ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
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influences. Practice guidelines are systematically developed
statements to assist practitioner and patient decisions
about appropriate health care for specific clinical circumstances.
In contrast, clinical pathways are tools to coordinate
the time-dependent progress of a typical uncomplicated
patient across many clinical departments specific to
the condition or disease being managed (64). The differences
between target patient population ranges from specific
conditions such as acute low back pain, migraine headaches,
sickle-cell disease, and complex pain syndromes,
to much more general guidelines applicable across a variety
of chronic painful conditions. The next issue of controversy
and contention is the definition of evidence. All
of the guidelines incorporate literature review. However,
the categorization of evidence of strength differs across
guidelines. Generally, evidence of strength ranges from
prospective, double-blind, randomized, controlled studies
to uncontrolled case reports. In addition to the evidence,
panels also attempt to use expert consensus, the application
of which varies across the development of the guidelines.
Each panel developing the guidelines feel that their
guidelines applied the most stringent and reasonable evidence.
On the other hand, one group developing the guidelines
tend to criticize another group when they differ philosophically
(3, 7, 21, 24, 25, 27-39, 45, 46, 62, 64-67, 83,
84). In addition, the same evidence may be evaluated by
different groups or authors with variability interpretation
of results. Author bias also exists regardless of the desire
to achieve substantially impartial, scientifically based recommendations.
It is unavoidable that guidelines reflect
authors’ clinical and practice biases, personal philosophy,
and the way the literature is interpreted. Certainly on the
same spectrum, influences of the special interest groups
are inescapable.
CHRONIC PAIN
“We must all die. But that I can save him from
days of torture, that is what I feel as my great and ever
new privilege. Pain is a more terrible Lord of mankind
than even death itself.”
- Albert Schweitzer
Schweitzer (85), the great humanitarian, physician, and
Nobel laureate, elegantly described the nature of pain and
the obligation and privilege of the physician and other
health professionals to relieve it in 1931, after nearly two
decades of experience of medical practice in the African
jungle. Approximately four decades later in 1974, John
Bonica, the father of pain medicine, observed: “Pain is
the most pressing issue of modern times.” Today, in the
new millennium as then, proper management of pain remains
one of the most important and most pressing issues
of society in general and the scientific community in the
health professions in particular.
Epidemiology
In spite of the best efforts of the public, providers and the
government, pain continues to be an epidemic (86, 87). In
addition, inadequate treatment of pain also continues to be
a public health problem, that is reaching epidemic proportions
in the United States and across the world (86-96).
The knowledge and understanding of this complex entity,
including diagnosis and treatment, are in infancy, in spite
of modern developments in medicine. Providers, patients,
and the government all understand the devastating nature
of chronic pain which destroys the quality of life by eroding
the will to live, disturbing sleep and appetite, creating
fatigue, and impairing recovery from illness or injury (86-
100). In elderly patients it may make the difference between
life and death by resulting in vocational, social, and
family discord (100-105). Pahor et al (102) found that
pain relief is particularly elusive for older women with disabling
back and lower extremity problems. In this study,
approximately two thirds of the women reported significant
levels of pain and difficulty in controlling it. Asch et
al (106) measured underuse of necessary care detecting
substantial underuse problems for various conditions, including
depression, and concluded that these problems
likely result in negative outcomes in the elderly population.
The concept of chronic pain is beset with controversy, starting
with its very definition. For some chronic painful conditions,
it is defined as, “pain that exists beyond an expected
time frame for healing.” For other conditions, it is
recognized that, “healing may never occur.” Bonica defined
chronic pain as, “Pain which persists a month beyond
the usual course of an acute disease or a reasonable
time for any injury to heal that is associated with chronic
pathologic processes that causes a continuous pain or pain
at intervals for months or years” (107). In many cases,
chronic pain is understood as persistent pain that is not
amenable to routine pain control methods. In a Gallup
Survey of “pain in America” more than 4 out of 10 adults
(42%) say they experience pain on a daily basis (108).
Americans age 65 and older are more likely to experience
pain for longer periods of time than younger Americans
(108). Andersson et al (109) reported incidence of persistent
pain for 6 months in 49% of the adult population, with
functional disability in 13%. Perquin et al (97) reported
Pain Physician Vol. 4, No. 1, 2001