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.
Do not refer axial lower lumbar back pain for spinal fusion surgery.
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.
- 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.
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.
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the 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.
- 7 Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place