Practice Guidelines for Chronic Pain Management

*Developed by the American Society of Anesthesiologists Task Force on Chronic Pain Management: 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.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.This document updates the “Practice Guidelines for Chronic Pain Management,” adopted by the ASA in 1996 and published in 1997.1For these Guidelines, chronic pain is defined as pain of any etiology 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.The purposes of these Guidelines are to (1) optimize pain control, recognizing that a pain-free state may not be attainable; (2) enhance functional abilities and physical and psychologic well-being; (3) enhance the quality of life of patients; and (4) minimize adverse outcomes.These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. These Guidelines apply to patients with chronic noncancer neuropathic, somatic (e.g ., myofascial), or visceral pain syndromes. 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 and do not address the administration of intravenous drugs or surgical interventions other than implanted intrathecal drug delivery systems and nerve stimulators.These Guidelines are intended for use by anesthesiologists and other physicians serving as pain medicine specialists. The Guidelines recognize that all anesthesiologists or other physicians may not have access to the same knowledge base, skills, or range of modalities. However, aspects of the Guidelines may be helpful to anesthesiologists or other physicians who manage patients with chronic pain in a variety of practice settings. They may also serve as a resource for other physicians, nurses, and healthcare providers (e.g ., rehabilitation therapists, psychologists, and counselors) engaged in the care of patients with chronic pain. They are not intended to provide treatment algorithms for specific pain syndromes.The 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 two 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 (appendix).Preparation of these Guidelines followed a rigorous methodological process (appendix). Evidence was obtained from two principal sources: scientific evidence and opinion-based 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.Randomized controlled trials report statistically significant (P < 0.01) differences between 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.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.Level 1: The literature contains observational comparisons (e.g ., cohort and case–control research designs) of clinical interventions or and statistically significant differences between clinical interventions for a specified clinical outcome.Level 2: The literature contains observational studies with (e.g ., and or 3: The literature contains case literature cannot there are beneficial or harmful relationships among clinical interventions and clinical outcomes.Level 1: not significant differences among or 2: is an insufficient number of studies to conduct meta-analysis and (1) randomized controlled trials have not significant differences among or or (2) randomized controlled trials report 3: studies report findings or do not inference of beneficial or harmful of scientific evidence in the literature is described by the identified studies address the specified relationships among interventions and The available literature cannot be used to assess relationships among clinical interventions and clinical The literature not the criteria for as defined in the of the Guidelines or not a of findings to methodological (e.g ., in or opinion-based evidence relevant to each topic (e.g ., and is considered in the development of these Guidelines. 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