Nancy A. Melville

April 08, 2015

NATIONAL HARBOR, MD — The transition from extensive use of intravenous (IV) sedation for interventional pain procedures to almost exclusive use of oral anxiolysis at an outpatient pain center led to significant improvements in patient satisfaction and recovery times, a new study shows.

But not all practitioners are on board with such a policy, citing potential safety issues.

"The shift from IV sedation to oral anxiolysis for procedures performed in an outpatient academic pain center has allowed successful interventional pain procedures to be completed with an increase in patient safety associated with patient awareness and feedback," write the authors of the study, conducted at the San Antonio Military Center, Fort Sam Houston, Texas.

For the study, presented here at the American Academy of Pain Medicine (AAPM) 31st Annual Meeting, first author Edward Lopez, MD, described a policy that the large academic military medical institution's outpatient pain center has implemented over the past 2 years, under which oral benzodiazepines, specifically diazepam, are used instead of IV sedation, such as opioids, propofol, or benzodiazepines, before most invasive pain intervention procedures.

Under the policy, the number of IV sedations for such procedures declined from 44.4% to just 1.5% over the 2 years.

The authors note that IV sedation, particularly heavy sedation, can compromise safety by preventing the patient from providing feedback.

"You look at each patient differently and try to give what's best for them, but for us, in general we find it's safer to use an anxiolytic because the patient can give feedback and let you know if you're going in the wrong direction or something," Dr Lopez told Medscape Medical News.

The change in policy has resulted in improvements, such as reduced procedure time and patient recovery times, without reducing customer satisfaction, Dr Lopez said. Because the research is still preliminary, exact figures could not be provided, but Dr Lopez said the improvements are statistically significant.

He noted that the average dose of oral anxiolytics, specifically diazepam (Valium, Roche), is usually about 10 mg.

Dr Lopez stressed that key to success in the approach is involving patients and keeping them informed of the process.

"I think a big part of this is doing the education up front, telling patients they're going to get the medication and how it works, and explaining the procedure and the importance and letting us know if they feel tingling or something they think they shouldn't be feeling," he said.

"Making them a part of their healthcare makes a big difference."

While the policy shift to oral anxiolysis at the San Antonio pain center was voluntary, pain specialists are increasingly finding themselves involuntarily having to take such measures as insurance companies back away from coverage of IV anesthesia for pain intervention procedures.

The shift is even causing some pain clinics to have to take matters into their own hands when it comes to IV anesthesia, explained Shailen Jalali, MD, from the Greater Philadelphia Spine and Pain Center, Havertown, Pennsylvania.

"The reason [insurers] say they are no longer covering IV sedation is that it is safer to take the oral approach and IV sedation is usually unnecessary, but I frankly think the reality is they saw how much money that can be saved by not having to pay for anesthesia," he told Medscape Medical News.

Dr Jalali questions the suggestion that such procedures are safer without IV sedation.

"Sometimes it is in fact safer when the patient is comfortable and calm and not moving around and nervous," he said. "If the patient is sedated, you can do the procedure quickly and efficiently and it can otherwise not be as safe."

Dr Jalali said his center's anesthesia group has even taken the action of launching a pilot program to help cover the costs of anesthesia for certain patients who need pain management procedures and don't have coverage for them.

"In our surgical center, we're taking a small amount of the facility to help pay for these services for the pilot program," he said.

"The patients are given three options: They can just get local anesthesia; they can have conscious sedation; or they can have anesthesia and will only have to pay a certain amount to receive it," he said.

With so many insurers declining coverage, the group can only extend the offer to help pay to a limited number of patients, Dr Jalali noted.

"We are giving it a try — we'll see how it works and then we'll regroup. Obviously it won't be a money maker, but we think it will help patients."

Samer Narouze, MD, chairman of the Center for Pain Medicine at Western Reserve Hospital, Cuyahoga Falls, Ohio, also expressed reservations about the idea of a policy using primarily oral sedation.

"I've mixed feelings about this abstract," Dr Narouze told Medscape Medical News.

"I do both oral and IV sedation [and] my issue with oral sedation is that you cannot predict the timing of the sedation and the quality of sedation," he said.

"One dose does not fit all, however with careful IV sedation titration, you will have better control on the sedation."

Dr Narouze added that, like Dr Jalali, he also sees challenges in terms of some insurers declining coverage but finds ways to work around it for the benefit and safety of the patient.

"I'm aware that some insurance carriers tend not to cover IV sedation, but still I provide this service to my patients — and eat the cost, as it is safer to have a calm, communicating patient during the procedure rather than an anxious, agitated, moving patient with a needle nearby delicate structures." 

Dr Lopez, Dr Jalali, and Dr Narouze have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 31st Annual Meeting. Abstract 121. Presented March 20, 2015.

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