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 individuals 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 raise 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

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 

BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2017). Intravenous anesthetics for the treatment of chronic pain (5.01.16). Retrieved February 22, 2018 from BlueWeb. (34 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.

Lauritsen, C., Mazuera, S., Lipton, R. B., & Ashina, S. (2016). Intravenous ketamine for subacute treatment of refractory chronic migraine: a case series. Journal of Headache and Pain, 17 (1), 106. Abstract retrieved February 22, 2017 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.

U. S. Food and Drug Administration. (2010, February). Center for Drug Evaluation and Research. Ketalar®- 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. Ketalar® (lidocaine HCL injection, USP). Retrieved April 7, 2015 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/016812s039lbl.pdf.

Winifred S. Hayes, Inc. Health Technology Brief. (2015, April; last update search March 2017). Intravenous ketamine for chronic nonmalignant pain. Retrieved February 22, 2018 from www.Hayesinc.com/subscribers. (29 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2017, April). Intravenous lidocaine infusion for neuropathic pain: a review of reviews. Retrieved February 22, 2018 from www.Hayesinc.com/subscribers. (57 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  6/9/2012

MOST RECENT REVIEW DATE:  4/12/2018

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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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