Not prescribing opioids first or as a long-term therapy for chronic, non-cancer pain and avoiding MRIs, CTs and X-rays for low-back pain are among the tests and treatments identified by ASA that are commonly ordered but not always necessary. As part of the ABIM Foundation’s Choosing Wisely campaign, ASA today released its second list of five targeted, evidence-based recommendations that can support conversations between patients and physician anesthesiologists about what care is really necessary.
ASA’s list identified the following recommendations:
1. Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain.
Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.
2. Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient.
Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.
3. Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications.
Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.
4. Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. *
Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice. 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 ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.
5. Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks.
Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.
*This recommendation does not apply to pediatric patients.
“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, M.D. “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 ASA Committee on Pain Medicine was charged with developing the Choosing Wisely list on pain medicine. Committee members submitted recommendations for the campaign, and from this list voted on which should be included in the Choosing Wisely list. The literature was then searched to provide supporting evidence. Once approved by the committee, the Choosing Wisely list was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee, and Administrative Council. ASA published its first Choosing Wisely list in October, 2013 regarding anesthesiology.
“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, M.D., president and CEO of the ABIM Foundation. “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, nearly 100 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 250 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss.
The campaign also continues to reach millions of consumers nationwide through a stable of consumer and advocacy partners, led by Consumer Reports—the world’s largest independent product-testing organization—which has worked with the ABIM Foundation to distribute patient-friendly resources for consumers and physicians to engage in these important conversations. Choosing Wisely consumer partners include:
• Alliance Health Networks
• Midwest Business Group on Health
• Minnesota Health Action Group
• National Business Coalition on Health
• National Business Group on Health
• National Center for Farmworker Health
• National Hospice and Palliative Care Organization
• National Partnership for Women & Families
• Pacific Business Group on Health
• The Leapfrog Group
• Union Plus
To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit ChoosingWisely.org.