One of the nation’s largest groups of anesthesiologists has joined a growing list of medical organizations in urging its members to reduce the prescribing of opioid painkillers.
The American Society of Anesthesiologists (ASA), which has over 52,000 members, says opioids should not be prescribed as “first-line therapy” to treat non-cancer pain.
The recommendation is one of five adopted by the society as part of the Choosing Wisely campaign, which encourages physicians and patients not to use medical tests and procedures that are overused or inappropriate.
“There has been a far greater use of opioid medications than the evidence suggests there should be. In most cases, pain management should be built on a foundation that does not include opioids, especially in the setting of chronic pain,” said ASA President Jane C. K. Fitch, MD.
“In many situations, the risks of chronic opioid use are far greater than the degree of relief obtained by the patient. In most instances, physician anesthesiologists should use other therapies to help with pain management before resorting to opioids.”
Fitch and the ASA believe non-drug treatments, such as behavioral and physical therapy, should be tried before analgesic medication is used to relieve pain. If the non-drug treatments don’t work, physicians should then try non-opioid pain relievers, such as non-steroidal anti-inflammatory drugs (NSAIDs) or anticonvulsants, before resorting to opioids.
“We want to make sure physicians are considering all options before prescribing opioids, and only doing so when it is absolutely necessary and the desired outcome will be achieved. Even then, the significant risks of chronic opioid use must be discussed with the patient,” Fitch said in an email to National Pain Report.
“Not only is the evidence lacking that patient outcomes are improved with chronic opioid use, but there are many side effects. These include drowsiness, lethargy, constipation and endocrine effects to name a few. In addition, there is a far greater risk of misuse, abuse and addiction than previously suspected.”
In addition to only prescribing opioids as a last resort, the ASA also recommends the following:
- Physicians and pain patients should sign written agreements that identify the responsibilities of each party (such as urine drug testing) and the consequences of non-compliance with the agreement.
- Avoid imaging studies (MRIs, cat scans or X-rays) for acute low-back pain in the first six weeks of treatment. Most low back pain does not need imaging.
- Avoid irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, which have significant long-term risks of weakness, numbness or increased pain.
- Avoid intravenous sedation for diagnostic and therapeutic nerve blocks, as well as joint injections, spinal injections and epidural steroid injections as a standard practice.
“In the past few years, there have been increases in the use of spinal injections, leaving some concerned about the risks of these procedures,” said Fitch.
“There are excellent guidelines available for treating low back pain as well as low back pain with radiculopathy that show positive outcomes with conservative treatment alone, such as physical therapy, exercise, and medication. However, if pain persists and injections are warranted, physician anesthesiologists should continue to use them when they are necessary and appropriate as part of an overall comprehensive treatment plan.”
“This is definitely a step in the right direction,” says Dawn Gonzalez, whose spine was damaged by an epidural during child birth. She now suffers from arachnoiditis and is an advocate for Arachnoiditis Society for Awareness and Prevention (ASAP).
“The more and more interventional procedures are used, namely steroid injections, the number of injured and disabled patients climbs at an extreme rate. I have been disabled for life from having needles in my spine. ESI’s (epidural steroid injections) as a first or even second line of defense needs to closely evaluated,” Gonzalez said.
ESI’s are increasingly being used to treat back pain of all kinds, with nearly 9 million spinal injections in the U.S. in 2011. Several studies have found that steroid injections increase the risk of spinal fracture and do little to relieve back pain.
“Steroid injections have been shown no more effective long term than placebo, or nothing at all. Not to mention the risks of bone fractures and tissue and bone degradation they bring on. It’s a sure fire way to make a surgical intervention necessary,” adds Gonzalez.
The ASA may have its work cut out for it in persuading physicians to adopt more conservative treatment options. A recent study published in JAMA Internal Medicine found that doctors who treat back pain are prescribing more narcotic painkillers, not less, and ordering too many unnecessary diagnostic tests,
“Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use,” said lead author John Mafi, MD, of Harvard Medical School.