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.

Chronic pain

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.

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

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 .

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

A total of 696 articles contained direct linkage-related 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.

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.

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

Not applicable

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

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.

None provided

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

Appropriate evaluation and treatment of patients with chronic pain

An implementation strategy was not provided.

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

American Society of Anesthesiologists

American Society of Anesthesiologists Task Force on Chronic Pain Management

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.

Not stated

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.

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

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

None available

None available

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.

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