BlueCross BlueShield of Tennessee Medical Policy Manual

Intravenous Anesthetics for the Treatment of Chronic Pain

DESCRIPTION

Intravenous (IV) infusion of lidocaine or ketamine has been investigated for the treatment of migraine and chronic daily headache, fibromyalgia and chronic neuropathic pain. Chronic neuropathic pain disorders include phantom limb pain, postherpetic neuralgia, complex regional pain syndromes (CRPSs), diabetic neuropathy, and pain related to stroke or spinal cord injuries. For this application, one or more courses of IV infusion would be administered over a period of several hours or several days.

Intractable pain presents a great challenge to patients and their healthcare providers.  Recent evidence, primarily from outside of the United States, suggests that IV courses of ketamine may provide at least temporary relief to some chronic pain patients.  However, the intense treatment protocols, severity of adverse effects, and limited durability raises questions about the overall health benefit of this procedure.  Additional clinical trials are needed to evaluate the long-term safety of repeat courses of IV anesthetics.

IV lidocaine is approved by the U.S. Food and Drug Administration (FDA) for systemic use in the acute treatment of arrhythmias and locally as an anesthetic. IV lidocaine for the treatment of chronic pain is an off-label use.

Ketamine hydrochloride injection is FDA-indicated for diagnostic and surgical procedures that do not require skeletal muscle relaxation, for the induction of anesthesia before the administration of other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide. IV ketamine for the treatment of chronic pain is an off-label use.

POLICY

See also:  Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

IV lidocaine is approved by the U.S. Food and Drug Administration (FDA) for systemic use in the acute treatment of arrhythmias and locally as an anesthetic. IV lidocaine for the treatment of chronic pain is an off-label use.

Ketamine hydrochloride injection is FDA-indicated for diagnostic and surgical procedures that do not require skeletal muscle relaxation, for the induction of anesthesia before the administration of other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide. IV ketamine for the treatment of chronic pain is an off-label use.

There is a lack of evidence in the peer-reviewed literature evaluating the overall health benefit and long-term safety of repeat courses of IV anesthetics in the treatment of chronic pain, therefore this technology remains investigational.

SOURCES 

American Society of Anesthesiologists. (2010). Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine. Retrieved February 27, 2012 from http://www.guideline.gov.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2015). Intravenous Anesthetics for the treatment of chronic pain (5.01.16). Retrieved May 5, 2016 from BlueWeb. (32 articles and/or guidelines reviewed)

Hocking, G., & Cousins, M. (2003). Ketamine in Chronic Pain Management: An Evidence-Based Review. Anesthesia & Analgesia, 97 (6), 1730 - 1739. (Level 2 evidence)

Institute for Clinical Systems Improvement. (2011). Assessment and management of chronic pain. Retrieved April 1, 2015 from http://www.guideline.gov.

Lauritsen, C., Mazuera, S., Lipton, R. B., & Ashina, S. (2016). Intravenous ketamine for subacute treatment of refractory chronic migraine: a case series. The Journal of Headache and Pain, 17 (1), Epub 2016 Nov 22. Abstract retrieved February 22, 2017 from PubMed database.

National Institute for Health and Care Excellence (NICE). (2014, December). Neuropathic pain - pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings. (NICE clinical guideline 173). Retrieved April 1, 2015 from www.nice.org.uk/guidance.

Niesters, M., Martini, C., & Dahan, A. (2014). Ketamine for chronic pain: risks and benefits. British Journal of Clinical Pharmacology, 77 (2), 357-367. (Level 2 evidence)

Pain Physician. (April, 2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic pain. Part II: guidance and recommendations. Retrieved April 7, 2015 from the National Guideline Clearinghouse (NGC: 009842).

Scottish Intercollegiate Guidelines (SIGN). (December 2013). Management of chronic pain. Retrieved April 6, 2015 from the National Guideline Clearinghouse (NGC: 010187).

Tremont-Lukats, I., Hutson, P. & Backonja, M. (2006). A randomized, double-masked, placebo-controlled pilot trial of extended IV lidocaine infusion for relief of ongoing neuropathic pain. The Clinical Journal of Pain, 22 (3), 266-271. Abstract retrieved April 7, 2015 from PubMed database.

U. S. Food and Drug Administration. (2010, February). Center for Drug Evaluation and Research. KetalarĀ®- ketamine hydrochloride injection. Retrieved April 7, 2015 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/006488s074lbl.pdf.

U. S. Food and Drug Administration. (2012, March). Center for Drug Evaluation and Research. KetalarĀ® (lidocaine HCL injection, USP). Retrieved April 7, 2015 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/016812s039lbl.pdf.

van der Wal, S. E., van den Heuvel, S. A., Radema, S. A., van Berkum, B. F., Vaneker, M., Steegers, M. A., et al. (2016). The in vitro mechanisms and in vivo efficacy of intravenous lidocaine on the neuroinflammatory response in acute and chronic pain. European Journal of Pain, 20 (5), 655-674. Abstract retrieved February 23, 2017 from PubMed database.

Wertli, M., Kessels, A., Perez, R., Bachmann, L., and Brunner, F. (2014) Rational Pain Management in Complex Regional Pain Syndrome 1 (CRPS 1) A Network Meta-Analysis. Pain Medicine 2014; 15: 1575-1589. (Level 4 evidence - Independent)

ORIGINAL EFFECTIVE DATE:  6/9/2012

MOST RECENT REVIEW DATE:  4/13/2017   

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