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Not prescribing opioids first or as a long-term therapy for chronic, non-cancer pain and avoiding MRIs, CTs and X-rays for low-back pain are among the tests and treatments identified by American Society of Anesthesiologists (ASA) that are commonly ordered but not always necessary. As part of the ABIM Foundation’s Choosing Wisely campaign, ASA today released its second list of five targeted, evidence-based recommendations that can support conversations between patients and physician anesthesiologists about what care is really necessary.

ASA’s list identified the following recommendations:

1. Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain. Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.

2. Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient. Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.

3. Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications. Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. * Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice. Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false positive responses ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.

5. Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks. Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.

The ASA Committee on Pain Medicine was charged with developing the Choosing Wisely list on pain medicine. Committee members submitted recommendations for the campaign, and from this list voted on which should be included in the Choosing Wisely list. The literature was then searched to provide supporting evidence. Once approved by the committee, the Choosing Wisely list was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee, and Administrative Council. The American Pain Society (APS) has endorsed ASA’s Choosing Wisely list on pain medicine.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit