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Pain Treatment - Guidelines Descriptions
 The following guidelines are organized by year of publication (descending order) within logical clinical categories. A guideline will be replaced when it is reviewed and updated, or it will be removed when the sponsoring organization determines that the content is outdated.
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Document Researchers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD
 Guidelines marked with this symbol are from external sources that are not in accord with the published Pain Treatment Topics Open Access Policy and require purchase from the publisher to view the full documents. In most cases, an abstract or a summary may be viewed at no charge.
 = entry added or changed during latest update.
CONTENTS
General Pain & Safety Topics
Guidelines on Pain Management
Access: http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Pain_Mngt.pdf
Source: European Association of Urology
Date: 2009
Description: This
revised 2009 guideline differs from an older, 2003, version in several ways. In a new discussion of pain assessment, more emphasis is placed on the evaluation of the patient's overall quality of life, and summaries are provided for neuropathic pain processes (central and peripheral). Evidence-based cancer pain treatment recommendations for non-pharmacologic modalities (including radiotherapy and physical therapies) and pharmacotherapy (including options for neuropathic pain relief) have both been expanded. The sections on pain management in male and female urological cancers include more options for the treatment of pain due to metastases. One important strength of the guideline is the thorough description of the pathophysiology of pain as it relates to the male and female urogenital systems. Opioid recommendations include information on dosing, routes of administration and the management of adverse effects. Presentations of evidence-based contraindications and cautions are specific to each relevant therapy. 84 Pages. Access checked April 13, 2009.
ACR Criteria for Diagnostic Imaging in Pain Conditions
Access: http://acsearch.acr.org/
Source: American College of Radiology (ACR)
Date: 2005-2008
Description: The ACR has developed evidence-based guidelines for use in a wide range of imaging decisions in patients presenting with pain. Each guideline is developed by a panel of experts in the field and reviewed by the ACR Committee on Appropriateness Criteria. The guideline for each condition lists several variants (e.g. symptoms, patient age, etc.) and rates the appropriateness of each relevant radiologic procedure. A summary of the literature regarding evidence for diagnostic effectiveness follows each set of procedure recommendations. A search for topics by condition or procedure can be performed at the URL address listed above, or you can access individual pain topic guidelines below:
Nontraumatic knee pain; Access PDF…>
Acute abdominal pain and fever or suspected abdominal abscess; Access PDF…>
Acute onset flank pain, suspicion of stone disease; Access PDF…>
Right lower quadrant pain; Access PDF…>
Right upper quadrant pain; Access PDF…>
Left lower quadrant pain; Access PDF…>
Acute onset of scrotal pain (without trauma, without antecedent mass); Access PDF…>
Acute chest pain – suspected myocardial ischemia; Access ACR link to HTML text and PDF…>
Acute chest pain – suspected aortic dissection; Access PDF…>
Acute chest pain – no ECG or enzyme evidence of myocardial ischemia/infarction; Access PDF…>
Low back pain; Access PDF…>
Chronic foot pain; Access PDF…>
Chronic wrist pain; Access PDF…>
Chronic ankle pain; Access PDF…>
Chronic elbow pain; Access PDF...>
Chronic neck pain; Access PDF...>
Headache; Access PDF...>
Headache—Child; Access PDF...
Access for all links checked April 10, 2009.
Use of Nonsteroidal Antiinflammatory Drugs. An Update for Clinicians. A Scientific Statement From the American Heart Association
Access: http://www.circ.ahajournals.org/cgi/reprint/115/12/1634
Source: American Heart Association (AHA)
Date: 2007
Print Reference: Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs. An update for clinicians. A scientific statement from the American Heart Association. Circulation. 2007(Mar);115(12):1634-1642.
Description: These guidelines were developed to update clinicians on the AHA recommendations for the selection of nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with existing cardiovascular disease or risk. Growing evidence demonstrating an increased risk of cardiovascular events with the use of NSAIDs has led to confusion about the selection of analgesic medications for pain relief. This scientific statement summarizes the trials that reported cardiovascular events in patients who took analgesic drugs that inhibit COX enzymes. The recommendations for pain management include a stepped approach beginning with nonpharmacologic interventions and continuing with appropriate drug therapy that is based on an individual risk-benefit analysis for each patient. 9 Pages. Access checked April 14, 2009.
Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult
Access: http://www.sccm.org/pdf/sedatives.pdf
Source: Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians
Date: 2002 (Originally published in 1995)
Print Reference: Jacobi J, Fraser GL, Coursin DB, Riker RR, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002 Jan;30(1):119-41.
Description: The challenges of assessing and treating patients under prolonged sedation and analgesia are unique in the patient requiring mechanical ventilation. Assessment methods and measurement scales for sedation and agitation are discussed; an algorithm and specific recommendations for drug selection are included. 23 Pages. Access checked April 14, 2009.
Nursing Best Practice Guideline: Assessment and Management of Pain
Access: http://www.rnao.org/bestpractices/PDF/BPG_Assessment_of_Pain.pdf
Source: Registered Nurses Association of Ontario
Date: 2002
Description: Recommendations for best nursing practices are presented as evidence-based guidelines for registered nurses and registered practical nurses. Seventy-nine recommendations are made for assessment (including documentation), healthcare organization policies, and pharmacological treatment. An appendix includes assessment tools, an analgesic ladder, sample subcutaneous injection protocol, and non-pharmacological interventions. 147 Pages. Access checked April 14, 2009.
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Acute Pain
Assessment and Management of Acute Pain
Access: http://www.icsi.org/pain_acute/pain__acute__assessment_and_management_of__3.html
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2008
Description: Acute pain strikes all ages and this evidence-based guideline has been developed for all, from infants to the elderly. An assessment algorithm aids in the evaluation of somatic, visceral, and neuropathic pain symptoms; a second algorithm includes specific treatment options for different types and causes of pain. The 3 mechanisms of pain are considered individually and in combination; great emphasis is placed on thorough assessment, including assessment tools for children and adults. To learn more about ICSI or to order a printed copy ($10), visit www.icsi.org. 59 Pages. Access checked April 14, 2009.
APS 2005 Recommendations for Improving the Quality of Acute and Cancer Pain Management
Access: http://www.ampainsoc.org/pub/bulletin/fal05/inno1.htm
Source: American Pain Society
Date: 2005 (Revision and expansion of the 1995 Quality Improvement Guidelines)
Print Reference: Gordon DB, Dahl JL, Miaskowski C, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Internal Med. 2005(Jul);165(14):1574-1580.
Description: Based on expert consensus and a systematic review of the literature on quality improvement in pain management, recommendations were made to improve the quality of pain management in all care settings. Recent knowledge in pain management led to the design and testing of new ways for communication and treatment continuity across care environments. Quality improvement recommendations are available at no charge by calling APS at (847) 375-4715 or writing info@ampainsoc.org. 7 Pages. Access checked April 14, 2009.
Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease
Access: http://www.ampainsoc.org/pub/sc.htm
Source: American Pain Society
Date: 2000
Description: An overview of sickle cell disease and the associated pain experience is described in this guideline. The pain assessment section includes a discussion of acute and chronic pain in the developmental stages of sickle cell disease. Pain management recommendations are multi-disciplined in approach and cover pharmacologic and nonpharmacologic therapies. Available for purchase only through the website (click on the APS Online Store); members $10, non-members $15. 60 Pages. Access checked April 14, 2009.
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Cancer Pain
Cancer Pain Algorithm
Access: http://utm-ext01a.mdacc.tmc.edu/mda/cm/CWTGuide.nsf/LuHTML/SideBar1?OpenDocument
Source: The University of Texas MD Anderson Cancer Center
Date: 2008
Description: Algorithms for adult cancer pain management in both inpatient and outpatient environments include nonopioid (acetaminophen, NSAIDs, anticonvulsants, antidepressants, muscle relaxants, and corticosteroids) and opioid drugs. Using a 1-10 intensity scale, the level of pain algorithm guides the clinician to recommendations for appropriate pharmacologic treatment. Other tools include a protocol for opioid rotation, an opioid conversion table, and dosing guidelines for fentanyl in 4 routes of administration. Additionally, techniques for the prevention of opioid adverse effects and an algorithm for the management of 5 key adverse events is provided. 15 pages. Access checked April 14, 2009.
Management of Cancer Pain
Access: http://annonc.oxfordjournals.org/cgi/reprint/19/suppl_2/ii119
Source: European Society for Medical Oncology
Date: 2008
Print Reference: Jost L, Roila F. Management of cancer pain. ESMO clinical recommendations. Annals of Oncology. 2008;19(Suppl. 2):ii119-ii121.
Description: This easy-to-read guideline addresses the basic management of cancer pain using the step-wise escalation approach of the World Health Organization (WHO). Route and administration (including scheduling and dosing) guidelines are provided; the management of adverse effects is discussed briefly. A table of selected co-analgesics contains dosing ranges and information on formulation strength. 3 Pages. Access checked April 14, 2009.
Guideline for the Management of Cancer Pain in Adults and Children
Access: http://www.ampainsoc.org/pub/cancer.htm
Source: American Pain Society
Date: 2005
Description: An evidence-based clinical practice guideline that is designed to help clinicians and patients improve control of the pain associated with cancer. It describes recent discoveries in the causes of pain, assessment techniques, and therapeutic strategies to manage cancer pain. Available for purchase only through the website (click on the APS Online Store); members $15, non-members $20. 166 Pages. Access checked April 14, 2009.
Intrathecal Drug Delivery for the Management of Cancer Pain: A Multidisciplinary Consensus of Best Clinical Practices
Access: http://www.supportiveoncology.net/journal/articles/0306399.pdf
Source: Multidisciplinary workshop; unrestricted grant to Valley Cancer Pain Foundation
Date: 2005
Print Reference: Stearns L, Boortz-Marx R, DuPen S,et al. Intrathecal drug delivery for the management of cancer pain. A multidisciplinary consensus of best clinical practices. J Support Oncol. 2005(Nov-Dec);3(6):399-408.
Description: The management of cancer pain often requires an interdisciplinary approach, and intrathecal delivery is a rapid method of treating intractable pain that can be used concurrently during radiology treatment or a chemotherapy regimen. It can provide effective pain management for patients who cannot tolerate oral medications, those with complex pain syndromes or opioid intolerance concerns. The guidelines include dosing and titration recommendations and algorithms for short-term and long-term cancer survivors. 10 Pages. Access checked April 14, 2009.
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Cardiac & Chest Pain
Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS)
Access: http://www.icsi.org/acs_acute_coronary_syndrome/acute_coronary_syndrome...
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2009
Description: Timely treatment is crucial to the success of emergency intervention for patients with high-risk chest pain. Seven clinical algorithms are presented: chest pain screening, emergency intervention, ST-segment elevation myocardial infarction (STEMI), acute myocardial infarction complications, special work-up for chest pain unrelated to coronary artery disease, non-cardiac causes, and clinic evaluation. Algorithm annotations include detailed risk assessment information on the significance of the timing of chest pain symptoms that are suggestive of immediate adverse outcomes. 70 Pages. Access checked March 19, 2010.
Management of Cocaine-Associated Chest Pain and Myocardial Infarction. A Scientific Statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology
Access: http://circ.ahajournals.org/cgi/reprint/117/14/1897
Source: American Heart Association (AHA)
Date: 2008
Print Reference: McCord J, Jneid H, Hollander JE, et al. Circulation. 2008(Apr 8);117(14):1897-1907.
Description: Symptoms of cocaine use can mimic those of myocardial infarction (MI) and 2 treatments typically used to treat an MI can be dangerous to cocaine users. Following a critical analysis of existing literature, the AHA developed recommendations for diagnostic evaluation and treatment by levels-of-evidence. The guidelines recommend early identification of cocaine use by self-report or by laboratory testing. While research showed that only 1% to 6% of patients with cocaine-associated chest pain actually had an MI, there are several important reasons for early identification of cocaine use. Access checked April 14, 2009.
Pain Management in Blunt Thoracic Trauma: An Evidence-Based Outcome Evaluation
Access: http://www.east.org/tpg/painchest.pdf
Source: Eastern Association for the Surgery of Trauma
Date: 2003
Description: These recommendations are the result of a review and grading of 91 studies of rib fractures, chest wounds, and thoracic injuries. Various modalities of analgesic management are evaluated and recommendations are made based on efficacy and technical considerations. 79 Pages. Access checked April 14, 2009.
ACC/AHA 2007 Focused Update and 2002 Guidelines for the Management of Patients With Chronic Stable Angina
Access Update: http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.08.002
Access Full 2002 Guideline: http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf
Source: American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Date: Revised 2007 (Originally published in 1999)
Description: The most common manifestation of ischemic heart disease is chronic stable angina. Considering the high rates of morbidity and mortality, the aim of the ACC/AHA Task Force was to improve patient outcomes and use the most effective strategies to reduce the overall cost of care. These guidelines use the 3 ACC/AHA classes for the recommendations presented in 4 sections: diagnosis, risk stratification, treatment, and patient follow-up. Three algorithms for management are presented: clinical assessment, stress testing/angiography, and treatment. A treatment mnemonic highlights the 10 treatment components that the Task Force identified as most important. Update - 14 pages, 2002 guideline - 125 pages. Access checked September 3, 2009.
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina and Non-ST- Elevation Myocardial Infarction
Access: http://content.onlinejacc.org/cgi/content/full/50/7/e1
Source: American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Date: 2007 (Originally published in 2000)
Description: These guidelines focus on 2 components of acute coronary syndrome which is a life-threatening disorder frequently requiring emergency medical care. Pathophysiology, presentation, assessment, and risk stratification are examined in the first two sections; hospital care, coronary revascularization, and the management of special populations are covered in the last 4 sections. These guidelines use the 3 ACC/AHA classes for the recommendations presented in each section. 162 Pages. Access checked September 3, 2009.
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Chronic & Intractable Pain (including CRPS/RSD)
Evidence Based Guidelines for Complex Regional Pain Syndrome Type 1
Access: http://www.rsds.org/2/library/article_archive/pop/Perez_Zollinger_BMCNeurol_2010.pdf
Date: 2010
Print Reference: Perez RS, Zollinger PE, Dijkstra PU, et al. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurology. 2010;10(20).
Description: A multidisciplinary task force graded literature evaluating treatment effects for CRPS-1 — formerly known as reflex sympathetic dystrophy (RSD) — according to their strength of evidence. Based on the findings treatment recommendations were formulated and approved for general pain treatment, neuropathic pain, inflammatory symptoms, promoting peripheral blood flow, and decreasing functional limitations. The prevention of primary and secondary CRPS-1 also is discussed. Access checked May 29, 2010.
Practice Guidelines for Chronic Pain Management [ASA/ASRA]
Access: http://journals.lww.com/anesthesiology/...13.aspx (PDF version also available at this site)
Source: American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA).
Date: 2010 (April)
Print Reference: Rosenquist RW, Benzon HT, Connis RT, et al. Practice Guidelines for Chronic Pain Management. Anesthesiology. 2010;112(4):810-833.
Description: These new recommendations, an evidence-based update of guidelines published by ASA/ASRA more than a decade ago, are designed to help all clinicians who treat chronic pain. Topics apply to patients with chronic noncancer, neuropathic, somatic, or visceral pain. A diversity of modalities are addressed, such as the latest advances in interventional and surgical procedures, medication management, and the full range of adjunctive or alternative therapies. Access checked April 3, 2010.
Assessment and Management of Chronic Pain
Access: http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/...
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2009
Description: This ICSI guideline aims to improve the effectiveness of chronic pain treatment and resulting physical functionality by using a biopsychosocial model and a multi-specialty team approach. Assessment and management algorithms are presented; patient questionnaires, agreements, and a pain inventory are also included. To learn more about ICSI or to order a printed copy ($10), visit www.icsi.org. 92 Pages. Access checked March 19, 2010.
Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Clinical Practice Guidelines, 3rd Edition
Access: http://rsdfoundation.org/en/en_clinical_practice_guidelines.html
Source: International Research Foundation for RSD/CRPS
Date: 2003 (Updated January, 2009)
Description: Reflex Sympathetic Dystrophy Syndrome (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a multi-symptom, multi-system, syndrome usually affecting one or more extremities, and continues to be poorly understood. This guideline covers the clinical features of RSD/CRPS and important diagnostic strategies. A comprehensive treatment protocol is defined and video presentations on sympathetic lumbar nerve block techniques are included. Additionally, a video on sympathetic nerve blocks in children has been added since the last update. 26 Pages. Access checked April 14, 2009.
Complex Regional Pain Syndrome: Treatment Guidelines
Access: http://www.rsds.org/3/clinical_guidelines/index.html#diagnosis
Source: Reflex Sympathetic Dystrophy Syndrome Association
Date: 2006
Description: Complex Regional Pain Syndrome (CRPS), formerly called Reflex Sympathetic Dystropy, is challenging to diagnose and treat. This guideline presents a history of the challenges involved in the validation of existing diagnostic criteria and summarizes two separate sets of criteria for use in clinical and research applications. An interdisciplinary approach to restoring the patient’s functionality by managing pain, edema and other symptoms is discussed. Treatment algorithms and recommendations for an evidence-based approach to pharmacology and interventional therapy are presented; physical therapy and psychotherapy are examined as crucial components of the overall treatment program. 68 Pages. Access checked April 14, 2009.
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Geriatric Pain
Pharmacological Management of Persistent Pain in Older Persons
Access: http://www.americangeriatrics.org/.../clinical_practice/clinical_guidelines_recommendations/2009/
Source: American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons.
Date: 2009
Print Reference: AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 2009 [in press].
Description: This AGS guideline on the pharmacological management of persistent pain in older adults replaces the 2002 edition. Based on more recent studies that show increased cardiovascular risk and gastrointestinal toxicity with the use of NSAIDs or COX-2 inhibitors, it is important to note that this guideline has nearly eliminated any recommendation of these agents in this population. Overall, 27 recommendations are presented for managing persistent pain in patients 75-years and older who have a tendency to be more frail and suffer from multiple chronic illnesses. The panel also recommends opioid therapy for elderly patients with moderate-to-severe pain or diminished quality of life due to pain. Adequate management of pain could reduce unwanted adverse outcomes like falls, sleep disruption, depression, and anxiety. A brief discussion on the use of newer adjuvant drugs and topical analgesics is also presented. Access checked May 21, 2010.
Clinical Practice Guideline: Pain Management in the Long Term Care Setting
Access: http://www.amda.com/tools/cpg/chronicpain.cfm
Source: American Medical Directors Association
Date: 2009 (Originally published in 1999, updated/revised in 2009)
Description: This guideline examines barriers to effective pain management as well as acute pain management in response to the Centers for Medicare & Medicaid Services (CMS) quality initiative measure for pain. The challenges of recognizing pain in the cognitively impaired, pain management in palliative care, and alternative therapies are also described. Available for purchase only; members $20, non-members $30. 31 Pages. Access checked April 10, 2009.
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Gynecological or Obstetrical Pain
European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain
Access: http://www.backpaineurope.org/web/files/586_2008_602_OnlinePDF.pdf
Source: Working Group 4 of the European Commission Research Directorate General
Date: 2008
Print Reference: Vleeming A, Albert HB, Ostgaard HC, et al. European Spine Journal. 2008(Feb 8); Early online publication prior to print.
Description: This guideline was developed following an evaluation of evidence-based literature and the creation of a grading system for recommendations on the diagnosis and treatment of patients with pelvic girdle pain (PGP). Working Group 4 concluded that PGP is a form of low back pain that can occur with or without low back pain. Factors that influence and those that appear not to influence risk are listed and explained. Treatment recommendations include medication use for nonpregnant women, education and reassurance, individualized exercises, and multidisciplined therapy. Access checked April 14, 2009.
Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.
Access: http://www.asahq.org/publicationsAndServices/OBguide.pdf
Source: American Society of Anesthesiologists (ASA)
Date: 2007
Print Reference: Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007(Apr);106(4):843-863.
Description: The ASA Task Force reviewed evidence-based literature and invited the opinions of a panel of consultants and practitioners to develop an update to guidelines that were originally adopted in 1998. The update provides expanded recommendations for pain management during labor, operative and non-operative deliveries, and the postpartum period. The revised guidelines include the recommendation that the level of care and equipment available to patients in the main operating room also be provided to all obstetric patients. Each recommendation is supported by a strength-of-evidence evaluation and the appendix to the guideline includes a meta-analysis summary. Text version: 52 Pages. Access checked April 14, 2009.
Consensus Guidelines for the Management of Chronic Pelvic Pain - Part One and Part Two
Access: Part One: http://www.sogc.org/guidelines/public/164E-CPG1-August2005.pdft
Access: Part Two: http://www.sogc.org/guidelines/public/164E-CPG2-September2005.pdf
Source: Chronic Pelvic Pain Working Group, Society of Obstetricians and Gynaecologists of Canada
Date: 2005
Print Reference: Part One: Jarrell JF, Vilos GA, Abu-Rafea B, et al. Chronic Pelvic Pain Committee. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005(Aug);27(8):781-826.
Print Reference: Part Two: Jarrell JF, Vilos GA, Abu-Rafea B, et al. Chronic Pelvic Pain Committee. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005(Sep);27(9):869-887.
Description: Part one contains 6 chapters which address individual aspects of chronic pelvic pain. Physiology, etiology, assessment, and laparoscopic investigations are examined in the first 4 chapters; specific gynecological, urological and gastrointestinal conditions are explored in chapters 5 and 6 (21 Pages). Part two contains 8 chapters covering myofascial dysfunction plus recommendations for medical, surgical and complementary/alternative interventions for the management of chronic pelvic pain (19 Pages). Access checked April 14, 2009.
The Initial Management of Chronic Pelvic Pain
Access: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT41InitialManagementChronicPelvicPain2005.pdf
Source: Royal College of Obstetricians and Gynaecologists
Date: 2005
Description: Because chronic pelvic pain is a symptom, not a diagnosis, this guideline stresses the importance of a comprehensive history and assessment that include psychological and social considerations. Diagnostic imaging and laparoscopy are recommended according to levels of evidence. A flowchart summarizes management and referral of chronic pelvic pain patients. 12 Pages. Access checked April 14, 2009.
Cyclic Perimenstrual Pain and Discomfort: Nursing Management. Evidence-Based Clinical Practice Guideline
Access: (National Guideline Clearinghouse summary) http://www.guideline.gov/summary
Source: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Date: 2003
Description: This evidence-based clinical practice guideline is designed to assist nurses in patient assessment strategies that includes identifying pain relief obtained from current interventions as well as current treatment adherence patterns. In addition to an evaluation of symptom and relief patterns, the nursing interventions include mutual goal-setting with the patient and multimodal treatment strategies. A print copy of the 48-page book is available for purchase through the website: http://www.awhonn.org (click on the AWHONN Store/Evidence Based Guidelines); members $30, non-members $45. The National Guideline Clearinghouse link provided above offers a 10-page summary of the guideline. Access checked April 14, 2009.
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Headache
EFNS Guideline on the Drug Treatment of Migraine – Revised Report of an EFNS Task Force
Access: https://www.efns.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2009...pdf
Source: European Federation of Neurological Societies
Date: 2009
Print Reference: Evers S, Afra J, Frese A, et al. EFNS guidelines on the drug treatment of migraine—revised report of an EFNS task force. Eur J Neurol. 2009(Sep);16(9):968-981.
Description: This revised guideline provides evidence-based drug therapy recommendations for the treatment of acute migraine attacks as well as prophylactic management. Based on the evidence of existing studies and the consensus of an expert panel, recommendations follow the concept of stratified treatment and provide guidance for the treatment of moderate to very severe attacks. A section on triptans discusses individual drug differences in efficacy, time to onset, and adverse effects or cautions. 14 Pages. Access checked October 13, 2009.
Diagnosis and Treatment of Headache
Access: http://www.icsi.org/headache/headache__diagnosis_and_treatment_of_2609.html
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2009
Description: This guideline emphasizes appropriate assessment and provides a thorough analytical framework that includes 10 algorithms for the diagnosis and treatment of headache. A drug table with a discussion of treatment considerations for the female population is provided. The authors include a presentation of the warning signs of potential disorders other than primary headache. To learn more about ICSI or to order a printed copy ($10), visit www.icsi.org. 77 Pages. Access checked April 14, 2009.
Standards of Care for Headache Diagnosis and Treatment
Access: (NHF summary) http://www.headaches.org/Standards...Headache_DiagnosisTreatment
Source: National Headache Foundation (NHF)
Date: 2008
Description: This expanded edition includes a wealth of information on assessment and therapy for all primary headache types as well as secondary causes of chronic daily headache. Additional chapters on pediatric headache, alternative therapy, and patient education provide comprehensive coverage of headache disorders. The authors also discuss specific issues such as the importance of selecting drugs for acute treatment while considering the risk of complicating the chronic treatment regimen. A print copy of the 181-page book Standards of Care for Headache Diagnosis and Treatment is available to healthcare practitioners for $12 from the NHF by calling 888-NHF-5552. The link above provides a 4-page abbreviated version. Access checked March 19, 2010.
Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache
Access: http://216.25.88.43/upload/NS_BASH/BASH_guidelines_2007.pdf
Source: British Association for the Study of Headache
Date: 2007; Third Edition
Description: The evidence for improved outcomes in headache management was evaluated and guidelines were developed by a team of headache specialists, members of the British Association for the Study of Headache and the Association of British Neurologists. These guidelines utilize the headache criteria of the 2003 International Class of Headache Disorders (ICHD-II) and address all forms of headache diagnosis and management. In addition to migraine, tension-type headache, cluster headache, and multiple coexistent headache disorders, recommendations are also included for medication overuse headache. A brief 6-part history questionnaire is included as a tool for diagnosis. 52 Pages. Access checked April 14, 2009.
EFNS Guidelines on the Treatment of Cluster Headache and Other Trigeminal-Autonomic Cephalalgias
Access:http://www.efns.org/...2006_cluster_headache_and_other_trigeminal_autonomic.pdf
Source: European Federation of Neurological Societies
Date: 2006
Print Reference: May A, Leone M, Afra J, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. 2006(Oct);13(10):1066-1077.
Description: This guideline begins with a description of each headache disorder using the International Headache Society’s diagnostic criteria. Cluster headache, paroxysmal hemicrania, and SUNCT syndrome are addressed individually. Following an extensive literature review and expert consensus, three grades of evidence-based recommendations for the treatment of these specific headache disorders are made; practice pointers for dosing and length of treatment are included. Guidelines are provided for prophylactic therapy as well as for the treatment of the acute cluster headache attack. 12 Pages. Access checked April 14, 2009.
The International Classification of Headache Disorders, 2nd Edition
Access: headacheclassification Web-based edition (2008) at: http://ihs-classification.org/en/
Source: International Headache Society (IHS)
Date: 2005
Print Reference: Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, Second Edition, first revision. (May) 2005.
Description: This new edition -- and the more recent web-based edition (recommended) -- replaces the original International Classification of Headache Disorders published in 1988 and was developed for research and clinical practice alike. Many sources of evidence were used to update the classification, including epidemiological studies and longitudinal studies that focused on diagnostic and treatment results. Additions to this version include a new classification for ‘Chronic Migraine’, as well as a chapter that looks at the small field of research on headaches that can be attributed to psychiatric disorders. 232 Pages. Access checked April 14, 2009.
2006 Report: New Appendix Criteria Open for a Broader Concept of Chronic Migraine. Following the release of the 2004 revised classification above, the Headache Classification Committee of the IHS expanded the ‘Chronic Migraine’ category in response to additional clinical evidence that the existing category included very few patients. In addition, the ‘Medication Overuse Headache’ category has been redefined. The abstract is available at: http://dx.doi.org/10.1111/j.1468-2982.2006.01172.x Access checked April 14, 2009.
Print Reference: Headache Classification Committee of the International Headache Society. New appendix criteria open for a broader concept of chronic migraine. Cephalalgia. 2006(Jun);26(6):742-746.
Practice Parameter: Evidence-Based Guidelines for Migraine Headache
Access: http://www.neurology.org/cgi/content/full/55/6/754
Source: Quality Standards Subcommittee of the American Academy of Neurology
Date: 2000
Print Reference: Silberstein SD. for the US Headache Consortium. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000(Sep); 55(6):754-762.
Description: This guide summarizes the results of 4 evidence-based reviews on the treatment of patients with migraine. A multidisciplinary panel from 7 professional organizations (The US Headache Consortium) produced treatment guidelines for 4 distinct management decisions: diagnostic testing (primarily neuroimaging studies), pharmacologic management of acute attacks, migraine-preventive drugs, and behavioral and physical treatments for migraine. 9 Pages. Access checked April 14, 2009.
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Musculoskeletal Pain (including Back Pain, Arthritis, and Fibromyalgia)
EULAR Recommendations for the Management of RA with DMARDS
Access PDF: http://ard.bmj.com/content/early/2010/05/04/ard.2009.126532.full.pdf
Source: European League Against Rheumatism (EULAR)
Date: 2010
Print Reference: Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Annals of the Rheumatic Diseases. 2010(Jun);69(6):964-975.
Description: Based on a review of the published evidence showing varied outcomes for different treatment strategies, experts within the European community of rheumatologists have established a consensus on the management of rheumatoid arthritis (RA) with biological and synthetic DMARDs and glucocorticoids. The resulting 15 recommendations cover general disease management as well as treatment considerations like: 1) therapy preferences, 2) patients with a history of tumor necrosis factor inhibitor (TNF-inhibitor) therapy failures, and 3) treatment during remission. The guidelines include an assessment of cost-effectiveness plus a discussion of the graded levels of evidence that support each recommendation. An easy-to-read algorithm showing 3 phases of treatment aimed at achieving clinical remission is included. Access checked June 18, 2010.
International Consensus Recommendations on Methotrexate Therapy
Canadian Recommendations for Use of Methotrexate in Patients with Rheumatoid Arthritis
Access PDF: http://www.jrheum.org/content/early/2010/05/27/jrheum.090978.full.pdf+html
Source: Canadian Rheumatologists, Canadian 3E Initiative Consensus Group
Date: 2010
Print Reference: Katchamart W, Bourré-Tessier J, Donka T, et al. Canadian Recommendations for use of methotrexate in patients with rheumatoid arthritis. Journal of Rheumatology. 2010(Jun). [Epub ahead of print].
Description: This Canadian guideline contains 9 additional recommendations that complement the 10 international recommendations on the administration of methotrexate (MTX) in RA published in 2009 (see immediately below). Using an evidence-based approach toward answering key disease management questions, guidance is offered for the assessment of variations in clinical response, prognostic factors for MTX response, strategies for non-serious adverse effect reduction, drug interactions, and patient treatment preferences. Access checked June 18, 2010.
Multinational Evidence-Based Recommendations for the Use of Methotrexate in Rheumatic Disorders With a Focus on Rheumatoid Arthritis
Access: http://ard.bmj.com/content/68/7/1086.full.pdf
Source: International 3E Initiative in Rheumatology Consensus Group
Date: 2009
Print Reference: Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E initiative. Annals of the Rheumatic Diseases. 2009(Jul);68(7):1086-1093.
Description: Methotrexate prescribing practices vary greatly among rheumatologists and primary care practitioners. Following a systematic review of the literature and a high level of expert consensus, 10 graded recommendations for the use of methotrexate in clinical practice management of rheumatoid arthritis (RA) were developed. The practice guidelines include: patient assessment, optimal methotrexate dosing and routes, monotherapy versus combination use, clinical monitoring, long-term safety, the protective effects of concurrent folic acid administration, and methotrexate administration in special situations. Access checked June 18, 2010.
Treating Rheumatoid Arthritis to Target: Recommendations of an International Task Force
Access PDF: http://ard.bmj.com/content/69/4/631.long
Source: European League Against Rheumatism (EULAR) T2T Expert Committee
Date: 2010
Print Reference: Smolen JS, Aletaha D, Bijlsma JWJ, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Annals of the Rheumatic Diseases. 2010;69:631-637.
Description: The committee’s goal was to assess available evidence and develop recommendations for achieving optimal therapeutic outcomes for patients on drug therapy for rheumatoid arthritis (RA). Following a review of published literature to identify treatment targets for RA, the evidence was evaluated by the task force and a consensus resulted in 10 recommendations for optimal outcomes in the treatment of RA. While the committee agreed that low disease activity may be acceptable for some patients, it was determined that the ultimate goal for most patients should be remission. Additionally, measures of disease activity within affected joints should be assessed every 3 months and changes in therapy are recommended until the treatment target is reached. Individual patient targets should be influenced by various patient factors, including comorbidities and drug-related risks. Follow-up evaluations are recommended on an ongoing basis and further treatment decisions should be based on structural changes, functional impairment, and health-related quality of life. Access checked April 9, 2010.
Symptomatic Treatment for Muscle Cramps
Access PDF: http://www.neurology.org/cgi/reprint/74/8/691
Source: American Academy of Neurology (AAN).
Date: 2010
Print Reference: Katzberg HD, Khan AH, So YT. Assessment: Symptomatic treatment for muscle cramps (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010;74;691-696.
Description: This AAN assessment systematically reviews available evidence on the symptomatic treatment of muscle cramps. Conclusions are that, although they are likely to be effective, quinine derivatives should be avoided except in select patients because of potential toxicity. Vitamin B complex, Naftidrofuryl [not available in U.S.], and calcium channel blockers such as diltiazem are possibly effective and may be considered in the management of muscle cramps. Limited data regarding the use of magnesium preparations and gabapentin show that these agents are probably not effective NOTE: This guideline did not evaluate treatments for muscle cramps due to muscle diseases, kidney diseases, menstruation, pregnancy, or excessive exercise, heat or dehydration. Access checked February 27, 2010.
Guidelines for the Management of Polymyalgia Rheumatica
Access: http://rheumatology.oxfordjournals.org/cgi/content/full/49/1/186
Source: British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR)
Date: 2010
Print Reference: Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR Guidelines for the Management of Polymyalgia Rheumatica. Rheumatology. 2010;49(1):186-190.
Description: Polymyalgia rheumatica (PMR) is a clinical syndrome characterized by severe aching and stiffness in the neck, shoulder girdle, and pelvic girdle. It is the most common inflammatory rheumatic disease in the elderly and is one of the biggest indications for long-term steroid therapy. It is classified as a rheumatic disease, although the etiology is undetermined and there are difficulties in diagnosis, with wide variations in presentation, response to steroids, and disease course. The aim of these guidelines is to provide a safe and specific diagnostic process for PMR, using continued assessment, and discouragement of hasty initial treatment. Their further scope is to provide advice for the management and monitoring of disease activity, complications and relapse. Management of the related inflammatory condition, giant cell arteritis (GCA), is not covered here. 5 pages. Access checked December 11, 2009
Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain
Access: http://www.painphysicianjournal.com/2009/july/2009;12;699-802.pdf
Source: American Society of Interventional Pain Physicians (ASIPP)
Date: 2009
Print Reference: Manchikanti L, Boswell MV, Singh V, et al. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Phys. 2009;12:699-802.
Description: This is the fifth revision of the ASIPP chronic spinal pain practice guidelines and replaces the previous 2007 version. Using an ongoing process to synthesize the evidence, these guidelines continue to represent the most current emerging techniques in interventional therapy for pain by examining results reported in systematic reviews, randomized trials, retrospective trials, and prospective trials. Expert opinion and consensus have also been used as needed to provide the best evidence available. Information is provided on the evaluation of spinal pain, the diagnosis of chronic back pain without disc herniation, the application of therapeutic interventional techniques in the management of chronic low back pain, and the diagnosis of chronic neck pain without disc herniation. 104 Pages. Access checked August 7, 2009.
Low Back Pain: Early Management of Persistent Non-Specific Low Back Pain.
Access: http://guidance.nice.org.uk/CG88
Source: National Institute for Health & Clinical Excellence (NICE), UK National Health Service.
Date: 2009
Description: This guideline focuses on the care of patients with persistent or recurrent non-specific low back pain, lasting from 6 weeks to 1 year. Recommended therapies include either a structured exercise program (8 sessions during up to 3 months), a course of manual therapy, including manipulation or massage (9 sessions during 3 months), a course of acupuncture (up to 10 sessions), or a combined physical and psychological treatment program (100 hours during up to 8 weeks). The guideline specifies that patients should not have X-rays taken or be offered therapeutic ultrasound, lumbar supports, or injections of therapeutic substances into their backs. Patients with spinal malignancy, infection, fracture, cauda equina syndrome, or ankylosing spondylitis or another inflammatory disorder are not covered by this guideline. Access checked May 30, 2009.
Guideline: Diagnosis and Treatment of Forefoot Disorders
Access: http://www.acfas.org/HealthcareCommunity/content.aspx?id=367
Source: American College of Foot and Ankle Surgeons (ACFAS)
Date: 2009
Print Reference: Clinical Practice Guideline: Forefoot Disorders Panel. J Foot Ankle Surg. 2009;48(2):239-272.
Description: This 5-part guideline was developed for the diagnosis and treatment of 5 common painful foot disorders: digital deformities, pain in the ball of the foot, pain due to nerve compression, bunions, and traumatic forefoot injury. Forefoot pain and deformity can increase with age but an early diagnosis and appropriate treatment can halt or delay progression of the disorder. While it is common for some forefoot disorders to be caused by stress fractures or injury, it is important to note that arthritic conditions can be important etiologies. Furthermore, the prophylactic correction of toe deformities in patients with diabetic peripheral neuropathy is critical for the prevention of future ulceration. Treatment recommendations vary, depending on the cause of the condition, but can range from a change in footwear or analgesic therapy to injection modalities or surgery. Accessed 10/27/09.
British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis — After the First Two Years
Access to 4-page summary: http://rheumatology.oxfordjournals.org/cgi/reprint/ken450av1
Access to full guideline: http://rheumatology.oxfordjournals.org/cgi/data/ken450a/DC1/1
Source: British Society for Rheumatology, British Health Professionals in Rheumatology
Date: 2009
Print Reference: Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first two years). Rheumatology (Oxford). 2009(Jan); [Early online publication prior to print].
Description: This guideline was written as an extension of the first guideline (see below) on early management of rheumatoid arthritis (RA) and provides 20 evidence-based, graded recommendations for long-term management. The proposed model of patient care uses a multi-disciplined approach for ongoing assessment, treatment modification, and the monitoring of effectiveness. Ongoing measures of disease activity and damage are stressed as important components of long-term comprehensive care. 23 Pages. Access checked April 14, 2009.
British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis -- the First Two Years
Access: http://rheumatology.oxfordjournals.org/cgi/data/kel215a/DC1/1
Source: British Society for Rheumatology, British Health Professionals in Rheumatology
Date: 2006
Print Reference: Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology (Oxford). 2006(Sep);45:1-16.
Description: This guideline provides 24 evidence-based, graded recommendations for the early management of rheumatoid arthritis. The patient care pathway uses a multi-disciplined approach for assessment, planning, treatment delivery, and the monitoring of effectiveness. 16 Pages. Access checked April 14, 2009.
Guideline on the Treatment of Osteoarthritis (OA) of the Knee
Access full guideline (278 pp); summary (5 pp) at: http://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp
Source: American Academy of Orthopaedic Surgeons (AAOS)
Date: December 2008
Description: A multi-disciplinary AAOS workgroup developed evidence-based guidelines for the treatment of osteoarthritis of the knee in adult patients. The 22 recommendations were explicitly developed to include only treatments that are less invasive than knee replacement surgery. The guidelines recommend against performing an arthroscopic lavage if a patient only displays symptoms of osteoarthritis and no other problems like loose bodies or meniscus tears. Furthermore, overweight patients, with a Body Mass Index (or BMI) greater than 25, should lose a minimum of 5% of their body weight.
Patients should be encouraged to begin or increase their participation in low-impact aerobic fitness programs.
The guidelines authors recommend against using glucosamine and/or chondroitin sulfate or hydrochloride, needle lavage (aspiration of the joint with injection of saline), or custom made foot orthotics. For symptomatic relief of knee pain due to OA, the group recommends acetaminophen (not to exceed 4 grams per day), non-steroidal anti inflammatory drugs (NSAIDs), or intra-articular corticosteroids (for short term pain relief). Insufficient evidence was available to recommend for or against the use of bracing, acupuncture, or intra-articular hyaluronic acid. Access checked April 14, 2009.
 Certain elements of the above guideline are contradicted by guidelines from the Work Loss Institute (WLI) for knee/leg arthritis. The latter document recommends acetaminophen as a safer but less effective agent than NSAIDs for relief of knee pain. Therefore, acetaminophen should be the first line treatment, with NSAIDs reserved for those who do not respond. Glucosamine is recommended as providing effective symptomatic relief, and for modifying the progression of arthritis over a 3-year period, in patients with osteoarthritis of the knee. Glucosamine is noted as having a tolerability profile similar to that of placebo and is better tolerated than ibuprofen or piroxicam. Intra-articular (IA) injection of hyaluronic acid (eg, Synvisc) is suggested as decreasing symptoms of osteoarthritis of the knee. Furthermore, the WLI guideline notes that the short-term benefit of IA corticosteroids in treatment of knee osteoarthritis is well established and few side effects have been reported; however, longer-term benefits have not been confirmed. The guidelines conclude that total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function.
Source: Work Loss Data Institute. Guideline: Knee & Leg (acute & chronic). 2008. [289 pages].
Access: http://www.guidelines.gov/summary/summary.aspx?doc_id=12673
Adult Low Back Pain
Access: http://www.icsi.org/low_back_pain/adult_low_back_pain__8.html
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2008
Description: An identification of symptoms that would indicate the presence of a serious underlying condition requiring urgent care is crucial to the initial patient evaluation. The guideline continues with an emphasis on acute and chronic management of low back pain and sciatica, including the indications for medical, surgical, and non-surgical referral. Discussions of prevention, lifestyle modifications, and self-care treatments are included. 67 Pages. Access checked Adult 14, 2009.
American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis
Access: http://www.rheumatology.org/practice/clinical/guidelines/recommendations.pdf
Source: American College of Rheumatology
Date: 2008
Print Reference: Saag KG, Teng GG, Patkar NM, et al. Arthritis & Rheumatism. 2008(Jun 15);59(6):762-784.
Description: These evidence-based guidelines begin with an explanation of the review methods used to evaluate evidence published subsequent to the release of the 2002 recommendations. Five specific topics are examined: 1) treatment indications, 2) tuberculosis screening with biologic DMARDs, 3) adverse effects, 4) efficacy, and 5) treatment selection based on patient preferences and cost. Recommendations for both nonbiologic and biologic DMARDs are presented in 3 separate algorithms based on disease duration. Two additional tables present contraindications to the use of nonbiologic and biologic DMARDs as well as recommendations for laboratory follow-up. 23 Pages. Access checked April 14, 2009.
OARSI Recommendations for the Management of Hip and Knee Osteoarthritis, Part II: OARSI Evidence-Based, Expert Consensus Guidelines
Access: http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf
Source: Osteoarthritis Research Society International (OARSI)
Date: 2008
Print Reference: Zhang W, Moskowitz RW, Nuki G, et al. Osteoarthritis Cartilage. 2008(Feb);16(2):137-162.
Description: Experts in 4 clinical disciplines from 6 countries evaluated existing guidelines on the management of hip and knee osteoarthritis. The evidence was evaluated and consensus recommendations were developed following a synthesis of expert clinical opinion and the strength of existing recommendations. The guidelines development team determined that optimal management of patients with hip or knee osteoarthritis requires a combination of non-pharmacological and pharmacological treatment modalities. The guideline includes 25 recommendations overall; 8 recommendations are related to the administration of non-opioid pain-relievers and 12 recommendations resulted following a review of the efficacy of non-pharmacological modalities from education to acupuncture. Five surgical recommendations are included. This guideline was developed in a manner that would allow adaptation for use in a variety of clinical settings and geographical regions. Access checked April 14, 2009.
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Access: http://www.annals.org/cgi/reprint/147/7/478.pdf
Source: American College of Physicians (ACP), American Pain Society (APS)
Date: 2007
Print Reference: Chou R, Qaseem A, Snow V, et al. Annals of Internal Medicine. 2007(Oct);147(7):478-491.
Description: Low back pain is reported to be the fifth most common healthcare complaint in the United States. This evidence-based guideline for the evaluation and treatment of acute and chronic low back pain in primary care settings was developed through a collaborative effort of the ACP and the APS. The guideline focuses on adults presenting with low-back pain unassociated with major trauma, with and without referred leg pain. Two algorithms were developed: 1) diagnostic evaluations and interpretation which can aid clinicians in identifying a general back pain category during the patient’s first visit, and 2) pain management that includes drug and nonpharmacologic therapies. Clinicians are encouraged to use the 7 evidence-based recommendations to expand current treatment modalities and to explore the benefits and drawbacks of traditional treatment methods. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for the Management of Hand Osteoarthritis: Report of a Task Force
Access: http://ard.bmj.com/cgi/gca?allch=&SEARCHID=1&FULLTEXT=management+of+hand+oa...
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism (EULAR)
Date: 2007
Print Reference: Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007(Mar);66(3):377-388.
Description: The EULAR task force responsible for developing these guidelines included experts from 15 different European countries in specialty disciplines from rheumatology to allied health. These evidence-based management recommendations for hand osteoarthritis are the result of existing evidence, clinical expertise, and perceptions of patient preference. The task force explains their rationale for the development of separate treatment recommendations for osteoarthritis of the hand (in contrast to the treatment of other joints) and the resulting guidelines include 11 key recommendations involving 17 treatment modalities. 12 pages. Access checked April 14, 2009.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline
Access: http://www.annals.org/cgi/reprint/147/7/492.pdf
Source: American Pain Society (APS), American College of Physicians (ACP)
Date: 2007
Print Reference: Chou R, Huffman LH, American Pain Society, American College of Physicians. Annals of Internal Medicine. 2007(Oct);147(7):492-504.
Description: Task force members of the APS and ACP examined systematic reviews and randomized trials on a wide range of nonpharmacologic therapies used to treat acute or chronic low back pain. Studies that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction were graded on methodological quality. In the final analysis, four modalities showed good levels-of-evidence for moderate efficacy in the treatment of chronic or subacute low back pain: cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. The only therapy that provided good evidence for effectiveness in acute low back pain was superficial heat. Access checked April 14, 2009.
EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/content/full/ard.2005.044354...
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism (EULAR)
Date: 2007
Print Reference: Combe B, Landewe R, Lukas C, et al. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007(Jan);66(1):34-45.
Description: Recent advances in rheumatology include the use of biological treatments which have demonstrated improved disease control when initiated early in the inflammatory process. Recommendations for the diagnosis, treatment, and continual monitoring of arthritis were developed by expert consensus following a review of the evidence-based literature. Each of twelve recommendations is supported by the level of evidence reflected in a review of 284 manuscripts. These guidelines represent the current knowledge base, available treatment, and present expert thinking on the most effective approach to managing early arthritis. 12 Pages. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for Gout. Part I: Diagnosis. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/reprint/65/10/1301?ijkey=7jOEXurujRa0k&keytype=ref&siteid=bmjjournals
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism
Date: 2006
Print Reference: Zhang W, Doherty M, Pascual E, et al. EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006(Oct);65(10):1301-1311.
Description: Nineteen rheumatologists representing 13 countries evaluated gout management recommendations and present guidelines that include 10 evidence-based diagnostic tests. A strength of recommendation score is provided for each proposition; radiological testing, biochemical testing, urate crystal analysis, and patient risk factors are evaluated. 12 Pages. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for Gout. Part II: Management. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/reprint/65/10/1312?ijkey=uZK1Nk6Uq8MCs&keytype=ref&siteid=bmjjournals
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism
Date: 2006
Print Reference: Zhang W, Doherty M, Bardin T, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006(Oct);65(10):1312-1324.
Description: Nineteen rheumatologists representing 13 countries evaluated gout management recommendations and present 12 important evidence-based treatment guidelines. Recommendations range from acute treatment to prophylactic therapy and include patient education and behavioral modification strategies. Pain management approaches are recommended according to the strength-of-evidence and urate lowering therapy is described in detail. 14 Pages. Access checked April 14, 2009.
Guidelines For the Use of Antidepressants in Painful Rheumatic Conditions
Access (abstract only): antidepressant/rheumatic
(Full document available for purchase.)
Source: CEDR, French Society of Rheumatology
Date: 2006
Print Reference: Perrot S, Maheu E, Javier RM, et al. Guidelines for the use of antidepressants in painful rheumatic conditions. European J Pain. 2006(Apr);10(3):185-192.
Description: While antidepressants have been used frequently to reduce pain, recommendations for their use in rheumatic conditions were lacking. The investigators identified 49 useful clinical studies in a review of the literature which, along with an expert consensus, were used to develop the recommendations in this guidance document. Specific painful rheumatic conditions are addressed: fibromyalgia, low back pain, osteoarthritis, and inflammatory rheumatic conditions. The analgesic effects of antidepressants are examined and 10 recommendations are made for their use on a level-of-evidence basis. 8 Pages. Access checked April 14, 2009.
Guideline for the Management of Fibromyalgia Syndrome Pain in Adults and Children
Access: http://www.ampainsoc.org/pub/fibromyalgia.htm
Source: American Pain Society
Date: 2005
Description: This peer-reviewed, evidence-based guideline discusses recent advances in the understanding of pain as it relates to fibromyalgia. Diagnosis, assessment, multidisciplinary therapy, and the controversies surrounding fibromyalgia are explored. Available for purchase only through the website (click on the APS Online Store); members $15, non-members $20. 109 Pages. Access checked April 14, 2009.
Knee Pain or Swelling: Acute or Chronic
Access: http://cme.med.umich.edu/pdf/guideline/knee.pdf
Source: University of Michigan Health System
Date: 2005
Description: Assessment and diagnostic evaluation are crucial to diagnosis and effective treatment. Four algorithms have been developed for 1) knee pain without constitutional symptoms, 2) knee pain with constitutional symptoms, 3) traumatic knee pain, and 4) knee effusion. Each algorithm includes diagnostic and evidence-based treatment recommendations. The guideline text includes discussions on differential diagnosis and special considerations for each condition. 13 Pages. Access checked April 14, 2009.
Evidence-Based Management of Acute Musculoskeletal Pain
Access: http://www.nhmrc.gov.au/publications/synopses/cp94syn.htm
Source: Australian Acute Musculoskeletal Pain Guidelines Group
Date: 2003
Description: This comprehensive guide begins with a discussion of etiology, effective patient communication, and assessment. The multi-disciplinary review examines five specific symptoms, describes evidence-based interventions for each and provides recommendations; these include acute low back pain, acute thoracic spinal pain, acute neck pain, acute shoulder pain, and acute knee pain. Access checked November 2, 2009.
Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis, 2nd Edition
Access: http://www.ampainsoc.org/pub/arthritis.htm
Source: American Pain Society
Date: 2002
Description: To address the multidimensional dynamic of arthritis pain, this APS guideline uses a multidisciplinary approach by utilizing an ongoing pain assessment, drug therapy, nutrition, exercise, and patient education. Available for purchase only through the website, (click on the APS Online Store); members $15, non-members $20. 184 Pages. Access checked April 14, 2009.
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Neurological/Neuropathic Pain
Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-Specialist Settings
Access: http://www.nice.org.uk/guidance/CG96
Source: National Institute for Health and Clinical Excellence (NICE)
Date: 2010
Description: The varied symptoms of neuropathic pain — manifested as continuous or intermittent pain or numbness — can be difficult to treat. This guideline was developed for non-specialist healthcare practices and begins by exploring the many causes of adult neuropathic pain from diabetic neuropathy and post-herpetic neuralgia to chemotherapy-induced neuropathies. The NICE web page link above offers access to 3 versions of the guideline: 1) the full 155-page guideline, 2) a 6-page quick-reference version, and 3) a 12-page patient edition. The full guideline takes a comprehensive look at therapeutic options and provides summaries of study outcomes by drug class and individual agent. Both versions for healthcare professionals emphasize good communication and include a 'Care Pathway' that makes recommendations for first-, second-, and third-line treatment approaches. The patient version offers a list of questions that may aid communication during the practitioner-patient office visit. Access checked April 9, 2010.
Practice Parameter: Evaluation of Distal Symmetric Polyneuropathy
Access – Role of laboratory and genetic testing (an evidence-based review): http://www.neurology.org/cgi/rapidpdf/01.wnl.0000336370.51010.a1v1.pdf
Access – Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review): http://www.neurology.org/cgi/rapidpdf/01.wnl.0000336345.70511.0fv1.pdf
Source: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation
Date: 2009
Print References: England JD, Gronseth GS, Franklin G, et al. Neurology. 2009(Jan); [Early online publication].
Description: Distal symmetric polyneuropathy (DSP), the most common type of neuropathy, can be difficult to diagnose due to the large number of existing etiologies. Published literature indicates that many patients with neuropathic pain may not be accurately diagnosed, and the correct selection of screening tests can become critical to an accurate diagnosis of DSP. These 2 reports provide graded, evidence-based recommendations to aid in the diagnosis of DSP as well as important assessment information for other etiologies of polyneuropathy. A discussion of hereditary neuropathies reviews the considerations for the appropriate use of genetic testing. 16 Pages (each report). Access checked April 14, 2009.
Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome
Access: http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp
Source: American Academy of Orthopaedic Surgeons (AAOS)
Date: 2008
Description: AAOS provides guidelines for carpal tunnel syndrome treatment in 3 different formats, all of which are available in pdf format at the website listed above. A summary of the 13 evidence-based recommendations is available in a 3-page format at the link entitled “CTS Treatment Recommendations Summary“. The “CTS Treatment Guideline” offers an 84-page document that begins with a summary of the recommendations and continues with a review of the process used to evaluate evidence for each recommendation. The supporting documents entitled “Evidence Report” and “Evidence Table” are 188 pages and 236 pages in length, respectively, and provide a full accounting of all studies evaluated and the rationale for grading the evidence. Access checked April 14, 2009.
Practice Parameter: The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia (an evidence-based review)
Access: http://www.neurology.org/cgi/reprint/71/15/1183
Source: American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS)
Date: 2008
Print Reference: Gronseth G, Cruccu G, Alksne J, et al. Neurology. 2008(Oct 7);71(15):1183-1190.
Description: The goal of experts from the AAN and the EFNS was to establish answers to 6 specific questions related to diagnosis and treatment of trigeminal neuralgia. Following a systematic review of published evidence-based studies, an analysis of each question resulted in a recommendation based on that evidence or a determination that there was insufficient evidence to support a decision. The final section of the paper makes recommendations for specific future research that can help improve practice guidelines. 52 Pages. Access checked April 14, 2009.
Pharmacologic Management of Neuropathic Pain: Evidence-Based Recommendations
Access: (National Guideline Clearinghouse summary) http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=11724&nbr=6049
Source: International Association for the Study of Pain, Independent Expert Panel of the Fourth International Conference on the Mechanisms and Treatment of Neuropathic Pain
Date: 2007
Print Reference: Dworkin RH, O’Connor AB, Backonja M, et al. Pain. 2007(Dec 5);132(3):237-251.
Description: Assessment considerations in neuropathic pain include an identification of the underlying disease process, the type of lesion, response to prior therapy, and any comorbid conditions. This guideline provides a stepwise pharmacologic management recommendations table and includes graded support for specific drug treatment based on available therapeutic evidence. Consideration is given to clinical efficacy, adverse effects, potential benefit to health-related quality of life, and treatment costs. 15 Pages. Access checked April 14, 2009.
EFNS Guidelines on Neurostimulation Therapy for Neuropathic Pain
Access: (National Guideline Clearinghouse summary) http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=11372&nbr=5909
Source: European Federation of Neurological Societies (EFNS)
Date: 2007
Print Reference: Cruccu G, Aziz TZ, Garcia-Larrea L, et al. Eur J Neurol. 2007(Sep);14(9):952-970.
Description: Neuropathic pain relief is oftentimes incomplete with drug therapy alone. The EFNS task force evaluated and classified the evidence for neurostimulation therapy in neuropathic pain conditions. The evidence for the effectiveness of spinal cord stimulation, transcutaneous electrical nerve stimulation, electro-acupuncture, repetitive transcranial magnetic stimulation, motor cortex stimulation, and deep brain stimulation was examined; recommendations were rated according to the evidence for efficacy in specific types of pain disorders. Access checked April 14, 2009.
Consensus Guidelines: Treatment Planning and Options. Diabetic Peripheral Neuropathic Pain
Access: http://www.paineducators.org/assets/uploads/2010/01/DPNPSuppl.pdf
(See page S12 in this document.)
Source: American Society of Pain Educators and the Johns Hopkins University School of Medicine
Date: 2006
Print Reference: Argoff CE, Backonja MM, Belgrade MJ, et al. Consensus guidelines: treatment planning and options. Diabetic neuropathic pain. Mayo Clinic Proceedings. 2006(Apr);81(Suppl 4):S12-S25.
Description: Diabetic peripheral neuropathic pain requires attention to many factors including existing comorbidities and potential adverse effects of treatment. A thorough evidence-based discussion of pharmacologic therapies includes antidepressants, anticonvulsants, opioids, and topical agents. Recommendations are made for 1st and 2nd tier therapeutic agents, including a table of factors to consider in drug selection. Guidelines are offered for monitoring the patient’s pain management and modifying therapy. 14 Pages. Access checked February 4, 2010.
EFNS Guidelines on Pharmacological Treatment of Neuropathic Pain
Access: http://www.efns.org/...2006_pharmacological_treatment_of_neuropathic_pain.pdf
Source: European Federation of Neurological Societies
Date: 2006
Print Reference: Attal N, Cruccu G, Haanpaa M, et al. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol. 2006(Nov);13(11):1153-1169.
Description: The management of neuropathic pain continues to provide challenges for the practitioner. This paper summarizes the evidence-based treatment for painful polyneuropathy (diabetic and non-diabetic), postherpetic neuralgia, trigeminal neuralgia, central neuropathic pain, and several conditions for which very few studies were available. The mechanism of action, efficacy and adverse effects were presented and recommendations were made for antidepressants, antiepileptics, opioids and the combination regimen. 17 Pages. Access checked April 14, 2009.
EFNS Guidelines on Neuropathic Pain Assessment
Access: http://www.efns.org/...2004_neuropathic_pain_assessment.pdf
Source: European Federation of Neurological Societies
Date: 2004
Print Reference: Cruccu G, Anand P, Attal N, et al. EFNS guidelines on neuropathic pain assessment. Eur J Neurol. 2004(Mar);11(3):153-162.
Description: The assessment of neuropathic pain is crucial to an accurate diagnosis and the development of an effective treatment protocol. This guideline provides recommended testing methods that are the result of a systematic review of the evidence-based studies on neuropathic pain assessment. In addition, a description and graded evidence for effectiveness is provided for electrodiagnostic studies, microneurography, laser-evoked potentials, reflex testing, biopsy and functional neuroimaging studies. 10 Pages. Access checked April 14, 2009.
Practice Parameter: Treatment of Postherpetic Neuralgia. An Evidence-Based Report of the Quality Standards Subcommittee of the American Academy of Neurology
Access: http://www.neurology.org/cgi/reprint/63/6/959.pdf
Source: Quality Standards Subcommittee of the American Academy of Neurology
Date: 2004
Print Reference: Dubinsky RM, Kabbani H, El-Chami Z, at al. Practice parameter: treatment of postherpetic neuralgia. An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004(Sep 28);63(6):959-65.
Description: The recommendations derived from the evidence of 51 studies in this systematic review are categorized and summarized in 4 classes of pharmacological treatment. 7 Pages. Access checked April 14, 2009.
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Non-Opioid & Complementary Therapies
Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis
Access: http://ptjournal.org/cgi/reprint/85/9/907
Source: Ottawa Panel and the University of Ottawa, Canada
Date: 2005
Print Reference: Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. Physical Therapy. 2008;85(9):907-971
Description: For adult patients with osteoarthritis, exercise can improve health outcomes. This comprehensive guideline for therapeutic exercise and physical therapy includes graded recommendations for patients at all stages of the disease. Full details of evaluation methodology and the quality of available studies is provided. The results contain 16 positive recommendations—primarily strengthening exercises and general physical activity—that show clinical benefit in the management of pain and improvement of functional status for patients with osteoarthritis. While the panel stated that more research is needed for a recommendation of manual therapy alone, one study reported benefits when combined with exercise. 65 Pages. Access checked April 14, 2009.
Antiepileptic Drugs Guideline for Chronic Pain
Access: http://lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/NeuropathicPain.pdf
Source: Washington State Department of Labor and Industries
Date: 2005
Description: Based on expert opinion and a systematic review of the literature, these guidelines make a summary statement about the lack of evidence for several antiepileptics and primarily focus on the use of Gabapentin for neuropathic pain. A dosing plan is recommended and adverse effects are stated. 2 Pages. Access checked April 14, 2009.
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Opioid Therapy & Safety
VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain
Access: http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp
Source: Department of Veterans Affairs and the Department of Defense (VA/DoD)
Date: 2010 (Version 2.0); Version 1.0 published in 2003
Description: Designed for use in an ambulatory care setting, the guideline provides all levels of pain management guidance from assessment to patient education. This guideline has a wider focus than the original version and includes treatment considerations for all patients who could benefit from chronic opioid therapy (defined as more than one month). The goal of this comprehensive set of recommendations is education and guidance for primary care practitioners and researchers who must assess and treat patients with persistent pain. Each best-practice recommendation is goal-focused and the treatment algorithm is designed to guide the clinician through assessment, a discussion of patient treatment goals, trial therapy, treatment evaluation, maintenance therapy, and treatment challenges. Tables that address drug interactions and contraindications are included; separate sections provide specific considerations for methadone use, titration challenges, managing adverse effects, and referral strategies. Two PDF versions of the guideline are available at the web address listed above: a 74-page summary and the 159-page full-text guideline. Both of these versions include the full 3-page algorithm. Access checked July 20, 2010.
Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain
Access: http://nationalpaincentre.mcmaster.ca/opioid/
Source: McMaster University; National Pain Center; Ontario, Canada
Date: April 30, 2010
Reference: Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain©. 2010. National Opioid Use Guideline Group (NOUGG).
Description: This extensive guideline is based on a systematic review to identify evidence from the literature regarding use of opioids for chronic noncancer pain. It was developed by a multidisciplinary National Advisory Panel that included 49 individuals from across Canada who provided medical expertise in family medicine, pain and addiction, patient perspectives, and views of other healthcare providers. The guideline includes 24 recommendations organized within 5 clusters; however, the vast majority of recommendations are based on consensus opinion (Grade C) rather than being derived from a higher level of published clinical-study evidence (Grade A or B). Access checked May 6, 2010.
Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain
Access: http://health.utah.gov/prescription/guidelines.html
Source: Utah Department of Health
Date: 2009
Description: This evidence-based Utah State guideline for opioid prescribing in acute and chronic pain was developed to provide practitioner guidance in the important balance between treatment and safety. Evidence and recommendations contained in previously developed guidelines — from government, state, and professional organizations — were used as a foundation for this guide; most of these documents are available for free access in this Pain-Topics.org ‘Guidelines’ section, including:
- ASIPP’s Opioid Guidelines in the Management of Chronic Non-Cancer Pain (2008).
- Washington State Guidelines on Opioid Dosing for Chronic Non-cancer Pain (2007).
- FSMB (Federation State Medical Boards) Model Guidelines for the Use of Controlled Substances for the Treatment of Pain (2004).
- VA/DOD Clinical Practice Guidelines for the Management of Chronic Non-Cancer Pain (2003).
- CPSO Evidence-based recommendations for medical management of chronic non-malignant pain. College of Physicians and Surgeons of Ontario (2000).
- ACOEM Occupation Medicine Practice Guidelines. American College of Occupational and Environmental Medicine (2008). This is only available for sale at the ACOEM website.
Recommendations for the management of acute pain include current evidence for assessment, prescribing, and monitoring. The section on chronic pain provides more detailed recommendations, including: the use of risk assessment tools, components of a comprehensive treatment plan, and methods for involving the patient and family members in the goals of treatment. Guidance for patient education is offered and the section on risk evaluation includes examples of many assessment tools currently in use. Because the need for adjustments during opioid treatment is common, recommendations are presented for the management of adverse effects, a change in pain management needs, and evidence of tolerance or misuse. Several discussion sections include contraindications to opioid prescribing, strategies for tapering opioids, and the appropriate use of methadone in pain management.
These guidelines are not proposed as being applicable to opioid prescribing on a nationwide basis, but they do offer potential value as a model for other state guidelines and practitioner training. Full guideline is 92 pages; summary 15 pages. Access checked April 20, 2009.
 Also see the Pain-Topics.org book review: Responsible Opioid Prescribing: A Physician’s Guide (from the Federation of State Medical Boards) at: http://pain-topics.org/education_CME_locator/indexbkrv.php#ROP
QTc Interval Screening in Methadone Treatment: Clinical Guidelines
Access: http://www.annals.org/cgi/content/full/150/6/387
Source: Annals of Internal Medicine
Date: March 2009
Print Reference: Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MCP. QTc Interval Screening in Methadone Treatment: Clinical Guidelines. Ann Intern Med. 2009;150(6):387-395.
Description: An independent panel recommends that clinicians inform patients of arrhythmia risk when prescribing methadone, and assess history of heart disease. They also recommend that all patients have pretreatment and follow-up electrocardiography (ECG) at 30 days and annually thereafter. Clinicians are instructed to learn about interactions between methadone and other drugs that can prolong the QTc interval or slow elimination of methadone. Accessed 4/14/09.
NOTE: There has been controversy surrounding publication of these guidelines and the recommendation for ECG monitoring of all patients prescribed methadone. This publication is not a federal guideline. A government agency has forwarded draft recommendations related to QTc interval screening in methadone treatment for field review prior to finalization.
Also see the rebuttal editorial accompanying the guidelines….
Gourevitch MN. First Do No Harm ... Reduction? Ann Intern Med. 2009;150(6).
Available at: http://www.annals.org/cgi/content/full/150/6/417. Access checked 4/14/09.
APS/AAPM Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
Access: http://www.jpain.org/article/S1526-5900(08)00831-6/abstract
(As of 3/11/09 the publisher was offering free access to the full document, but this may change.)
Source: American Pain Society (APS), American Academy of Pain Medicine (AAPM)
Date: 2009
Print Reference: Chou R, Fanciullo GJ, Fine PG, et al. The Journal of Pain. 2009(Feb);10(2):113-130.
Description: This clinical practice guideline was developed by a multi-disciplinary panel of experts representing the American Pain Society and the American Academy of Pain Medicine. Based on a systematic review of the literature through November 2007, 25 recommendations were developed to guide the use of opioids for carefully selected and monitored patients with chronic non-cancer pain. However, the panel identified numerous research gaps and they did not rate any of the recommendations as supported by high-quality evidence. Only 4 recommendations were viewed as supported by moderate-quality evidence. Nonetheless, the panel came to a unanimous consensus on almost all of its recommendations. 17 pages + appendices. Access checked April 14, 2009.
Also of interest…
Two additional papers in this same edition of the Journal of Pain discuss important research limitations encountered during the development of the above guideline. Access to both checked 4/14/09; free access to full documents was available from the journal publisher as of 3/11/09.
- Research Gaps on Use of Opioids for Chronic Noncancer Pain (Chou R, et al. 2009) – concludes that clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to address these critical needs if the care of patients with chronic noncancer pain is to improve. 12 pages + appendices.
Access full document at: http://www.jpain.org/article/S1526-5900(08)00830-4/abstract
- Opioids for Chronic Noncancer Pain: Prediction and Identification of Aberrant Drug-Related Behaviors (Chou R, et al. 2009) – concludes that evidence on the prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments exist, evidence for their external validity is lacking. Further studies evaluating clinical outcomes associated with different assessment and monitoring strategies are needed. 15 pages + appendices.
Access full document at: http://www.jpain.org/article/S1526-5900(08)00832-8/abstract
ASIPP Guidelines: Opioids in the Management of Chronic Non-Cancer Pain — An Update of American Society of the Interventional Pain Physicians’ Guidelines
Access: http://www.painphysicianjournal.com/2008/april/2008;11;S5-S62.pdf
Source: American Society of Interventional Pain Physicians
Date: 2008
Print Reference: Trescot AM, Helm S, Hansen H, et al. Pain Physician. 2008(Mar);11(Suppl 2):S5-S62.
Description: The ASIPP guidelines for the use of opioids in the treatment of chronic non-cancer pain have been updated following an evaluation of evidence-based treatment in randomized clinical trials, systematic reviews, and observational trials since the last guidelines published in 2005. In light of evidence that shows a wide variance in the use of opioids, the primary objective of this revision is to provide concise guidelines that improve patient access to opioids while avoiding diversion and abuse. The pharmacology and efficacy of specific opioids is described, principles of use are reviewed, and issues related to improving patient education—their rights as well as their responsibilities—during opioid therapy are discussed. A 10-step approach for the management of long-term opioid therapy is described. 58 Pages. Access checked April 14, 2009.
[Washington State] Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: An Educational Pilot to Improve Care and Safety With Opioid Treatment
Access: http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf (14 pp)
Source: Washington State Agency Medical Directors’ Group
Date: March 2007
Description: The development of this guideline — on the safe and effective administration of opioids in chronic non-cancer pain — is the result of collaboration by 5 Washington State organizations. It was developed for the non-specialist primary care provider and is divided into 2 parts: Part 1 includes general patient assessment and opioid prescribing recommendations, and Part 2 provides guidance for treating patients who need high dose opioid therapy (specifically, >120 mg morphine-equivalent dose per day). It is important to note that this guideline was created for pilot-testing purposes with recommendations that are specific to Washington State and, therefore, are not necessarily appropriate or applicable on a nationwide basis. Access checked April 20, 2009.
Guidelines for the Use of Methadone in Office-Based Management of Chronic Non-Cancer Pain and A Review of the Use of Methadone for Treatment of Chronic Non-Cancer Pain
Access: http://www.cpsns.ns.ca/publications/2006-methadone-pain-guidelines.pdf
Source: College of Physicians & Surgeons of Nova Scotia
Date: 2006
Description: The use of methadone in cases where conventional opioid therapy is inappropriate or has failed is increasing and this guideline serves as a comprehensive guide to its use in chronic non-cancer treatment. The unique characteristics of methadone are reviewed, contraindications are discussed, and guidelines for initiating a trial regimen, including dosing and conversion ratios, are presented. Tables include 1) studies with varied protocols for opioid conversion to methadone, 2) a morphine to methadone dose conversion ratio, and 3) a list of potential drug-drug interactions. Costs listed in this paper are based on Canadian currency. 50 Pages. Access checked April 14, 2009.
Methadone for Pain Guidelines
Access: http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1986
Source: College of Physicians and Surgeons of Ontario
Date: November 2004
Description: These guidelines were developed to assist clinicians in the use of methadone to treat chronic pain. Due to increasing interest in methadone’s analgesic properties, this guideline attempts to provide sufficient information to clarify any potential confusion that may relate to its use. Pharmacology and duration of action are explained and the issue of variations in individual patient response to methadone is discussed. Prescribing options for acute and chronic pain in specific patient populations are presented; these include opioid naïve patients, individuals in methadone maintenance, patients who are being switched from another opioid, and others. Some of the information for pharmacists is based on Canadian standards of practice, but other clinical recommendations for methadone withdrawal and cautions regarding drug interactions are universally appropriate. 58 Pages. Access checked April 14, 2009.
FSMB Model Policy for the Use of Controlled Substances for the Treatment of Pain
Access: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf (45 KB, 5 pp)
Source: Federation of State Medical Boards of the United States, Inc. (FSMB)
Date: May 2004
Description: These Model Policy guidelines have been widely distributed and endorsed by the Drug Enforcement Administration, American Academy of Pain Medicine, American Pain Society, and National Association of State Controlled Substances Authorities. Many states have adopted pain policies using all or part of the Model Policy. Despite increasing concern in recent years regarding the abuse and diversion of controlled substances, pain policies have improved due to the efforts of medical, pharmacy, and nursing regulatory boards committed to improving the quality of and access to appropriate pain care.
Circumstances that contribute to the prevalence of undertreated pain include: (1) lack of knowledge of medical standards, current research, and clinical guidelines for appropriate pain treatment; (2) the perception that prescribing adequate amounts of controlled substances will result in unnecessary scrutiny by regulatory authorities; (3) misunderstandings of addiction and dependence; and (4) lack of understanding of regulatory policies and processes. Adding to this problem is the reality that the successful implementation of state medical board pain policy varies among jurisdictions. Access checked April 20, 2009.
Also see the Pain-Topics.org book review: Responsible Opioid Prescribing: A Physician’s Guide (from the Federation of State Medical Boards) at:
http://pain-topics.org/education_CME_locator/indexbkrv.php#ROP
CPSO Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain [including Opioids]
Access: http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1982
Source: College of Physicians and Surgeons of Ontario (CPSO)
Date: 2000
Description: The information in this Reference Guide for Clinicians was extracted from a longer guideline that is now only available in paper format from the publisher. Recommendations are limited to 4 types of chronic non-malignant pain: headache, neuropathic pain, musculoskeletal pain, and opioid use in chronic pain. Sections on the use of opioid therapy for chronic non-malignant pain consider the evidence according to pain type. Simple “Do’s and Don’t’s” of prescribing opioids (sometimes referred to in this older document as “narcotics”) for chronic noncancer pain of various types are provided, and there is helpful advice for patients. Several sample forms to aid in patient monitoring and risk management are provided. 32 Pages. (Note: It must be considered that this is a relatively old document on this subject and may not reflect more current thinking or research evidence.) Access checked April 22, 2009.
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Pain in Palliative Care
NHPCO Statement [guideline] on Palliative Sedation in Terminally Ill Patients
Access: http://www.nhpco.org/files/public/JPSM/NHPCO_Pall-Sedation-Ther_JPSM_May2010.pdf
Date: May 2010
Print Reference: Kirk TW, Mahon MM, et al. National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients. J Pain Sympt Manage. 2010(May);39(5):914-923.
Description: This statement and commentary seek to clarify the position of NHPCO on the use of palliative sedation for patients at the end of life, recommend questions and issues to be addressed in each case for which palliative sedation is being considered, and assist health care organizations in the development of policies for the use of palliative sedation. This addresses the use of palliative sedation only for patients who are terminally ill and whose death is imminent. Access checked May 29, 2010.
EAPC Framework for the Use of Sedation in Palliative Care
Access: http://www.eapcnet.org/download/forProjects/Sedation/PMJ(23.7)Cherny_et_al.pdf
Date: 2009
Print Reference: Cherny NI, Radbruch L, et al. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Pall Med. 2009;27(3):581-593.
Description: Sedation is considered to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution with attention to potential risks; problematic approaches can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions. This document provides procedural guidelines from the EAPC to help educate medical providers and set standards for best practice. Access checked May 29, 2010.
Clinical Practice Guidelines for Quality Palliative Care, Second Edition
Access: http://www.nationalconsensusproject.org/Guideline.pdf
Source: National Consensus Project for Quality Palliative Care
Date: 2009
Description: These guidelines for palliative care were developed to promote consistent high quality care in a variety of healthcare settings. Models of assessment and care that integrate multiple disciplines are presented. While pain management is not addressed on a treatment level, the guidelines emphasize the importance of pain assessment and relief. The integration of physical palliative care with psychological, social, spiritual, cultural and ethical components is discussed as an important aspect of good palliative care. 90 Pages. Access checked April 14, 2009.
Consensus Guideline on Parenteral Methadone Use in Pain and Palliative Care
Access (abstract only): http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1885928
(Full document available for purchase.)
Source: Cambridge Journals Online
Date: 2008
Print Reference: Shaiova L, Berger A, Blinderman CD, et al. Palliat Support Care. 2008(Jun);6(2):165-176.
Description: Consensus guidelines were developed by expert practitioners from 8 palliative care facilities to assist clinicians with the use of parenteral methadone for patients with life-limiting illnesses. The authors provide recommendations for opioid conversion and methadone dosing that could allow the drug to be used as a first- or second-line therapy to benefit palliative care patients. 12 Pages. Access checked April 14, 2009.
Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians
Access: http://www.annals.org/cgi/reprint/148/2/141.pdf
Source: American College of Physicians (ACP)
Date: 2008
Print Reference: Qaseem A, Snow V, Shekelle P, et al. Annals of Internal Medicine. 2008(Jan);148(2):141-146.
Description: This guideline, written for all practitioners caring for patients who need end-of-life care, begins with a working definition for end-of-life. Based on the 2003 report from the Institute of Medicine on the weaknesses in palliative care as well as a synthesis of existing evidence for effective end-of-life care, 5 recommendations were developed. The guideline only presents interventions with strong to moderate evidence for the management or prevention of the symptoms of pain, dyspnea, and depression. It does not address many other important aspects of physical, psychological and social needs at the end of life. Access checked April 14, 2009.
Procedure Guideline for Palliative Treatment of Painful Bone Metastases
Access: http://interactive.snm.org/index.cfm?PageID=804&RPID=772
Source: Society of Nuclear Medicine
Date: 2003
Description: Radiopharmaceuticals are approved for the treatment of bone pain in patients with metastatic malignancy in multiple skeletal sites. This guideline is the result of a systematic review of the literature with a subsequent analysis and compilation of procedural recommendations for intravenous injection of radiopharmaceuticals by the Guideline Development Subcommittee and Task Force. The recommendations cover patient preparation, instructions for patients, precautions, guidelines for dosing, measurement of the agent activity, interventions reporting, quality issues and potential complications. 8 Pages. Access checked April 14, 2009.
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Pediatric Pain
Consensus Guidelines for Sustained Neuromuscular Blockade in Critically Ill Children
Access (abstract only): http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1460-9592.2007.02313.x
(Full document available for purchase.)
Source: United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group
Date: 2007
Print Reference: Playfor S, Jenkins I, Boyles C, et al. Paediatric Anaesthesia. 2007(Sep);17(9):881-887.
Description: This multidisciplinary consensus guideline was developed through multiple consensus conferences and a systematic review of the literature. The authors state that this is the first set of guidelines on sedation, analgesia and maintenance neuromuscular blockade in the critically ill pediatric patient (not including neonates). The guideline includes 6 key levels-of-evidence recommendations and the Working Group recommends the implementation of further trials in this area. Access checked April 14, 2009.
Guideline Statement: Management of Procedure-Related Pain in Children and Adolescents
Access (abstract only): http://www.blackwell-synergy.com/doi/abs/10.1111/j.1440-1754.2006.00798_2.x
(Full document available for purchase.)
Source: Royal Australasian College of Physicians
Date: 2006
Print Reference: Guideline statement. Management of procedure-related pain in children and adolescents. Journal of Paediatrics and Child Health. 2006(Feb);42(Suppl 1):S2-S30.
Description: Based on the theory that children experience more pain that necessary during procedures, this guideline begins with an examination of the assessment of pain and anxiety and continues with a discussion of the consequences of under-treating pain. An evaluation of the child and an assessment of appropriate preparations prior to the procedure are important steps before implementing recommended environmental, behavioral, and pharmacological techniques. Levels of evidence recommendations are made for a very comprehensive list of procedures from suturing a laceration or biopsy site to tube insertion and removal. Special considerations for children with communication problems are discussed. 29 Pages. Access checked April 14, 2009.
Guideline Statement: Management of Procedure-Related Pain in Neonates
Access (abstract only): http://www.blackwell-synergy.com/doi/abs/10.1111/j.1440-1754.2006.00799_2.x
(Full document available for purchase.)
Source: Royal Australasian College of Physicians
Date: 2006
Print Reference: Guideline statement. Management of procedure-related pain in neonates. Journal of Paediatrics and Child Health. 2006(Feb);42(Suppl 1):S31-S39.
Description: The guideline begins with a discussion of the consequences of neonatal pain and continues with pain assessment techniques. Strength of evidence recommendations for pain reduction from blood sampling to tube insertion and laser therapy are presented. Guidance is offered for preventive pain measures as well as environmental, behavioral, procedural, and pharmacological modifications for each procedure. 9 Pages. Access checked April 14, 2009.
Practice Parameter: Evaluation of Children and Adolescents With Recurrent Headaches
Access: http://www.neurology.org/cgi/reprint/59/4/490.pdf
Source: Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society
Date: Guideline re-affirmed in October 2005
Print Reference: Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches. Neurology. 2002(Aug);59(4):490-498.
Description: Diagnostic guidelines are based on 4 levels of evidence for recommendation. A discussion on the use of routine laboratory studies, lumbar puncture, EEG testing and neuroimaging is based on evidence of appropriateness following the clinical neurological examination. 9 Pages. Access checked April 14, 2009.
Clinical Report: Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems
Access: http://pediatrics.aappublications.org/cgi/reprint/114/5/1348
Source: American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
Date: 2004
Print Reference: Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2004(Nov);114(5):1348-56.
Description: Emergency department pain management can minimize distress and pain in children if a systematic approach is used. The environment, staff education, use of protocols, and new modalities of pain control can help manage this complex element of emergency care. Guidelines are provided for triaging oral analgesics, the use of EMLA/LMX4, the placement of topical anesthetics on open wounds, and the use of sucrose in neonates. This document is titled "clinical report"; however, it is included in the Clinical Guidelines section on the American Academy of Pediatrics website. 9 Pages. Access checked April 14, 2009.
Practice Parameter: Pharmacological Treatment of Migraine Headache in Children and Adolescents
Access: http://www.neurology.org/cgi/reprint/63/12/2215.pdf
Source: American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society
Date: 2004
Print Reference: Lewis D, Ashwal S, Hershey A, et al. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology. 2004(Dec 28);63(12):2215-2224.
Description: The authors reviewed 166 articles on the acute and preventive pharmacological treatment of children and adolescents. Recommendations are made according to the strength of evidence. The authors state that "there is a paucity of controlled data regarding the treatment of primary headache disorders” in this population and make 7 recommendations for further study. 10 Pages. Access checked April 14, 2009.
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Perioperative Pain
ASPAN Pain and Clinical Comfort Guideline
Access: http://www.aspan.org/Portals/6/docs/ClinicalPractice/Guidelines/ASPAN_ClinicalGuideline_PainComfort.pdf
Source: American Society of PeriAnesthesia Nurses
Print Reference: ASPAN pain and comfort clinical guideline. J Perianesth Nurs. 2003(Aug);18(4):232-6.
Description: Guidelines for the perianesthesia environment begin with the pre-operative assessment and continue through postanesthesia phases I/II/III assessments, interventions, and expected outcomes. Complementary non-pharmacologic strategies are included in this nursing care plan protocol. 5 Pages. Access checked April 14, 2009.
Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management
Access: http://www.asahq.org/publicationsAndServices/pain.pdf
Source: American Society of Anesthesiologists - Medical Specialty Society
Date: 2004 (Originally published in 1995)
Description: This updated report was designed to review recent evidence-based studies and revise recommendations on acute pain management in the perioperative setting to improve efficacy and safety while reducing the risk of adverse outcomes. The guidelines address: 1) institutional policies, 2) preoperative patient evaluation, 3) preoperative preparation, 4) perioperative pain management including multimodal techniques, and 5) subpopulations at greater risk. 21 Pages. Access checked April 14, 2009.
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