Pain Experts Poke Holes in Published Clinical Treatment Guidelines

Although they have all participated in the development of treatment guidelines for a variety of pain conditions, 3 comprehensive pain experts openly acknowledged and discussed the practical limitations of published evidence-based recommendations during the closing session of the American Academy of Pain Medicine (AAPM) 2014 Annual Meeting, held March 6-9, 2014, in Phoenix, AZ.

“No matter how great we (experts) think we are, there are often depressing outcomes, so we must be realistic in our expectations of what treatments can do for patients,” session moderator Charles E. Argoff, MD, Director of the Comprehensive Pain Center at Albany Medical Center in New York, explained. “People need to understand there are limits to the evidence, so applying it to practice can be like trying to put a square bolt in a round hole.”

To demonstrate the guidelines’ discrepancy with real-world clinical practice, Argoff noted all of the treatments that were given a Level A recommendation in the American Academy of Neurology (AAN) guidelines for pharmacologic migraine therapy “failed to benefit a large percentage of patients.” In other words, the AAN guidelines deemed anticonvulsants like topiramate, divalproex sodium, and sodium valproate effective for episodic migraine prevention, despite the fact that “50% of patients did not respond to those drugs.”

Additionally, Argoff indicated modern medications are not well-represented in pain treatment guidelines because expert authors consider data that typically become outdated by the time the guidelines are published. For example, the AAN recommendations said there was “no consistent or strong evidence pointing to permit drawing conclusions on the efficacy of botulinum neurotoxin in chronic daily headache,” even though “just as the guidelines were going out, (Botox) was simultaneously about to be approved by the US Food and Drug Administration (FDA) for the treatment of chronic migraine,” Argoff derided.

In a subsequent presentation, Mark S. Wallace, MD, Professor of Clinical Anesthesiology at the UC San Diego School of Medicine in California, described similar clinical disconnect between current guidelines for interventional pain management and actual patient outcomes.

“In 2007, when the AAN released the ‘(Task Force) Report on Efficacy of Epidural Steroid Injection (ESI) for Lumbar Radiculopathy,’ I thought it made the right conclusions, but the wrong recommendations,” Wallace said, explaining the clinical evidence supported pain relief of up to 3 months, yet the AAN task force concluded it could not recommend the routine use of ESI. “I’ve found that patients like it and it’s inexpensive, so why not support giving ESI to a patient every 3 months for the rest of their life if that’s what they want?”

Wallace also pointed out that interventional pain therapies are less effective when used as single modalities than as part of integrated multimodal care models, “yet the guidelines only focus on the single modality setting,” which “makes it difficult for interdisciplinary care teams to determine the treatment’s effect on outcomes,” he added.

To conclude the “Square Pegs in Round Holes: Do Clinical Treatment Guidelines Fit Our Patients’ Treatment Needs?” AAPM session, Brett R. Stacey, MD, of the Comprehensive Pain Center at Oregon Health & Science University, reminded physicians that “guidelines are information or guideposts, not specific directions, so you’re still allowed to think and use your judgment.”

“Your patients are never studied in clinical trials, because those only enroll the ideal folks,” Stacey noted. “We’re asking our patients, ‘How are we doing given your situation?’ Not, ‘How are we doing given an ideal world?’ ”