Faculty of Pain Medicine, ANZCA
Recommendations from the Faculty of Pain Medicine, ANZCA on chronic pain, neuropathic pain and low back pain. The Faculty of Pain Medicine is a faculty of the Australian and New Zealand College of Anaesthetists and is the professional organisation for specialist pain medicine physicians (Fellows) and specialist pain medicine physicians in training (trainees). The Faculty is responsible for the training, examination and specialist accreditation of specialist pain medicine physicians and for the standards of clinical practice for pain medicine in Australia and New Zealand. Formed in 1998, the Faculty is the first multidisciplinary medical academy in the world to be devoted to education and training in pain medicine.
Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain
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.
- 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]
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.
FPM Board directed that a poll of the fellowship be conducted to assess support for a sixth Choosing Wisely recommendation regarding the role of medicinal cannabis in chronic non-cancer pain treatment. The survey question was very similar to the final wording of the recommendation, and was supported by 79% of the fellows who responded (more than 25% of the active fellowship).
The final draft wording of the recommendation, explanation and list of key references was then approved by the Board and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the following Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.
- 1 Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain (CNCP).
- 2 Do not continue opioid prescription for chronic non-cancer pain (CNCP) without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms.
- 3 Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain
- 4 Do not prescribe benzodiazepines for low back pain.
- 5 Do not refer axial lower lumbar back pain for spinal fusion surgery.
- 6 Do not prescribe currently available medicinal cannabis products to treat chronic non-cancer pain (CNCP) unless part of a registered clinical trial.