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 prescribe currently available medicinal cannabis products to treat chronic non-cancer pain (CNCP) unless part of a registered clinical trial.
Cannabis-derived products are now available for use with therapeutic intentions in Australia and New Zealand. By far the most common reason for their proposed use is chronic pain. More than 90% of Special Access Scheme – Category B (SAS-B) approvals for cannabis products have been for chronic pain of various types. Cannabidiol-only formulations have not been the subject of a published randomised controlled trial (RCT) for pain indications, yet they are projected to become the most widely used type of product.
However, there is a critical lack of evidence of consistent benefit from cannabinoids of any type for chronic non-cancer pain. The evidence available is either unsupportive or is of such low quality that no valid scientific conclusion can be drawn.
In addition, evidence of harms does exist, particularly in relation to sedative effects, interactions with other medications and neuropsychiatric effects (for products which contain tetrahydrocannabinol (THC)).
Given the above, until high-quality evidence for specific indications is published, the clinical use of cannabinoid products cannot be ethically recommended outside of a properly established and registered clinical trial environment.
- IASP Presidential Taskforce on Cannabis and Cannabinoid Analgesia Position Statement. PAIN: March 16, 2021 Special Edition
- Fisher E., Moor A., Fogarty A., Finn D., et al. Cannabinoids, cannabis and cannabis-based medicine for pain management – a systematic review of randomized controlled trials. PAIN: May 18, 2020 Online ahead of print
- Arnold J, Nation T, McGregor I Prescribing Medicinal Cannabis Aust Prescr 2020;43:152-9 1 October 2020
- Stockings E, Campbell G, Hall W, Nielsen S, Zagic D, Rahman R, Murnion B, Farrell M, Weier M, Degenhardt L Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies PAIN 2018 Oct 159(10):1932-1954
- FreshLeaf Analytics. Australian Medicinal Cannabis Market - Patient, Product and Pricing Analysis. H1 2021
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