BlueCross BlueShield of Tennessee Medical Policy Manual

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

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. IV infusion of lidocaine or ketamine has also been investigated for the treatment of psychiatric disorders, e.g., treatment resistant depression, suicidal ideation and obsessive-compulsive disorder.

Intractable pain presents a great challenge to individuals and their healthcare providers.  Recent studies, primarily from outside of the United States, suggests that IV courses of ketamine may provide at least temporary relief to some individuals with chronic pain.  The intense treatment protocols, severity of adverse effects, and limited durability raise questions about the overall health benefit of this procedure.  Additional clinical trials are needed to evaluate the long-term safety of repeated 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. 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 and lidocaine for the treatment of chronic pain and psychiatric disorders is an off-label use.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

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 and psychiatric disorders.

SOURCES 

American Psychiatric Association. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. Retrieved December 26, 2018 from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf.

American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Retrieved December 26, 2018 from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf.

BlueCross BlueShield Association. Evidence Positioning System. (11:2018). Intravenous anesthetics for the treatment of chronic pain (5.01.16). Retrieved December 26, 2018 from https://www.evidencepositioningsystem.com. (32 articles and/or guidelines reviewed)

Chang, Y.C., Liu, C.L., Liu, T.P., Yang, P.S., Chen, M.J., & Cheng, S.P. (2017). Effect of perioperative intravenous lidocaine infusion on acute and chronic pain after breast surgery: a meta-analysis of randomized controlled trials. Pain Practice, 17 (3), 336-343. Abstract retrieved February 22, 2018 from PubMed database.

Hutson, P., Backonja, M., & Knurr, H. (2015). Intravenous lidocaine for neuropathic pain: a retrospective analysis of tolerability and efficacy. Pain Medicine, 16 (3), 531-536. Abstract retrieved February 22, 2018 from PubMed database.

Kim, Y.C., Castañeda, A.M., Lee, C.S., Jin, H.S., Park, K.S., & Moon, J.Y. (2018). Efficacy and safety of lidocaine infusion treatment for neuropathic pain: a randomized, double-blind, and placebo-controlled study. Regional Anesthesia and Pain Medicine, 43 (4), 415-424. Abstract retrieved December 26, 2018 from PubMed database.

National Institute for Health and Care Excellence (NICE). (2014, December; last updated February 2017). Neuropathic pain in adults: pharmacological management in non-specialist settings. Retrieved April 1, 2015 from www.nice.org.uk/guidance/cg173.

Przeklasa-Muszyńska, A., Kocot-Kepska, M., Dobrogowski, J., Wiatr, M., & Mika, J. (2016). Intravenous lidocaine infusions in a multidirectional model of treatment of neuropathic pain patients. Pharmacological Reports, 68 (5), 1069-1075. Abstract retrieved February 22, 2018 from PubMed database.

Winifred S. Hayes, Inc. Medical Technology Directory. (2017, April; last update search April 2018). Intravenous lidocaine infusion for neuropathic pain: a review of reviews. Retrieved December 26, 2018 from www.Hayesinc.com/subscribers. (57 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  6/9/2012

MOST RECENT REVIEW DATE:  4/30/2019

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment. 

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