Appropriate Interventions for Chronic Pain

The management of chronic pain has been a major public health issue over the last few decades. In April 2010, the Chronic Pain Management Task Force of the American Society of Anesthesiologists published their updated practice guidelines for the management of chronic pain in the journal Anesthesiology. The practice guidelines offer doctors and patients a starting point for making treatment decisions in cases of chronic pain and were originally published by the Society in 1997.

The task force defined chronic pain as neuropathic, visceral, or somatic pain that negatively affects the function or well-being of the adult individual, but is not associated with cancer or chronic disease, or with acute injury, surgery, or healing. This is a much more specific set of guidelines than those offered by the World Health Organization. The guidelines aim to increase the quality of life and well-being of the patient, reduce adverse outcomes of treatment, and increase treatment effectiveness while pursuing a pain-free state.

Accumulating evidence and advice from multiple sources, including the medical literature and members of the Society, the following guidelines were developed for anesthesiologists and other pain medicine specialists treating patients with chronic pain:

Patient history and thorough medical examination

Disorders that cause chronic pain may be found by physical exam, indicating specific courses of treatment. Psychological findings may indicate potential treatment effectiveness, and observational findings from interventional evaluations (i.e. peripheral blocks to pinpoint peripheral pain) may indicate the source of pain. The pain history should include an onset and symptom timeline, along with any known details regarding what exacerbates and relieves the pain, duration, intensity, quality, distribution, and sensory/affective components. Family history and any history of substance use/abuse should also be taken into account. In addition, the impact of previous treatments should be reviewed, including a history of surgery, as well as the effect of the pain on the patient’s quality of life and daily function.

Multimodal and multidisciplinary interventions

The patient’s status should be re-evaluated from time to time to account for changes that require adjustments in treatment. A long-term approach open to multiple types of treatments is recommended. Treatments drawn from more than one discipline based on the context of the pain are indicated as being more effective than conventional therapies.

The types of approaches recommended include, but are not limited to:

1. Chemical denervation, cryoneurolysis, radiofrequency ablation, and thermal intradiscal procedures

2. Acupuncture as an adjuvant for nonspecific, noninflammatory lower back pain

3. Joint and nerve, or nerve root blocks

4. Botulism injections as an adjunct in the treatment of piriformis syndrome, but not for use in myofascial pain

5. Neuromodulation with electrical stimulus or transcutaneous electrical nerve stimulation

6. Epidural steroids – with or without local anesthetics for radicular pain or radiculopathy

7. Intrathecal (under the skin) drugs – neurolytic blocks, non-opioids (steroids, anesthetics), or opioids (for neuropathic pain)

8. Minimally invasive spinal procedures for vertebral compression fractures– vertebroplasty, krphoplasty, percutaneous disc decompression

9. Pharmacological intervention with anticonvulsants, antidepressants, benzodiazipines, NMDA receptor antagonists, NSAIDs (e.g., naproxen), opioids (e.g., morphine, codeine), muscle relaxers, or lidocaine

10. Physical, restorative, or psychological therapy – biofeedback, relaxation, counseling and support

11. Trigger point injections for myofascial pain over 1 to 4 months

The supporting information for the task force’s recommendations can be read at Anesthesiology.