as long-term therapy to treat chronic noncancer pain until the risks are considered and discussed with the patient. Inform patients of the risks of such treatments, including the potential for addiction. Review and sign a written agreement identifying both your and the patient’s responsibilities (eg, urine drug testing) and the consequences of noncompliance with the agreement. Be cautious in coprescribing opioids and benzodiazepines. Proactively evaluate and treat, if indicated, the nearly universal adverse effects of constipation and low testosterone or estrogen.

3. Avoid imaging tests, such as MRI, computed tomography, or radiography, for acute low back pain without specific indications. Avoid these interventions for low back pain in the first 6 weeks after pain begins if there are no specific clinical indications (eg, history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit). Most low back pain doesn’t require imaging, and performing such tests may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Don’t use intravenous sedation, such as propofol, midazolam, or ultra-short-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, as a default practice. (This recommendation does not apply to pediatric patients.) 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. Follow ASA Standards for Basic Anesthetic Monitoring in cases where moderate or deep sedation is provided or anticipated.

5. Avoid irreversible interventions for noncancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation. Such interventions may be costly and carry significant long-term risks of weakness, numbness, or increased pain.

To create this list, members of the ASA’s Committee on Pain Medicine submitted recommendations and then voted on which items to include on the final list. The literature was then searched to provide supporting evidence. The list was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee, and Administrative Council.

“ASA has shown tremendous leadership by releasing its list of tests and treatments they say are commonly done in pain medicine, but aren’t always necessary,” said Richard J. Baron, MD, president and CEO of the ABIM Foundation, in the release. “The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what care they need, and what we can do to reduce waste and overuse in our health care system.”

To date, the Choosing Wisely campaign has covered more than 250 tests and procedures that specialty society partners say are overused and inappropriate, and that physicians and patients should discuss. Almost 100 national and state medical specialty societies, regional health groups, and consumer partners have now participated in conversations about appropriate medical care.