Top 5 Pain Interventions to Avoid- by The Evidence Based Chiropractor

The top 5 pain inventions to avoid by the ASA touch on a variety of spine related conditions.  This list was created because many medical doctors are commonly performing these procedures in spite of the fact that evidence based guidelines suggest they shouldn't.  

At the top of the list is a recommendation to avoid prescribing opioid analgesics for non cancer pain.  These are commonly prescribed even though there is an extremely high addiction rate and virtually no benefit in terms of outcomes.  

As you look through the list, you will find a array of procedures/interventions which are probably being performed on your current patients.  As evidence based practitioners it is imperative that we stay up to date on these topics and keep our patients informed regarding their health care choices.  

The following five recommendations were made-

http://www.medscape.com/viewarticle/819517

1. Don't prescribe opioid analgesics as first-line therapy to treat chronic noncancer pain. Consider multimodal therapy, including nondrug treatments, such as behavioral and physical therapies, before pharmacologic intervention. If drug therapy appears indicated, try nonopioid medication, such as nonsteroidal anti-inflammatory drugs, or anticonvulsants, before starting opioids.

2. Don't prescribe opioid analgesics as long-term therapy to treat chronic noncancer pain until the risks are considered and discussed with the patient. Inform patients of the risks of such treatments, including the potential for addiction. Review and sign a written agreement identifying both your and the patient's responsibilities (eg, urine drug testing) and the consequences of noncompliance with the agreement. Be cautious in coprescribing opioids and benzodiazepines. Proactively evaluate and treat, if indicated, the nearly universal adverse effects of constipation and low testosterone or estrogen.

3. Avoid imaging tests, such as MRI, computed tomography, or radiography, for acute low back pain without specific indications. Avoid these interventions for low back pain in the first 6 weeks after pain begins if there are no specific clinical indications (eg, history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit). Most low back pain doesn't require imaging, and performing such tests may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Don't use intravenous sedation, such as propofol, midazolam, or ultra-short-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, as a default practice. (This recommendation does not apply to pediatric patients.) Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false-positive responses. Follow ASA Standards for Basic Anesthetic Monitoring in cases where moderate or deep sedation is provided or anticipated.

5. Avoid irreversible interventions for noncancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation. Such interventions may be costly and carry significant long-term risks of weakness, numbness, or increased pain.

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