ASPN Guidelines for Advanced Practice Providers in Interventional Spine and Pain Management Practice: Updated
By Admin | November 07, 2025
Casey Grillo,1 Alaa Abd-Elsayed,2 Tariq A Yousef,1 Brittney Misercola,3 Zohra Hussaini,4 Morteza Rabii,5 Ashley Comer,6 Kristen Durkin,7 Patrick McGinn,8 Timothy Deer6
1The Spine and Pain Institute of New York, New York, NY, USA; 2Anesthesiology Department, University of Wisconsin- Madison, Madison, WI, USA; 3Pain Specialists of America, Austin, TX, USA; 4Department of Anesthesiology, the University of Kansas Health System, Kansas City, KS, USA; 5Crimson Pain Management, Overland Park, KS, USA; 6The Spine and Nerve Center of the Virginias in Charleston, Charleston, WV, USA; 7NY Spine & Pain Specialists, Port Jefferson Station, NY, USA; 8National Spine and Pain Centers, Shrewsbury, NJ, USA
Correspondence: Casey Grillo, The Spine and Pain Institute of New York, 860 Fifth Ave, Suite 1B, New York, NY, 10065, USA, Tel +1 212 724 7246, Fax +1 212 724 7256, Email Cgrillo@spinepainny.com
Background: Chronic pain management has advanced with minimally invasive interventions that reduce surgical trauma and recovery time. Specialized interventional spine clinics rely on multidisciplinary approaches to improve outcomes. Advanced Practice Providers (APPs), including nurse practitioners, physician assistants, and clinical nurse specialists, play increasingly important roles in these settings. However, standardized guidance on APP integration, training, and scope of practice remains limited. This guideline, developed by an expert panel, is the first to address APP roles in interventional pain management. It is intended for a broad audience including APPs, physicians, and healthcare administrators/policymakers who are involved in spine and pain management.
Methods: In 2024, a multidisciplinary American Society of Pain and Neuroscience (ASPN) panel conducted a targeted literature review and iterative consensus process. Relevant studies, regulations, and guidelines up to 2025 were reviewed. No formal Delphi or grading system was used; recommendations were finalized by group agreement. Topics included APP training, regulatory frameworks, collaborative care models, procedural involvement, medication management, and future directions.
Results: The panel identified nine domains central to APP practice. Recommendations emphasize structured specialty training with fellowship-style onboarding and ongoing competency maintenance; collaborative models in which APPs conduct evaluations, education, and peri-/post-procedural care, while physicians perform high-risk interventions; and strict adherence to state, payer, and institutional rules. ASPN does not endorse independent APP performance of advanced interventional procedures. APPs are key to patient safety through pre-procedure risk assessment, informed consent, and complication monitoring, and they play a central role in medication management, including reconciliation, non-opioid therapy, and opioid prescribing under collaborative frameworks with consistent risk-mitigation practices. Limitations include regulation variability, lack of standardized training pathways, and limited APP-specific outcome data.
Conclusion: These consensus-based guidelines can expand access, improve safety, and enhance patient satisfaction. Standardizing APP roles and training will allow practices to meet rising demand while maintaining high-quality care. Continued evaluation of APP-driven outcomes and development of formal fellowships and certification pathways will be essential to refine these recommendations.
Keywords: interventional pain, spine, advanced practice providers, nurse practitioner, physician assistant, clinical nurse specialist, guidelines
Introduction
The management of spine and pain conditions has shifted toward non-surgical and minimally invasive techniques that reduce tissue trauma and recovery time compared with open surgery.1 These approaches have become central to modern spine care and are increasingly delivered in specialized interventional clinics that use multimodal strategies to optimize outcomes. Within these settings, Advanced Practice Providers (APPs), including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), are increasingly integrated into team-based care models.
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Figure 1 Methodology for guideline development, from expert panel assembly to final consensus recommendations. |
Hamric’s model of advanced practice nursing delineates six core competencies that define the role of advanced practice providers: direct clinical practice, guidance and coaching, evidence-based practice, leadership, collaboration, and ethical practice.2 Collectively, these competencies underscore the versatility of APPs in clinical care, education, and systems-level leadership.
Evidence supports that APP integration enhances access and patient satisfaction. A randomized Canadian trial showed higher patient satisfaction on several measures with NP-led postoperative cardiac surgical care versus hospitalist-led care.3 In emergency fast-track units, patients randomized to Emergency NP care reported higher satisfaction than those treated by physicians.4 Beyond satisfaction, APPs expand service availability and improve access to care.5 Studies also demonstrate comparable safety for common procedures, including cardioversion and large-volume paracentesis, when performed by APPs.6–8 In surgical services, APPs have been associated with improved adherence to care protocols (eg, DVT prophylaxis).9 Nurse-led rheumatology clinics have shown cost-effectiveness relative to physician-led care,10 and surgical specialties such as oral–maxillofacial surgery and breast reconstruction report efficiency gains that offset PA salary costs.11,12
Despite these benefits, interventional pain medicine faces a training gap. Most graduate APP programs lack structured curricula in interventional pain, leaving new graduates with limited exposure to spine procedures, multimodal pharmacotherapy, and peri-procedural care. This absence of formal training pathways delays competency development and contributes to variability in role definition across practices.
The American Society of Pain and Neuroscience (ASPN) convened a multidisciplinary panel of physicians and APPs to develop consensus-based guidelines for APP integration in interventional spine and pain management to address this gap. These guidelines are designed for APPs, physicians, administrators, and policymakers to clarify roles, support competency-based training, and establish collaborative frameworks that enhance safety, efficiency, and quality of care.
The document focuses on several key areas. It considers how APPs can expand access, improve outcomes, and support continuity of care within interventional practices. It also defines the education, training, and competencies required for APPs to participate safely in procedures and peri-procedural care. In addition, the guidelines review legal and regulatory frameworks, including scope of practice laws, licensure, and supervision requirements, that shape APP activity. Responsibilities in assessment, procedural support, medication management, and follow-up care are outlined, with special attention to maintaining physician leadership for high-risk interventions. Together, these elements provide a structured approach to APP integration that balances safety with the growing demand for interventional spine and pain services.
Methods
Guideline Development Process
This project was conducted under the auspices of ASPN and followed an expert consensus model. In early 2024, ASPN convened a multidisciplinary panel of physicians and advanced practice providers representing a wide range of geographic locations, academic settings, and private practices. The panel included specialists in pain management, anesthesiology, physical medicine and rehabilitation, functional neurosurgery, and neurology. All panelists had significant experience in interventional pain management. No external funding or sponsorship was provided for this work, and all participants declared that they have no conflicts of interest related to the content of these guidelines.
Literature Review and Evidence Gathering
The panel performed a targeted literature review to inform the recommendations. Relevant English-language publications were identified via PubMed, Google Scholar, and professional society resources. Search terms included combinations of “advanced practice provider AND pain management”, “nurse practitioner AND spine interventions”, “physician assistant AND pain clinic role”, “clinical nurse specialist AND chronic pain”, as well as specific topics (eg, APP opioid prescribing, APP outcomes, interdisciplinary collaboration in pain clinics). Foundational documents such as the HHS Pain Management Best Practices Task Force report and CDC opioid prescribing guidelines were also reviewed to ensure consistency with national standards. The search encompassed literature up to April 2025, focusing on clinical outcomes, safety, regulatory policies, and educational frameworks relevant to APPs in pain management. Where high-level evidence was lacking (as is common in emerging scope-of-practice topics), illustrative studies from analogous fields and expert opinion were used.
Consensus Formation
Draft recommendations were formulated based on the literature findings and the panel’s collective clinical experience. An iterative consensus process was employed: the panel held a series of virtual meetings and email exchanges to discuss and refine draft statements. No formal Delphi voting was performed; consensus was defined as unanimous or near-unanimous agreement among panel members on each recommendation after successive revisions. Key content areas (APP education, certification, scope-of-practice regulations, collaboration models, procedural roles, etc). were iteratively edited until consensus was achieved. Given the narrative consensus nature of this guideline, we did not assign formal levels of evidence or grades to recommendations. However, we cite supporting evidence or existing guidelines wherever possible to bolster each recommendation. All recommendations presented represent the agreed expert opinion of the panel, intended to complement (not replace) existing evidence-based guidelines. The scope of recommendations was reviewed to ensure consistency with US laws and regulations, and the context of this guideline is limited to the United States. No external validation outside the author group was performed before journal submission. The methodology for guideline development is summarized in Figure 1.
Note on Terminology
For this guideline, APPs refers collectively to NPs, PAs, and CNSs working in interventional pain management. “Physician” refers to the board-certified or fellowship-trained interventional pain physician overseeing the practice. All discussions and recommendations assume compliance with relevant state laws, which may use specific terms like “Advanced Practice Registered Nurse (APRN)” for NPs or require distinct supervisory agreements for PAs; readers should interpret recommendations in light of their jurisdiction’s terminology and regulations.
Results
Summary of Key Recommendations
The panel identified nine domains central to integrating APPs in interventional spine and pain management through literature review and expert consensus. These are summarized in Table 1 and expanded below, covering training, regulatory compliance, collaborative practice, communication, patient safety, pre- peri- and post-procedure care, and medication management.
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Table 1 Summary of Key Recommendations for APP Integration in Interventional Spine and Pain Management |
Recommendation #1: Education, Training, and Competencies
Licensure alone does not prepare APPs for interventional pain practice. Structured onboarding, often modeled after a fellowship, can help standardize skills across settings and improve safety. Effective programs combine didactic teaching, simulation or cadaver labs, proctored cases, and direct mentorship by experienced pain physicians. Training should also focus on diagnostic reasoning, risk assessment, and...(More)
For more info please read, ASPN Guidelines for Advanced Practice Providers in Interventional Spine and Pain Management Practice, by Dove Press
