January 21, 2014 — As part of ABIM Foundation’s Choosing Wisely campaign, the American Society of Anesthesiologists (ASA) released its second list of five targeted, evidence-based recommendations to support conversations between patients and physician anesthesiologists about what care is really necessary.
- Avoid imaging studies for acute low-back pain without specific indications.
Unnecessary imaging in the first six weeks after pain begins may reveal incidental findings that divert attention and increase risk of unhelpful surgery. Clinical indications include history of cancer with potential metastases, known aortic aneurysm and progressive neurologic deficit.
- Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain.
Physicians should first consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies. Medication such as NSAIDs and anticonvulsants should be trialed prior to commencing opioids.
- Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until risks are considered and discussed with the patient.
Physicians should inform patients of risks including addiction, and physicians and patients should sign written agreements identifying each party’s responsibilities and consequences of non-compliance. Physicians should be cautious in co-prescribing opioids and benzodiazepines, and should proactively evaluate side effects such as constipation and low testosterone or estrogen.
- Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice.
When possible, diagnostic procedures, therapeutic nerve blocks and joint injections should be performed with local anesthetic alone rather than with propofol, midazolam or ultrashort-acting opioid infusions. Intravenous sedation can be used after evaluation and discussion of risks, including interference in assessing acute pain-relieving effects of the procedure and 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.
- Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks.
Irreversible interventions such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation may carry significant long-term risks of weakness, numbness or increased pain.
Members of the ASA Committee on Pain Medicine submitted recommendations for this list, which were then voted on and researched to provide supporting evidence.