Faculty of Pain Medicine, ANZCA: tests, treatments and procedures clinicians and consumers should question

The true place of opioids in chronic non-cancer pain (CNCP) is unknown. Most trials of their efficacy have been of less than twelve weeks duration and have shown only modest effects. By contrast opioid use in CNCP has been associated with increased distress, poorer self-rated health, inactivity during leisure, unemployment, higher healthcare utilisation and lower quality of life, suggesting failure to appreciate the complex nature of these conditions.

Opioids should not be used alone or as analgesics of first choice in patients with CNCP. A trial of opioid may be indicated in some patients, according to published guidance. If such an opioid trial is undertaken, then a long-acting preparation should be prescribed, in conjunction with non-drug therapies – physical, behavioural and cognitive – that promote functional restoration, reduce distress and potentially lower pain intensity.

Supporting evidence

  • Eriksen J, Sjøgren P, Bruera E, et al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain 2006; 125:172–9.
  • Dowell D, Haegerich T, Chou R. CDC Guidelines for prescribing opioids for chronic pain – United States, 2016. JAMA 2016; 315(15):1624-45.
  • Chou R, Fanciullo G, Fine PG, et al. Clinical Guidelines for the use of chronic opioid therapy in chronic non-cancer pain. The Journal of Pain 2009; 10(2):113-30.
  • Busse J, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain.  CMAJ 2017; 189(18):E659-66.
  • Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – Guidance. Pain Physician 2012; 15:S67–116.
  • International Association for the Study of Pain, IASP Taxonomy, 2017 [cited 2018 Jan]

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Comprehensive assessment of patients with CNCP is essential before prescribing an opioid. An opioid ‘contract’ should describe the purpose of the prescription and would include agreed criteria for functional improvement, risks and side-effects of opioid analgesics, and ground rules regarding their use and cessation. There should be a single prescriber (and a deputy) to take responsibility for opioid prescription, in accordance with the regulatory requirements of the relevant jurisdiction.

Supporting evidence

  • Royal Australasian College of Physicians. Prescription opioid policy: improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use. Sydney, Australia: The Royal Australasian College of Physicians 2009.
  • Dowell D, Haegerich T, Chou R. CDC Guidelines for prescribing opioids for chronic pain – United States, 2016. JAMA 2016; 315(15):1624-45.
  • Chou R, Fanciullo GJ, Fine PG, et al. Clinical Guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain 2009; 10(2):113-30.
  • Busse J, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain.  CMAJ 2017; 189(18):E659-66.
  • Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – Guidance. Pain Physician 2012; 15:S67-116.

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The IASP definition of neuropathic pain (2011) requires demonstration of a lesion or disease of the somatosensory system. In effect, that means demonstration of neurological signs. Descriptors that may suggest the pain may be neuropathic, such as burning, painful cold, electric shock-like etc., on their own do not meet this criterion.

Pregabalin has a restricted PBS authority for ‘neuropathic pain’. Although the definition being applied is not stated in the PBS Authority listing, use of the 2011 IASP definition is recommended. As with any pharmacotherapy used in pain medicine, the outcome of a trial of pregabalin or of gabapentin should be judged by improvement in everyday physical, emotional and cognitive functioning, including activity, sleep, absence of adverse effects, and improvement in quality of life.

Supporting evidence

  • Neuropathic pain – pharmacological management. NICE Clinical Guideline 173; 2017.
  • Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015; 14:162-73.
  • Finnerup NB, Haroutounian S, Kamerman P, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain 2016; 157(8):1599-606.
  • International Association for the Study of Pain, IASP Taxonomy, 2017 [cited 2018 Jan]
  • Jensen TS, Baron R, Haanpää M, et al. A new definition of neuropathic pain. Pain 2011; 152(10)2204-5.
  • The Pharmaceutical Benefits Scheme, Pregabalin, [cited 2018 Jan]

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Lifetime prevalence of low back pain in Australia is reported to be as high as 80% with one in ten experiencing significant activity limitation.

Although benzodiazepines continue to be commonly prescribed as ‘muscle relaxants’ for low back pain (LBP), there is an absolute lack of evidence of benefit for this indication. Only one RCT has been conducted on diazepam in acute LBP during the last 40 years, and it showed no additional benefit when added to NSAID therapy alone. A recent systematic review found no additional studies to support the use of benzodiazepines in treating acute or chronic back pain.

Well-described risks are associated with benzodiazepine usage, including abuse, addiction, tolerance and overdose. Accidental death from pharmaceutical benzodiazepines in Australia were highest in the 40-49 and 30-39 year age groups. The number of deaths in the older age groups also remains high.

There is no place for use of benzodiazepine for low back pain.

Supporting evidence

  • Briggs AM, Buchbinder R. Back pain: a national health priority area in Australia? Med J Aust 2009; 190(9):499-502.
  • Chou R, Huffman LH. Medications for Acute and Chronic Low Back Pain: A Review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med 2007; 147(7):505-14.
  • Friedman BW, Irizarry E, Solórzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain. Ann Emerg Med 2017; 70(2):169-76.
  • Penington Institute. Australia’s Annual Overdose Report 2017.
  • Shaheed AC, Maher CG, Williams KA, et al. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain 2016; 21(2):228-37.

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Chronic low back pain (CLBP) that is not due to underlying disease (infection, cancer) and is not associated with neurological signs is a common problem that is difficult to treat.

Historically, lumbar spinal fusion was used for the treatment of demonstrated spinal instability following trauma or cancer. More recently, lumbar spinal fusion has been used for leg pain attributed to an underlying structural change such as spinal stenosis or spondylolisthesis.

Spinal fusion has been proposed as a treatment for uncomplicated axial CLBP. The rationale for it is elusive, as accurate determination of a single source of the pain, especially when central sensitisation may have occurred, is not usually possible. Though some positive studies have been reported, pooled data from multiple randomised trials do not provide support for performing spinal fusion surgery in preference to non-operative treatment.

In the absence of adequate rationale and compelling new evidence, lumbar spinal fusion is not recommended for treatment of uncomplicated axial CLBP.

Supporting evidence

  • Briggs AM, Buchbinder R. Back pain: a national health priority area in Australia? Med J Aust 2009; 190(9):499-502.
  • Gore M, Sadosky A, Stacey BR, et al. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976) 2012; 37(11):E668-77.
  • Eck JC, Sharan A, Ghogawala Z, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: Lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine 2014; 21(1):42-7.
  • Bydon M, De la Garza-Ramos R, Macki M, et al. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech 2014; 27(5):297-304.
  • Fritzell P, Hägg O, Wessberg P, et al. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicentre randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 2001; 26(23):2521-34.

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The Faculty of Pain Medicine (FPM), ANZCA established a working group to develop a preliminary list of pain medicine related practices that were identified, using current clinical evidence, as having possible limited benefit, no benefit or which may potentially cause harm to patients.  An online survey tool was used to survey all FPM fellows and trainees inviting them to rank these recommendations and to provide any comment related to them. This engagement facilitated consensus and informed the Fellows and trainees about FPM’s involvement with the Choosing Wisely campaign.

FPM's final list of 5 Choosing Wisely recommendations reflects those that were the most broadly supported by the clinicians and which were considered to be the most relevant to community practice.

Last reviewed 13 February 2018