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, suggest 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
Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of psychiatric disorders and chronic pain, including, but not limited to chronic neuropathic pain, chronic daily headache, and fibromyalgia, is considered investigational.
IMPORTANT REMINDERS
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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. (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.
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.
BlueCross BlueShield Association. Evidence Positioning System. (12:2022). Intravenous anesthetics for the treatment of chronic pain and psychiatric disorders (5.01.16). Retrieved November 13, 2023 from www.bcbsaoca.com/eps/. (22 articles and/or guidelines reviewed)
Challapalli, V., Temont-Lukats, W., McNicol, E.D., Lau, J., & Carr, D.B. (2019). Systemic administration of local anesthetic agents to relieve neuropathic pain. The Cochrane Database of Systematic Reviews, doi: 10.1002/14651858. Abstract retrieved November 26, 2019 from PubMed database.
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.
Cohen, S.P., Bhatia, A., Buvanendran, A., Schwenk, E.S., Wasan, A.D., Hurley, R.W., et al. (2018). Consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the american society of regional anesthesia and pain medicine, the American academy of pain medicine, and the american society of anesthesiologists. Regional Anesthesia and Pain Medicine, 43 (5), 521-546. (Level 1 evidence)
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.
McIntyre, R.S., Carvalho, I.P., Lui, L.M W., Majeed, A., Masand, P.S., Gill, H., et al. (2020). The effect of intravenous, intranasal, and oral ketamine in mood disorders: A meta-analysis. Journal of Affective Disorders, 276, 576-584. Abstract retrieved August 27, 2021 from PubMed database.
National Institute for Health and Care Excellence (NICE). (2014, December; last updated September 2020). Neuropathic pain in adults: pharmacological management in non-specialist settings. Retrieved August 26, 2021 from www.nice.org.uk/guidance/cg173.
National Institute for Health and Care Excellence (NICE). (2021, April). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. Retrieved August 26, 2021 from www.nice.org.uk/guidance/cg173.
Pickering, G., Pereira, B., Morel, V., Corriger, A., Giron, F., Marcaillou, F., et al. (2020). Ketamine and magnesium for refractory neuropathic pain: A randomized, double-blind, crossover trial. Anesthesiology, 133 (1), 154–164, doi: 10.1097/ALN.0000000000003345. (Level 2 evidence)
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.
Singh, J.B., Fedgchin, M., Daly, E.J., De Boer, P., Cooper, K., Lim, P., et al. (2016). A double-blind, randomized, placebo-controlled, dose-frequency study of intravenous ketamine in patients with treatment-resistant depression. American Journal of Psychiatry, 173 (8), 816-826. (Level 2 evidence)
Winifred S. Hayes, Inc. Health Technology Assessment. (2021, March; last update search April 2023). Intravenous ketamine for chronic nonmalignant pain. Retrieved November 14, 2023 from www.Hayesinc.com/subscribers. (42 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, April; last update search June 2021). Intravenous lidocaine infusion for neuropathic pain: a review of reviews. Retrieved October 20, 2022 from www.Hayesinc.com/subscribers. (57 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, November; last update search January 2022). Ketamine as an adjunct to electroconvulsive therapy for treatment-resistant depression. Retrieved October 20, 2022 from www.Hayesinc.com/subscribers. (36 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, November; last update search January 2022). Ketamine as primary therapy for treatment-resistant unipolar depression or posttraumatic stress disorder. Retrieved October 20, 2022 from www.Hayesinc.com/subscribers. (59 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 6/9/2012
MOST RECENT REVIEW DATE: 1/11/2024
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