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Guideline Summary
Guideline Title
Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.
Bibliographic Source(s)
American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010 Apr;112(4):810-33. [1 reference] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Practice guidelines for chronic pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997 Apr;86(4):995-1004.

Scope

Disease/Condition(s)

Chronic pain

Guideline Category
Evaluation
Management
Clinical Specialty
Anesthesiology
Internal Medicine
Nursing
Physical Medicine and Rehabilitation
Psychiatry
Psychology
Rheumatology
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Patients
Physical Therapists
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
  • To optimize pain control, recognizing that a pain-free state may not be attainable
  • To enhance functional abilities and physical and psychologic well-being
  • To enhance the quality of life of patients
  • To minimize adverse outcomes
Target Population

Patients with chronic noncancer neuropathic, somatic (e.g., myofascial), or visceral pain syndromes

Note: The Guidelines do not apply to patients with acute pain from an injury or postoperative recovery, cancer pain, degenerative major joint disease pain, headache syndromes (e.g., migraine and cluster), temporomandibular joint syndrome, or trigeminal or other neuralgias of the head or face. In addition, the Guidelines do not apply to pediatric patients.

Interventions and Practices Considered

Evaluation

  1. History
  2. Physical examination
  3. Psychosocial evaluation
  4. Interventional diagnostic procedures (selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, provocative discography)

Treatment

  1. Multimodal or multidisciplinary interventions
  2. Single modality interventions
    • Ablative techniques
      • Chemical denervation
      • Cryoablation
      • Thermal intradiscal procedures
      • Intervertebral disc annuloplasty (IDET)
      • Radiofrequency ablation
  3. Acupuncture (adjuvant)
  4. Blocks
    • Joint blocks (intra-articular facet joint injections, sacroiliac joint injections)
    • Nerve and nerve root blocks (celiac plexus blocks, lumbar sympathetic blocks or stellate ganglion blocks, medial branch blocks)
  5. Botulinum toxin
  6. Electrical nerve stimulation
    • Neuromodulation with electrical stimulus (subcutaneous peripheral nerve stimulation, spinal cord stimulation)
    • Transcutaneous electrical nerve stimulation (TENS)
  7. Epidural steroids with or without local anesthetics
  8. Intrathecal drug therapies
    • Neurolytic blocks
    • Intrathecal nonopioid injections
    • Intrathecal opioid injections
  9. Minimally invasive spinal procedures
    • Vertebroplasty
  10. Pharmacologic management
    • Anticonvulsants
    • Antidepressants (tricyclic antidepressants, serotonin–norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors)
    • Other drugs (extended-release oral opioids, N-ionotropic N-methyl-D-aspartate [NMDA], nonsteroidal anti-inflammatory drugs [NSAIDs], benzodiazepines, skeletal muscle relaxants
  11. Physical or restorative therapy
  12. Psychological treatment
    • Cognitive behavioral therapy (biofeedback, relaxation training)
    • Supportive psychotherapy, group therapy, or counseling
  13. Trigger point injections
Major Outcomes Considered
  • Efficacy of analgesia
  • Adverse effects from pain therapy
  • Function and quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

For all American Society of Anesthesiologists (ASA) practice parameters, the initial electronic search is conducted using Pubmed. This search is followed by focused searches, where needed, of databases such as the Cochrane or other specialty databases (e.g., nursing), or the Web sites of targeted journals. Finally, all articles reviewed will include a manual search of listed references.

For these Guidelines, a literature review was used in combination with opinions obtained from expert consultants and other sources (e.g., ASA members, American Society of Regional Anesthesia and Pain Medicine [ASRA] members, open forums, and Internet postings). Both the literature review and opinion data were based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The interventions listed below were examined to assess their impact on a variety of outcomes related to chronic noncancer pain.*

  1. Patient evaluation:
    1. Medical records review or patient condition
    2. Physical examination
    3. Psychological and behavioral evaluation
    4. Interventional diagnostic procedures
      • Diagnostic facet joint block
      • Diagnostic sacroiliac joint block
      • Diagnostic nerve block (e.g., peripheral or sympathetic, medial branch, celiac plexus, and hypogastric)
      • Provocative discography
  2. Multimodal or multidisciplinary pain management programs (e.g., pain centers vs. single discipline care)
  3. Single modality interventions
    1. Ablative techniques:
      Chemical denervation
      Cryoneurolysis or cryoablation
      Thermal intradiscal procedures (intervertebral disc annuloplasty [IDET], transdiscal biacuplasty)
      Conventional or thermal radiofrequency ablation (facet joint, sacroiliac joint, dorsal root ganglion)
    2. Acupuncture
    3. Blocks:
      Joint blocks
      Facet joint injections
      Sacroiliac joint injections
      Nerve or nerve root blocks
      Celiac plexus blocks
      Lumbar sympathetic blocks or lumbar paravertebral sympathectomy
      Medial branch blocks
      Peripheral nerve blocks
      Stellate ganglion blocks or cervical paravertebral sympathectomy
    4. Botox
    5. Electrical nerve stimulation:
      Peripheral nerve stimulation
      Spinal cord or dorsal column stimulation
      Transcutaneous electrical nerve stimulation (TENS)
    6. Epidural steroids:
      Interlaminar steroids versus placebo
      Interlaminar steroids with local anesthetics versus without local anesthetics
      Transforaminal steroids versus placebo
      Transforaminal steroids with local anesthetics versus without local anesthetics
    7. Intrathecal drug therapies
      Intrathecal neurolytic blocks
      Intrathecal nonopioid injection (e.g., ziconotide, clonidine, or local anesthetics)
      Intrathecal opioid injection
    8. Minimally invasive spinal procedures
      Kyphoplasty (percutaneous, glue, and balloon)
      Vertebroplasty
      Percutaneous disc decompression
    9. Pharmacologic interventions
      Anticonvulsants
      Alpha-2-delta calcium channel antagonists
      Sodium channel blockers
      Membrane-stabilizing drugs
      Antidepressants
      Tricyclic antidepressants
      Selective serotonin–norepinephrine reuptake inhibitors
      Selective serotonin reuptake inhibitors
      Benzodiazepines
      N-methyl-D-aspartate (NMDA) receptor antagonists
      Nonsteroidal anti-inflammatory drugs (NSAIDs)
      Opioid therapy
      Sustained or controlled-release opioids
      Tramadol
      Skeletal muscle relaxants
      Topical agents
      Capsaicin
      Lidocaine
      Ketamine
    10. Physical or restorative therapy
    11. Cognitive behavioral therapy, biofeedback, or relaxation training
      Supportive psychotherapy or group therapy
    12. Trigger point injections

For the literature review, potentially relevant clinical studies were identified through electronic and manual searches of the literature. The electronic and manual searches covered a 56-yr period from 1944 to 2009. More than 5,000 citations were initially identified, yielding a total of 2,246 nonoverlapping articles that addressed topics related to the evidence linkages. After a review of the articles, 1,550 studies did not provide direct evidence and were subsequently eliminated. A complete bibliography used to develop these Guidelines, organized by section, is available as Supplemental Digital Content 2, http://links.lww.com/ALN/A566 External Web Site Policy.

*Unless otherwise specified, outcomes for the listed interventions refer to pain scores or relief, health, and functional outcomes.

Number of Source Documents

A total of 696 articles contained direct linkage-related evidence.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Scientific Evidence

Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g., randomized controlled trials, observational studies, and case reports) relevant to each topic was considered when evaluating the findings. However for reporting purposes in this document, only the highest level of evidence (i.e., levels 1, 2, or 3 identified below) within each category (i.e., A, B, or C) is included in the summary.

Category A: Supportive Literature

Randomized controlled trials report statistically significant (P<0.01) differences among clinical interventions for a specified clinical outcome.

Level 1: The literature contains multiple randomized controlled trials, and the aggregated findings are supported by meta-analysis.*

Level 2: The literature contains multiple randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of these Guidelines.

Level 3: The literature contains a single randomized controlled trial.

*All meta-analyses are conducted by the American Society of Anesthesiologists (ASA) methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document.

Category B: Suggestive Literature

Information from observational studies permits inference of beneficial or harmful relations among clinical interventions and clinical outcomes.

Level 1: The literature contains observational comparisons (e.g., cohort, case-control research designs) of two or more clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.

Level 2: The literature contains noncomparative observational studies with associative (e.g., relative risk, correlation) or descriptive statistics.

Level 3: The literature contains case reports.

Category C: Equivocal Literature

The literature cannot determine whether there are beneficial or harmful relations among clinical interventions and clinical outcomes.

Level 1: Meta-analysis did not find significant differences among groups or conditions.

Level 2: There is an insufficient number of studies to conduct meta-analysis and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings.

Level 3: Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.

Category D: Insufficient Evidence from the Literature

The lack of scientific evidence in the literature is described by the following conditions.

  1. No identified studies address the specified relationships among interventions and outcomes.
  2. The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the "Focus" of the Guidelines or it does not permit a clear interpretation of findings due to methodologic concerns (e.g., confounding in study design or implementation).

Opinion-based Evidence

All opinion-based evidence relevant to each topic (e.g., survey data, open-forum testimony, Internet-based comments, letters, and editorials) is considered in the development of these Guidelines. However, only the findings obtained from formal surveys are reported.

Opinion surveys were developed by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to three groups of respondents: expert consultants, ASA, and American Society of Regional Anesthesia and Pain Medicine (ASRA) members.

Category A: Expert Opinion

Survey responses from Task Force–appointed expert consultants are reported in summary form in the text. A complete listing of consultant survey responses is reported in Table 2, Appendix 2 in the original guideline document.

Category B: Membership Opinion

Survey responses from ASA and ASRA members with expertise in chronic pain management are reported in summary form in the text. A complete listing of ASA and ASRA members' survey responses are reported in tables 3 and 4 in appendix 2 of the original guideline document.

Expert consultant, ASA membership, and ASRA membership survey responses are recorded using a 5-point scale and summarized based on median values.**

Strongly Agree: Median score of 5 (at least 50% of the responses are 5)

Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5)

Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contains at least 50% of the responses)

Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2)

Strongly Disagree: Median score of 1 (at least 50% of responses are 1)

Category C: Informal Opinion

Open-forum testimony, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.

**When an equal number of responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula.

Methods Used to Analyze the Evidence
Meta-Analysis
Other
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Initially, each pertinent outcome reported in a study was classified as supporting an evidence linkage, refuting a linkage, or equivocal. The results were then summarized to obtain a directional assessment for each evidence linkage before conducting a formal meta-analysis. Literature pertaining to eight evidence linkages contained enough studies with well-defined experimental designs and statistical information sufficient for meta-analyses. These linkages were (1) ablative techniques: radiofrequency ablation versus placebo; (2) acupuncture versus sham acupuncture; (3) botulinum toxin A versus placebo; (4) electrical nerve stimulation: transcutaneous electrical nerve stimulation (TENS) versus sham TENS; (5) anticonvulsants: calcium channel antagonists versus placebo, and sodium-channel blockers or membrane-stabilizing drugs versus placebo; (6) antidepressants: tricyclic antidepressants, selective serotonin–norepinephrine reuptake inhibitors, and selective serotonin reuptake inhibitors versus placebo; (7) N-methyl-D-aspartate (NMDA) receptor antagonists versus placebo; and (8) extended or controlled-release opioids versus placebo.

General variance-based effect-size estimates or combined probability tests were obtained for continuous outcome measures, and Mantel-Haenszel odds-ratios were obtained for dichotomous outcome measures. Two combined probability tests were used as follows: (1) the Fisher combined test, producing chi-square values based on logarithmic transformations of the reported P values from the independent studies, and (2) the Stouffer combined test, providing weighted representation of the studies by weighting each of the standard normal deviates by the size of the sample. An odds-ratio procedure based on the Mantel-Haenszel method for combining study results using 2 x 2 tables was used with outcome frequency information. An acceptable significance level was set at P<0.01 (one tailed). Tests for heterogeneity of the independent studies were conducted to ensure consistency among the study results. DerSimonian-Laird random-effects odds ratios were obtained when significant heterogeneity was found (P<0.01). To control for potential publishing bias, a "fail-safe n" value was calculated. No search for unpublished studies was conducted, and no reliability tests for locating research results were done.

Meta-analyses were limited to single modality interventions (e.g., extended-release oral opioids vs. placebo) because multimodal interventions (e.g., multidisciplinary pain programs) typically combine a variety of different treatment or comparison groups. These groupings of interventions (or controls) were not consistent across the aggregated studies, leading to high levels of heterogeneity in meta-analytic findings. Findings from such meta-analyses may be unclear and could risk undue bias in interpretation.

Meta-analytic results from single modality interventions are reported in table 1 in the original guideline document. To be accepted as significant findings, Mantel-Haenszel odds ratios must agree with combined test results whenever both types of data are assessed. In the absence of Mantel-Haenszel odds ratios, findings from both the Fisher and weighted Stouffer combined tests must agree with each other to be acceptable as significant.

Interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. Agreement levels using a kappa (k) statistic for two-rater agreement pairs were as follows: (1) type of study design, k = 0.63–0.88; (2) type of analysis, k = 0.87; (3) evidence linkage assignment, k =0.82–1.00; and (4) literature inclusion for database, k = 0.83–1.00. Three-rater chance-corrected agreement values were (1) study design, Sav = 0.72, Var (Sav) = 0.008; (2) type of analysis, Sav = 0.87, Var (Sav) = 0.005; (3) linkage assignment, Sav = 0.88, Var (Sav) = 0.003; (4) literature database inclusion, Sav = 0.88, Var (Sav) = 0.018. These values represent moderate to high levels of agreement.

Consensus-based Evidence

Consensus was obtained from multiple sources, including (1) survey opinion from consultants who were selected based on their knowledge or expertise in chronic pain management, (2) survey opinions solicited from active members of the ASA and ASRA membership, (3) testimony from attendees of publicly held open forums at two national anesthesia meetings, (4) Internet commentary, and (5) Task Force opinion and interpretation. The survey rate of return was 78 of 182 (42.9%) for the consultants, 304 surveys were received from active ASA members, and 171 surveys were received from active ASRA members. Results of the surveys are reported in tables 2–4 in the original guideline document and in the text of the Guidelines.

The consultants were asked to indicate which, if any, of the evidence linkages would change their clinical practices if the Guidelines were instituted. The rate of return was 16% (n = 29 of 182). The percent of responding consultants expecting no change associated with each linkage were as follows: (1) history, physical, and psychological examination = 91%; (2) interventional diagnostic procedures = 92.5%; (3) multidisciplinary programs = 88%; (4) thermal intradiscal procedures = 91%; (5) radiofrequency ablation = 97%; (6) acupuncture = 91%; (7) joint blocks = 94%; (8) nerve or nerve root blocks = 97%; (9) botulinum toxin injections = 88%; (10) neuromodulation with electrical stimulus = 97%; (11) TENS = 98.5%; (12) epidural steroids =92.5%; (13) intrathecal drug therapies = 95.5%; (14) anticonvulsants = 98.5%; (15) antidepressants = 98.5%; (16) NMDA receptor antagonists = 97%; (17) opioid therapy = 100%; (18) topical agents = 100%; (19) physical therapy = 100%; (20) psychological treatment or counseling = 94%; and (21) trigger point injections = 98.5%. Seventy-two percent of the respondents indicated that the Guidelines would have no effect on the amount of time spent on a typical case, and 27.6% indicated that there would be an increase in the amount of time spent on a typical case with the implementation of these Guidelines. Seventy-three percent indicated that new equipment, supplies, or training would not be needed to implement the Guidelines, and 64% indicated that implementation of the Guidelines would not require changes in practice that would affect costs.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The American Society of Anesthesiologists (ASA) appointed a Task Force of 12 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States and 2 consulting methodologists from the ASA Committee on Standards and Practice Parameters.

The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to chronic pain were reviewed and evaluated. Third, expert consultants were asked to (1) participate in opinion surveys on the effectiveness of various chronic pain management recommendations and (2) review and comment on a draft of the Guidelines. Fourth, opinions about the Guidelines recommendations were solicited from a sample of active members of the ASA and the American Society of Regional Anesthesia and Pain Medicine (ASRA). Fifth, the Task Force held open forums at two major national meetings† to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines (see the Appendix in the original guideline document).

†World Institute of Pain Fifth World Congress, New York, New York, March 14, 2009; and American Pain Society Annual Meeting, San Diego, California, May 7, 2009

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Expert consultants were asked to (1) participate in opinion surveys on the effectiveness of various chronic pain management recommendations and (2) review and comment on a draft of the Guidelines.

Opinions about the Guidelines recommendations were solicited from a sample of active members of the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA).

The Task Force held open forums at two major national meetings to solicit input on its draft recommendations and the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines.

Recommendations

Major Recommendations
  1. Patient Evaluation
    • All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.
      • History:
        • 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 should include information about the onset, quality, intensity, distribution, duration, course, and sensory and affective components of the pain and details about exacerbating and relieving factors.
        • Additional symptoms (e.g., motor, sensory, and autonomic changes) should be noted.
        • Information regarding previous diagnostic tests, results of previous therapies, and current therapies should be reviewed by the physician.
        • In addition to a history of current illness, the history should include (1) a review of available records, (2) medical history, (3) surgical history, (4) social history including substance use or misuse, (5) family history, (6) history of allergies, (7) current medications including use or misuse, and (8) review of systems.
        • The causes as well as the effects of pain (e.g., physical deconditioning, change in occupational status, and psychosocial dysfunction) and the impact of previous treatment(s) should be evaluated and documented.
      • Physical examination: The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation, with attention to other systems as indicated.
      • Psychosocial evaluation: The psychosocial evaluation should include information about the presence of psychological symptoms (e.g., anxiety, depression, or anger), psychiatric disorders, personality traits or states, and coping mechanisms.
        • An assessment should be made of the impact of chronic pain on a patient's ability to perform activities of daily living.
        • An evaluation of the influence of pain and treatment on mood, ability to sleep, addictive or aberrant behavior, and interpersonal relationships should be performed.
        • Evidence of family, vocational, or legal issues and involvement of rehabilitation agencies should be noted.
          • The expectations of the patient, significant others, employer, attorney, and other agencies may also be considered.
      • Interventional diagnostic procedures: 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 (e.g., 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.
        • Interventional diagnostic procedures should be performed with appropriate image guidance.
        • Diagnostic medial branch blocks or facet joint injections may be considered for patients with suspected facet-mediated pain to screen for subsequent therapeutic procedures.
        • Diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of patients with suspected sacroiliac joint pain.
        • Diagnostic selective nerve root blocks may be considered to further evaluate the anatomic level of radicular pain.
        • The use of sympathetic blocks may be considered to support the diagnosis of sympathetically maintained pain.
          • They should not be used to predict the outcome of surgical, chemical, or radiofrequency sympathectomy.
        • Peripheral blocks may be considered to assist in the diagnosis of pain in a specific peripheral nerve distribution.
        • Provocative discography may be considered for the evaluation of selected patients with suspected discogenic pain.
          • Provocative discography should not be used for the routine evaluation of the patient with chronic nonspecific back pain.
    • Findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide the foundation for an individualized treatment plan focused on the optimization of the risk–benefit ratio with an appropriate progression of treatment from a lesser to greater degree of invasiveness.
    • Whenever possible, direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care management.
  2. Multimodal or Multidisciplinary Interventions
    • Multimodal interventions should be part of a treatment strategy for patients with chronic pain.
    • A long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.
    • When available, multidisciplinary programs may be used.
  3. Single Modality Interventions
    • Ablative techniques (other treatment modalities should be attempted before consideration of the use of ablative techniques):
      • Chemical denervation (e.g., alcohol, phenol, or high concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain.
      • Cryoablation may be used in the care of selected patients (e.g., postthoracotomy pain syndrome, low back pain [medial branch], and peripheral nerve pain).
      • Thermal intradiscal procedures: intervertebral disc annuloplasty (IDET) may be considered for young, active patients with early single-level degenerative disc disease with well-maintained disc height.
      • Radiofrequency ablation:
        • Conventional (e.g., 80°C) or thermal (e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief.
        • Conventional radiofrequency ablation may be performed for neck pain.
        • Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain.
        • Conventional or other thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.
    • Acupuncture: Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, non-inflammatory low back pain.
    • Blocks:
      • Joint blocks:
        • Intra-articular facet joint injections may be used for the symptomatic relief of facet-mediated pain.
        • Sacroiliac joint injections may be considered for the symptomatic relief of sacroiliac joint pain.
      • Nerve and nerve root blocks:
        • Celiac plexus blocks using local anesthetics with or without steroids may be used for the treatment of pain secondary to chronic pancreatitis.
        • Lumbar sympathetic blocks or stellate ganglion blocks may be used as components of the multimodal treatment of complex regional pain syndrome (CRPS) if used in the presence of consistent improvement and increasing duration of pain relief.
        • Sympathetic nerve blocks should not be used for the long-term treatment of non-CRPS neuropathic pain.
        • Medial branch blocks may be used for the treatment of facet-mediated spine pain.
        • Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.
    • Botulinum toxin:
      • Botulinum toxin should not be used in the routine care of patients with myofascial pain.
      • Botulinum toxin may be used as an adjunct for the treatment of piriformis syndrome.
    • Electrical nerve stimulation:
      • Neuromodulation with electrical stimulus:
        • Subcutaneous peripheral nerve stimulation: Subcutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies.
        • Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies.
          • Spinal cord stimulation may also be considered for other selected patients (e.g., CRPS, peripheral neuropathic pain, peripheral vascular disease, and post-herpetic neuralgia).
          • Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement.
          • A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device.
      • Transcutaneous electrical nerve stimulation (TENS):
        • TENS should be used as part of a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g., neck and phantom limb pain).
    • Epidural steroids with or without local anesthetics:
      • Epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy.
        • Shared decision making regarding epidural steroid injections should include a specific discussion of potential complications, particularly with regard to the transforaminal approach.
        • Transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before injecting a therapeutic substance.
        • Image guidance may be considered for interlaminar epidural injections to confirm correct needle position and spread of contrast before injecting a therapeutic substance
    • Intrathecal drug therapies:
      • Neurolytic blocks: Intrathecal neurolytic blocks should not be performed in the routine management of patients with noncancer pain.
      • Intrathecal nonopioid injections:
        • Intrathecal preservative-free steroid injections may be used for the relief of intractable postherpetic neuralgia nonresponsive to previous therapies.
        • Ziconotide infusion may be used in the treatment of a select subset of patients with refractory chronic pain.
      • Intrathecal opioid injections: Intrathecal opioid injection or infusion may be used for neuropathic pain patients.
        • Shared decision-making regarding intrathecal opioid injection or infusion should include a specific discussion of potential complications.
        • Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems.
    • Minimally invasive spinal procedures: Minimally invasive spinal procedures (e.g., vertebroplasty) may be used for the treatment of pain related to vertebral compression fractures.
    • Pharmacologic management:
      • Anticonvulsants: Anticonvulsants (e.g., alpha-2-delta calcium channel antagonists, sodium-channel antagonists, and membrane-stabilizing drugs) should be used as part of a multimodal strategy for patients with neuropathic pain.
      • Antidepressants:
        • Tricyclic antidepressants should be used as part of a multimodal strategy for patients with chronic pain.
        • Serotonin–norepinephrine reuptake inhibitors should be used as part of a multimodal strategy for a variety of chronic pain patients.
        • Selective serotonin reuptake inhibitors may be considered specifically for patients with diabetic neuropathy.
      • Other drugs:
        • As part of a multimodal pain management strategy, extended-release oral opioids should be used for neuropathic or back pain patients, and transdermal, sublingual, and immediate-release oral opioids may be used.
        • For selected patients, ionotropic N-methyl-D-aspartate (NMDA) receptor antagonists (e.g., neuropathic pain), nonsteroidal anti-inflammatory drug (NSAIDs) (e.g., back pain), and topical agents (e.g., peripheral neuropathic pain) may be used, benzodiazepines and skeletal muscle relaxants may be considered.
      • A strategy for monitoring and managing side effects, adverse effects, and compliance should be considered for all patients undergoing any long-term pharmacologic therapy.
    • Physical or restorative therapy:
      • Physical or restorative therapy may be used as part of a multimodal strategy for patients with low back pain.
      • Physical or restorative therapy may be considered for other chronic pain conditions.
    • Psychological treatment:
      • Cognitive behavioral therapy, biofeedback, or relaxation training: These interventions may be used as part of a multimodal strategy for patients with low back pain, as well as for other chronic pain conditions.
      • Supportive psychotherapy, group therapy, or counseling: These interventions may be considered as part of a multimodal strategy for chronic pain management.
    • Trigger point injections: These injections may be considered for treatment of myofascial pain as part of a multimodal approach to pain management.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate evaluation and treatment of patients with chronic pain

Potential Harms
  • Chemical denervation: An observational study indicates that chemical denervation using phenol is effective in providing pain relief for patients with neuropathic, facet, or musculoskeletal pain for a period of assessment ranging from 2 to 24 weeks. A case report indicates similar efficacy for alcohol denervation, with a transient burning sensation as a reported side effect.
  • Spinal cord stimulation: Reported side effects include insertion-site pain and infections.
  • Anticonvulsants: Dizziness, somnolence or sedation, and peripheral edema are reported side effects of pregabalin.
  • Antidepressants: Meta-analyses of randomized controlled trials indicate that tricyclic antidepressants provide effective pain relief for a variety of chronic pain etiologies for assessment periods ranging from 2 to 8 weeks, with dry mouth and somnolence or sedation as reported side effects.
  • Opioid therapy: A meta-analysis of randomized controlled trials indicates that controlled or extended release opioid therapy (e.g., morphine, codeine, and oxycodone) provides effective pain relief for patients with low back pain or neuropathic pain for assessment periods ranging from 1 to 9 weeks, with nausea or vomiting and constipation as side effects. Randomized controlled trials indicate that tramadol provides effective pain relief for assessment periods ranging from 4 to 6 weeks. Studies with observational findings report that immediate release opioids, transdermal opioids, and sublingual opioids provide relief for back, neck, leg, and neuropathic pain for assessment periods ranging from 2 weeks to 3 months. Dizziness, somnolence, and pruritus are among reported side effects associated with opioid therapy.

Qualifying Statements

Qualifying Statements
  • Practice Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies.
  • In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010 Apr;112(4):810-33. [1 reference] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1997 Apr (revised 2010 Apr)
Guideline Developer(s)
American Society of Anesthesiologists - Medical Specialty Society
Source(s) of Funding

American Society of Anesthesiologists

Guideline Committee

American Society of Anesthesiologists Task Force on Chronic Pain Management

Composition of Group That Authored the Guideline

Task Force Members: Richard W. Rosenquist, M.D. (Chair), Iowa City, Iowa; Honorio T. Benzon, M.D., Chicago, Illinois; Richard T. Connis, Ph.D., Woodinville, Washington; Oscar A. De Leon-Casasola, M.D., Buffalo, New York; D. David Glass, M.D., Lebanon, New Hampshire; Wilhelmina C. Korevaar, M.D., Bala Cynwyd, Pennsylvania; Nagy A. Mekhail, M.D., Ph.D., Cleveland, Ohio; Douglas G. Merrill, M.D., Iowa City, Iowa; David G. Nickinovich, Ph.D., Bellevue, Washington; James P. Rathmell, M.D., Boston, Massachusetts; Christine Nai-Mei Sang, M.D., M.P.H., Boston, Massachusetts; and Dana L. Simon, M.D., Des Moines, Iowa

The Task Force thanks Timothy R. Deer, M.D. for his early contributions (September 2006-June 2008) to the development of these Practice Guidelines.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Practice guidelines for chronic pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997 Apr;86(4):995-1004.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) and EPUB for eBook devices from the Anesthesiology Journal Web site External Web Site Policy.

Print copies: Available from the American Society for Anesthesiologists, 520 North Northwest Highway, Park Ridge, IL 60068-2573.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated by ECRI Institute on November 4, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the American Society of Anesthesiologists.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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