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Zhu AC, Tram J, Waterman R, Wallace M, Chakravarthy K. Recommendations for anesthetic management for intraoperative neuromodulation cases. Pain Manag 2021; 12:557-567. [PMID: 34886683 DOI: 10.2217/pmt-2020-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This paper performs a review of current literature as well as uses our single-center experience to discuss pre-operative, intra-operative and, briefly, postoperative management for dorsal column stimulators (DCSs), dorsal root ganglion (DRG) stimulators, peripheral nerve stimulators (PNSs) and intrathecal pumps. Generally, pre-operative antibiotics are recommended with discontinuation within 24 h postoperatively. For dorsal column and DRG stimulation, monitored anesthesia care or general anesthesia with intra-operative neuromonitoring is recommended; for peripheral nerve stimulation and intrathecal pump implementation, monitored anesthesia care is preferred. There is little information on appropriate anesthetic management during these forms of neuromodulation. More research is necessary to articulate specific pre-operative, intra-operative and postoperative management guidelines and recommendations for dorsal column stimulator, DRG stimulation, PNS and intrathecal pump implantation.
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Affiliation(s)
- Alyssa C Zhu
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Jennifer Tram
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Ruth Waterman
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA.,VA San Diego Health Care, 3350 La Jolla Village Dr, San Diego, CA 92161, USA
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Bienfait F, Jubier-Hamon S, Seegers V, Pluchon YM, Lebrec N, Jaoul V, Boré F, Delorme T, Robert J, Bellanger M, Sorrieul J, Dupoiron D. First Evaluation Switching From Ropivacaine to Highly Concentrated Bupivacaine in Intrathecal Mixtures for Cancer Pain. Neuromodulation 2021; 24:1215-1222. [PMID: 34181790 DOI: 10.1111/ner.13469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/23/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intrathecal drug delivery is widely used for intractable cancer pain treatment. A combination of drugs with morphine and bupivacaine is recommended in first line therapy. In France, we use ropivacaine 10 mg/mL instead of bupivacaine 5 mg/mL, the only concentration available. Bupivacaine 40 mg/mL has been available in France only since July 2020 under temporary authorization of use. OBJECTIVES The main objective of the study was to evaluate the safety, efficacy by pain assessment, to analyze drug dosage changes, to report adverse events (AEs) and conversion ratios switching from ropivacaine to bupivacaine. Secondary objective was to evaluate costs differences. MATERIALS AND METHODS We conducted this retrospective follow-up monocentric study within the Institut de Cancérologie de l'Ouest (ICO) Pain Department in Angers, France. We included 14 patients aged 18 years and above, implanted with an Intrathecal Drug Delivery Systems (IDDS) for cancer pain treatment and followed up at ICO from July 2020 to February 2021 after switching from ropivacaine to bupivacaine. We used a continuous infusion mode and Bolus could be added through Personal Therapy Manager (PTM). RESULTS The median conversion ratio between ropivacaine and bupivacaine was 0.68 (0.65; 0.69) and resulted in no significant change in numeric rating scale evaluation (p = 0.10). We observed moderate and rapidly reversible AEs such as clinical hypotension (29%) and motor block after bolus (21%). The estimated median hospital cost per day was significantly lower (p = 0.05) for the bupivacaine refills than for the last ropivacaine pump refill, decreasing from US$ 61.7 (49.6; 70.5) to US$ 50.4 (45.9; 60.4). The median reimbursement per day from the National Health Insurance (NHI) was three times lower for bupivacaine pump refill when compared to the last ropivacaine pump refill (p < 0.01), decreasing from US$ 179.10 (156.79; 182.91) to US$ 64.59 (59.85; 71.89). CONCLUSION Switching from ropivacaine to bupivacaine in IDDS appears more efficacious while remaining just as secure, and at lower cost.
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Affiliation(s)
- Florent Bienfait
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Sabrina Jubier-Hamon
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Valérie Seegers
- Department of Epidemiology and Biostatistics, Institut de Cancerologie De l'Ouest, Angers, France
| | | | - Nathalie Lebrec
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Virginie Jaoul
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - François Boré
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Thierry Delorme
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Julien Robert
- Pharmacy, Institut de Cancerologie de l'Ouest, Angers, France
| | - Martine Bellanger
- Department of Human and Social Sciences, Institut de Cancerologie de l'Ouest, Nantes, France.,EHESP School of Public Health, Paris, France
| | - Jérémy Sorrieul
- Pharmacy, Institut de Cancerologie de l'Ouest, Angers, France
| | - Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
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Spiegel MA, Chen GH, Solla AC, Hingula LP, Legler A, Gulati A. Evaluation of an Intrathecal Drug Delivery Protocol Leads to Rapid Reduction of Systemic Opioids in the Oncological Population. J Palliat Med 2020; 24:418-422. [PMID: 32640912 DOI: 10.1089/jpm.2020.0206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: The article that follows is purposed at demonstrating how IT opioid plus bupivacaine achieves sustained acceptable pain relief while simultaneously rapidly reducing oral morphine equivalents (OME). Background: Cancer patients represent a population with significant morbidity, pain, and limited life expectancy. It is, therefore, vital to achieve satisfactory analgesia quickly and safely. To date, there is limited data in the literature that discusses efficacy of combined intrathecal (IT) medication therapy in reducing systemic opioids in the oncological population. Methods: This was a retrospective analysis that reviewed cancer pain patients from day of IT pump implantation through the six-month postoperative time point. A cohort of 50 oncological patients who had intrathecal drug delivery systems (IDDSs) implanted at Memorial Sloan Kettering Cancer Center between 2017 and 2019 were studied. Median OMEs were the primary modality of analysis for this review. Mean visual analogue scale scores were secondarily reviewed. Results: Median OMEs decreased from 503 preoperative to 105 at six months postoperative time point. Median time to discharge was 6.5 days. Unfortunately, due to malignant mortality, 27 patients did not make it to the 6-month postoperative time point. Discussion: IDDSs with opioid plus bupivacaine represent a safe and efficient route toward expeditious pain relief and decreased OMEs in the cancer pain population.
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Affiliation(s)
- Matthew A Spiegel
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York, USA
| | - Grant H Chen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Antonio C Solla
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York, USA
| | - Lee P Hingula
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Yang J, Choi Y, Park J, Jeong J, Lee B, Lee K, Lee J, Choi R. Suspected transcutaneous cerebral spinal fluid leakage without postural headache after implantable intrathecal drug delivery system removal - A case report -. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.2.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jaeyoung Yang
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Yusun Choi
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Juyoung Park
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Junhyug Jeong
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Bousung Lee
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Kwanghaeng Lee
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Jaedo Lee
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
| | - Rakmin Choi
- Department of Anesthesiology and Pain Medicine, VHS Medical Center, Seoul, Korea
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Patel N, Huddart M, Makins H, Mitchell T, Gibbins JL, Graterol J, Stevens D, Perkins P. 'Was it worth it?' Intrathecal analgesia for cancer pain: A qualitative study exploring the views of family carers. Palliat Med 2018; 32:287-293. [PMID: 28832240 DOI: 10.1177/0269216317723777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intrathecal drug delivery is known to reduce pain in patients where conventional systemic analgesia has been ineffective or intolerable. However, there is little information regarding the effects of intrathecal drug delivery on quality of life and function in those with advanced, incurable cancer. AIM Retrospective exploration of the views of bereaved carers regarding the physical and psychosocial effects of external tunnelled intrathecal drug delivery in patients with advanced incurable cancer. DESIGN Thematic analysis of qualitative interviews with carers of deceased individuals who received percutaneous external tunnelled intrathecal drug delivery as part of their pain management, within two UK centres. SETTING A total of 11 carers were recruited from two UK Palliative Care centres. Family carers of adult patients who had received external tunnelled intrathecal drug delivery analgesia for cancer pain and had died between 6 and 48 months prior to contact were included. Carer relatives who were considered likely to be too vulnerable or who had lodged a complaint about treatment within the recruiting department or who had been treated directly by the interviewer were excluded. RESULTS In total, 11 interviews took place. The emerging themes were (1) making the decision to have the intrathecal - relatives described desperate situations with severe pain and/or sedation, meaning that the individual would try anything; (2) timing and knowing they were having the best - an increased access to pain and palliative care services, meant carers felt everything possible was being done, making the situation more bearable; (3) was it worth it? - the success of the external tunnelled intrathecal drug delivery was judged on its ability to enable the individual to be themselves through their final illness. Side effects were often considered acceptable, if the external tunnelled intrathecal drug delivery enabled improvements in quality of life. CONCLUSION Carers perceived external tunnelled intrathecal drug delivery as most valuable when it improved quality of life towards the end of life, by reducing pain and side effects of conventional systemic analgesia to enable individuals 'to be themselves'. Under these circumstances, the carers judged significant side effects to be acceptable.
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Affiliation(s)
- Nishi Patel
- 1 Department of Chronic Pain, Cheltenham Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Melanie Huddart
- 2 St Julia's & Mount Edgcumbe Hospices, Cornwall Hospice Care, Cornwall, UK
| | - Helen Makins
- 1 Department of Chronic Pain, Cheltenham Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | | | - Jane L Gibbins
- 2 St Julia's & Mount Edgcumbe Hospices, Cornwall Hospice Care, Cornwall, UK
| | | | - Deborah Stevens
- 2 St Julia's & Mount Edgcumbe Hospices, Cornwall Hospice Care, Cornwall, UK
| | - Paul Perkins
- 5 Gloucestershire Hospitals NHS Foundation Trust and Sue Ryder Leckhampton Court Hospice, Cheltenham, UK
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Duarte RV, Lambe T, Raphael JH, Eldabe S, Andronis L. Intrathecal Drug Delivery Systems for the Management of Chronic Noncancer Pain: A Systematic Review of Economic Evaluations. Pain Pract 2017; 18:666-686. [DOI: 10.1111/papr.12650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/08/2017] [Accepted: 10/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rui V. Duarte
- Liverpool Reviews and Implementation Group; Department of Health Services Research; University of Liverpool; Liverpool U.K
| | - Tosin Lambe
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
| | - Jon H. Raphael
- Faculty of Health; Birmingham City University; Birmingham U.K
- Department of Pain Management; Russells Hall Hospital; Dudley U.K
| | - Sam Eldabe
- Department of Pain and Anaesthesia; The James Cook University Hospital; Middlesbrough U.K
| | - Lazaros Andronis
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
- Populations; Evidence and Technologies Group; Division of Health Sciences; University of Warwick; Coventry U.K
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Pope JE, Deer TR, Amirdelfan K, McRoberts WP, Azeem N. The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain. Curr Neuropharmacol 2017; 15:206-216. [PMID: 26861471 PMCID: PMC5412702 DOI: 10.2174/1570159x14666160210142339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/01/2015] [Accepted: 02/05/2016] [Indexed: 12/29/2022] Open
Abstract
Background Intrathecal drug delivery has undergone a revitalization following a better understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes, clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and indications. We review the current understanding of the pharmacology of commonly employed intrathecal agents and the clinical relevance. Methods Search strategies for data acquisition included Medline database, PubMed, Google scholar, along with international and national professional meeting content, with key words including pharmacology of opioids, intrathecal therapy, ziconotide, pharmacokinetics, and intrathecal drug delivery. The search results were limited to the English language. Results Over 300 papers were identified. The literature was condensed and digested to evaluate the most commonly used medications in practice, sto serve as a foundation for review. We review on-label medications: ziconotide and morphine, and off label medications including fentanyl, sufentail, and hydromorphine. Conclusion Intrathecal therapy has level-one evidence for use for malignant pain and nonmalignant pain, with continued cost savings and improved safety. To most effectively serve our patients, a clear appreciation for the pharmacology of these commonly employed medication is paramount..
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Affiliation(s)
- J E Pope
- Center for Pain Relief, Charleston, WV, USA. United States
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Vigneri S, Sindaco G, La Grua M, Zanella M, Ravaioli L, Paci V, Pari G. Combined epidural morphine and bupivacaine in the treatment of lumbosacral radicular neuropathic pain: a noncontrolled prospective study. J Pain Res 2016; 9:1081-1087. [PMID: 27920574 PMCID: PMC5123724 DOI: 10.2147/jpr.s113996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this study was to investigate the therapeutic effectiveness of epidural morphine and bupivacaine in patients with chronic lumbosacral radicular neuropathic pain after the cessation of treatment. Methods Twenty-two patients with chronic lumbosacral pain with neuropathic features were enrolled. An indwelling catheter was placed into the epidural space, and each patient received an epidural injection of morphine chlorhydrate and bupivacaine up to three times a day. The medication was administered for 4 weeks. The pain intensity score on a 0–10 numeric rating scale (NRS), the total pain rating index rank (PRIr-T), and its coefficients were evaluated before treatment and 1 month after catheter removal. P-value <0.05 was considered statistically significant. Results NRS and PRIr-T were significantly reduced at follow-up (P=0.001 and P=0.03, respectively), whereas the parallel evolution of the two scores (r=0.75 and P<0.001, respectively) confirmed significant pain relief lasting up to 1 month after treatment cessation. None of the four pain rating coefficients was significantly modified compared to the others in either responders or nonresponders. Successful clinical outcome (pain reduction >30% in NRS) was reached and maintained in half of the patients at follow-up. Conclusion Combined epidural morphine and bupivacaine seems to be effective in the treatment of neuropathic pain.
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Affiliation(s)
- Simone Vigneri
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo; Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Gianfranco Sindaco
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Marco La Grua
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Matteo Zanella
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Laura Ravaioli
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Valentina Paci
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
| | - Gilberto Pari
- Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, RO, Italy
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Veizi E, Hayek S. Interventional therapies for chronic low back pain. Neuromodulation 2015; 17 Suppl 2:31-45. [PMID: 25395115 DOI: 10.1111/ner.12250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/28/2014] [Accepted: 08/31/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain (LBP) is a highly prevalent condition and one of the leading causes of lost productivity and health-care costs. The objective of this review is to discuss the role of interventional pain procedures and evidence of their effectiveness in treatment of chronic LBP. METHODS This is a narrative review examining published studies on interventional procedures for LBP. The rationales, indications, technique, evidence, and complications for the interventional procedures are discussed. RESULTS Interventional pain procedures are used extensively in diagnosis and treatment of chronic pain. LBP is multifactorial, and while significant progress has been made in understanding its pathophysiology, this has not resulted in a proportional improvement of functional outcomes. For certain procedures, such as spinal cord stimulation, medical branch blocks and radiofrequency ablations, and epidural steroid injections for radiculopathy, safety, efficacy, and cost-effectiveness in treating LBP have been well studied. For others, such as interventions for discogenic pain, treatment successes have been modest at best. CONCLUSIONS Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.
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Affiliation(s)
- Elias Veizi
- Department of Anesthesiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA; Pain Medicine & Spine Care, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
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Micheli L, Di Cesare Mannelli L, Guerrini R, Trapella C, Zanardelli M, Ciccocioppo R, Rizzi A, Ghelardini C, Calò G. Acute and subchronic antinociceptive effects of nociceptin/orphanin FQ receptor agonists infused by intrathecal route in rats. Eur J Pharmacol 2015; 754:73-81. [PMID: 25704616 DOI: 10.1016/j.ejphar.2015.02.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/06/2015] [Accepted: 02/11/2015] [Indexed: 12/11/2022]
Abstract
Severe pain occurs in the context of many diseases and conditions and is a leading cause of disability. Nociceptin/orphanin FQ (N/OFQ) is the endogenous ligand of the N/OFQ peptide (NOP) receptor. This peptidergic system controls pain transmission and in particular spinally administered N/OFQ has robust antinociceptive properties. The aim of this study was to investigate the spinal antinociceptive properties of NOP peptide agonists after acute and subchronic treatment in rats. Doses unable to alter motor coordination were selected. UFP-112 (full NOP agonist) and UFP-113 (partial NOP agonist) were administered intrathecally (i.t.) by spinal catheterization. Acute injection of UFP-112 induced antinociceptive response at lower dosages (0.03-1nmol i.t.) compared to morphine and similar to N/OFQ. UFP-113 was effective in a 0.001-1nmol i.t. dose range. The antinociceptive effects of NOP ligands were no longer evident in rats knockout for the NOP gene, while those of morphine were maintained. The continuous spinal infusion (by osmotic pumps) of 0.1nmol/h UFP-112 and UFP-113 showed antinociceptive action comparable to 1-3nmol/h morphine or N/OFQ. The antinociceptive effect of morphine progressively decreased and was no longer significant after 6 days of treatment. Similar results were obtained with N/OFQ, UFP-112, and UFP-113. The acute i.t. injection of morphine in animals tolerant to N/OFQ and UFP-112 evoked analgesic effects. Neither morphine nor N/OFQ induced antinociceptive effects in morphine- and UFP-113-tolerant rats. In conclusion this study highlights the analgesic efficacy and potency of UFP-112 and UFP-113 underlining the relevance of NOP system in analgesia.
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Affiliation(s)
- Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy.
| | - Remo Guerrini
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Claudio Trapella
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Matteo Zanardelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Roberto Ciccocioppo
- School of Pharmacy, Pharmacology Unit, University of Camerino, Camerino, Italy
| | - Anna Rizzi
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
| | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Girolamo Calò
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
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Ellis DJ, Dissanayake S, McGuire D, Charapata SG, Staats PS, Wallace MS, Grove GW, Vercruysse P. Continuous Intrathecal Infusion of Ziconotide for Treatment of Chronic Malignant and Nonmalignant Pain Over 12 Months: A Prospective, Open-label Study. Neuromodulation 2013; 11:40-9. [PMID: 22150990 DOI: 10.1111/j.1525-1403.2007.00141.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives. This study aims to assess the safety and efficacy of long-term intrathecal (IT) ziconotide infusion. Materials and Methods. In this prospective study, 155 patients with severe chronic pain (48 with malignant pain, 107 with nonmalignant pain) who had been responsive to short-term IT ziconotide in a double-blind, placebo-controlled study received long-term, open-label IT ziconotide monotherapy. Efficacy assessments included the mean percentage change on the visual analog scale of pain intensity from baseline in the study of origin; safety was monitored by adverse event (AE) reports, periodic laboratory tests, and vital sign measurements. Results. At the last available observation, the visual analog scale of pain intensity scores had decreased by a mean of 36.9% from baseline in the short-term trial (N = 144; 95% CI: 30.1-43.7%; p < 0.0001). The mean IT ziconotide dose remained stable over 12 months in the 31 patients who participated in the study for ≥ one year. Ziconotide-related AEs were reported in 147 out of 155 patients (94.8%); 39.4% of patients discontinued treatment because of AEs, the majority of which were considered ziconotide related. Conclusions. Ziconotide IT monotherapy provided patients with analgesia for 12 months in this open-label study, with an acceptable benefit/risk profile and no evidence of tolerance.
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Affiliation(s)
- David J Ellis
- ARYx Therapeutics, Fremont, CA, USA; Medicines and Healthcare Products Regulatory Agency, London, UK; California Pacific Medical Center, San Francisco, CA, USA; Pain Management Associates of Kansas City, Kansas City, MO, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Pain Medicine, University of California, San Diego, La Jolla, CA, USA; Orthopedic and Sports Medicine Center, Elkhart, IN, USA; and Brugge Multidisciplinary Pain Unit, Brugge, Belgium
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Kumar K, Rizvi S, Bishop S, Tang W. Cost Impact of Intrathecal Polyanalgesia. PAIN MEDICINE 2013; 14:1569-84. [DOI: 10.1111/pme.12204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Anderson VC, Burchiel KJ, Cooke B. A Prospective, Randomized Trial of Intrathecal Injection vs. Epidural Infusion in the Selection of Patients for Continuous Intrathecal Opioid Therapy. Neuromodulation 2013; 6:142-52. [PMID: 22151017 DOI: 10.1046/j.1525-1403.2003.03023.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objective of this study was to compare the cost and safety of intrathecal injection (IN) vs. epidural infusion (CE) trial and to provide a preliminary assessment of the prognostic value of each in the selection of patients for long-term continuous intrathecal opioid therapy (CIOT). Thirty-seven patients with chronic nonmalignant pain who were being considered for CIOT were randomized to morphine trial by IN or CE. Analgesic response and complications were monitored throughout trial. Sixty-seven percent of IN (12/18) and 79% (15/19) of CE subjects reported good pain relief (defined as ≥ 50% pain reduction) and were implanted with a permanent infusion system. Eighty-nine percent (24/27) of subjects provided six-month CIOT follow-up data. Cost of trial and health care utilization during six months of CIOT were compared between groups. Analgesic and functional response during CIOT was also compared between IN and CE groups. The cost of IN trial was significantly less than CE trial (p < 0.001). Complications were generally mild in both groups, although opioid-related side effects tended to be more common in the IN group. Successful pain relief after six months of CIOT was reported by 10 (60%) and 14 (64%) patients who underwent IN and CE trial, respectively (p = 0.32; Fisher's exact test). There was no difference between IN and CE groups in McGill Pain rating, quality of life (VAS), mood (Profile of Mood States), or function (Sickness Impact Profile) after six months of CIOT. We conclude that intrathecal injection is a safe procedure for use in selection of patients for CIOT and is less costly than epidural infusion. Differences in pain and functional response to long-term opioids among patients selected by either trial method are not large.
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Affiliation(s)
- Valerie C Anderson
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Guillemette S, Witzke S, Leier J, Hinnenthal J, Prager JP. Medical Cost Impact of Intrathecal Drug Delivery for Noncancer Pain. PAIN MEDICINE 2013; 14:504-15. [DOI: 10.1111/j.1526-4637.2013.01398.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Deer T, Winkelmüller W, Erdine S, Bedder M, Burchiel K. Intrathecal therapy for cancer and nonmalignant pain: patient selection and patient management. Neuromodulation 2012; 2:55-66. [PMID: 22151109 DOI: 10.1046/j.1525-1403.1999.00055.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. Patient selection criteria for cancer and nonmalignant pain are similar; however, a more comprehensive psychological and social assessment is required for patients with nonmalignant pain. In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
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Affiliation(s)
- T Deer
- The Center for Pain Relief, Charleston, West Virginia, USA; Gemeinschaftspraxis für Neurochirurgie, Hannover, Germany; Department of Algology, Medical Faculty of Istanbul, Istanbul, Turkey; Advanced Pain Management Group, Inc., Portland, Oregon, USA; Oregon Health Sciences University, Portland, Oregon, USA
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Willis KD, Doleys DM. The effects of long-term intraspinal infusion therapy with noncancer pain patients: evaluation of patient, significant-other, and clinic staff appraisals. Neuromodulation 2012; 2:241-53. [PMID: 22151257 DOI: 10.1046/j.1525-1403.1999.00241.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective. This study examines, in a retrospective fashion, the effects of intraspinal infusion therapy, primarily using opioids, in the treatment of recalcitrant noncancer pain in a sample of 29 consecutive patients. Patients were, on average, 58 years of age having had one surgery, with a pain duration of 221 months. Mean follow-up duration was 31 months. Telephone interviews by a disinterested party were used to obtain follow-up data from patients and their significant others. In addition, clinic staff rated patient improvement. Results. The patients reported an average of 63.4% improvement in pain; 45.5% improvement in activity level; and a 53.8% improvement in "ease" of performing activities. Average pain level on a numerical rating scale decreased from 8.91/10 to 5.03/10. The number of patients reporting a pain level of 5/10 or less increased from 1/29 to 15/29. Patients generally reported long-term benefit to be equal to or greater than that realized during the intrathecal trial. Approximately 86% of patients reported a "good" or "excellent" outcome. Significant-other ratings of improvement correlated more highly with clinic staff than with patients. No statistically significant differences were observed when worker's compensation (WC) patients were compared with nonworker's compensation (NWC) patients. Nearly 50% of the patients reported some type of transient or persistent side effect, mostly related to the infused substance. No mechanical failure of the DAS system was observed. Conclusion. These results in part replicate those from previous studies examining the long-term effects of infusion therapy. Side effects remain fairly common and require continued attention. Their presence, however, did not appear to deter from the patient's overall sense of satisfaction. Acquiring information from significant others and clinic staff may be a useful adjunct in interpreting the overall outcome.
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Affiliation(s)
- K D Willis
- Alabama Pain Center, Huntsville, Alabama and Pain and Rehabilitation Institute, Birmingham, Alabama
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Mironer YE, Tollison CD. Methadone in the intrathecal treatment of chronic nonmalignant pain resistant to other neuroaxial agents: the first experience. Neuromodulation 2012; 4:25-31. [PMID: 22151568 DOI: 10.1046/j.1525-1403.2001.00025.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intrathecal drug delivery is a widely used and effective method of treatment for chronic intractable pain. Unfortunately all currently used agents can not provide adequate pain relief in all patients. A prospective study of neuroaxial methadone was performed in 24 patients, all of whom had failed treatment with multiple previous intrathecal drugs. Thirteen patients experienced improvement of their pain control with methadone, nine continued to receive this agent for 6 months with good pain relief, improved quality of life and no side effects. The final rates of methadone infusion were 2.2 times higher than preceding morphine rates. The only observed possible side effect of methadone was transient blurred vision in one patient. Methadone is a promising alternative neuroaxial agent in the treatment of chronic pain.
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Affiliation(s)
- Y Eugene Mironer
- NFIPC, Carolinas Center for Advanced Management of Pain, Greenville-Spartanburg-Anderson, South Carolina
| | - C David Tollison
- NFIPC, Carolinas Center for Advanced Management of Pain, Greenville-Spartanburg-Anderson, South Carolina
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Hassenbusch SJ, Satterfield WC, Gradert TL, Binhazim AW, Ahad G, Mokhtarzadeh M, Schapiro SJ, Payne R. Preclinical toxicity study of intrathecal administration of the pain relievers dextrorphan, dextromethorphan, and memantine in the sheep model. Neuromodulation 2012; 2:230-40. [PMID: 22151256 DOI: 10.1046/j.1525-1403.1999.00230.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives To determine the toxicity window for the continuous intrathecal administration of dextrorphan, dextromethorphan, and memantine via an implanted delivery pump. Materials and Methods Using 48 sheep with programmable continuous intrathecal infusion systems we determined the behavioral, motor, neurological, and histopathological changes produced by a 43-day continuous infusion study of dextrorphan, dextromethorphan, and memantine dissolved in 0.9% NaCl. Daily doses of each N-methyl-D-aspartate (NMDA) antagonist were 0.013, 0.051, 0.203, 0.510, 0.811, and 2.533 mg/kg/day, flow rates ranged from 13.25 ml/day to 0.051 ml/day at a concentration of 10 mg/ml. Control animals received saline in the range of 7.9985 ml/day to 1 ml/day. Conclusions Infusion of saline in the control animals produced no behavioral or motor changes. However, infusion of dextrorphan, dextromethorphan, and memantine at the higher doses (> 0.051 mg/kg/day) produced dose-dependent negative behavioral, motor, and histopathologic changes as indicated by a series of nonparametric statistical analyses. The minimal toxic doses were dextrorphan dose 3, dextromethorphan dose 1 and memantine dose 1. This study suggests that continuous intrathecal infusion of dextrorphan, dextromethorphan, and memantine via an implantable pump system can cause significant toxicities at the higher doses studied.
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Affiliation(s)
- S J Hassenbusch
- Departments of Neurosurgery and Pain and Symptom Management, The University of Texas M. D. Anderson Cancer Center, Houston, Texas and Department of Veterinary Sciences, The University of Texas M. D. Anderson Cancer Center-Science Park, Bastrop, Texas
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Wallace M, Yaksh TL. Characteristics of distribution of morphine and metabolites in cerebrospinal fluid and plasma with chronic intrathecal morphine infusion in humans. Anesth Analg 2012; 115:797-804. [PMID: 22822192 DOI: 10.1213/ane.0b013e3182645dfd] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite widespread use of chronic intrathecal (IT) infusions of morphine, there is little systematic human work evaluating the steady state morphine concentrations or cerebrospinal (CSF) chemistry after long-term IT morphine delivery. We sought to address these issues in patients receiving chronic IT morphine infusion. METHODS Pain patients with implanted catheters and pumps (range: 127 to 2165 days), receiving a stable dosing (>1 week) of IT morphine by infusion, were entered into the study. The following sequence was performed: (1) estimation of pain score; (2) radiograph localization of catheter tip; (3) percutaneous sampling of lumbar CSF at the L4 to 5 or L5-S1 space. CSF/plasma samples were assayed for chemistry, and morphine and its 3/6 glucuronide metabolites (M3G, M6G) by liquid chromatography mass spectrometry. RESULTS Nineteen patients were enrolled. CSF samples were obtained from 16 subjects. Three patients were not included in the primary analysis because 1 catheter was epidural, 1 catheter was fractured, and 1 had a granuloma at the catheter tip. Of the 13 sampled patients, the range of daily doses, rates, and concentrations were 1.6 to 25 mg/d and 0.1 to 1 mL/d, 5 to 50 mg/mL, respectively. The principal observations were as follows: (i) morphine, M3G, and M6G were present in the CSF and plasma and showed a significant regression slope when plotted versus daily dose; (ii) in contrast, the regression slope of the group ratio morphine:M3G:M6G plotted versus daily dose in CSF or plasma was not different from zero; (iii) plotting "normalized" CSF analyte concentration (e.g., concentration at site/daily IT morphine dose) against the segmental distance of the sampling site from the catheter tip revealed a significant decline in concentration of morphine, but not of conjugates as a function of distance from the catheter tip; (iv) plotting CSF protein, glucose, and red and white cell counts versus daily morphine dose or morphine concentration at the sampling site revealed no significant regression; and (v) patients with a catheter failure or a granuloma showed reduced concentrations of morphine in their CSF. CONCLUSION Chronic infusion of morphine shows high concentrations, which correlate with the infusion dose and the proximity of the sampling site to the infusion site with no effects on CSF chemistry.
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Affiliation(s)
- Mark Wallace
- Department of Anesthesiology, University of California-San Diego, La Jolla, CA, USA.
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Krames ES. A History of Intraspinal Analgesia, a Small and Personal Journey. Neuromodulation 2012; 15:172-93; discussion 193. [DOI: 10.1111/j.1525-1403.2011.00414.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Upadhyay SP, Mallick PN. Intrathecal drug delivery system (IDDS) for cancer pain management: a review and updates. Am J Hosp Palliat Care 2011; 29:388-98. [PMID: 22089523 DOI: 10.1177/1049909111426134] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cancer pain remains undertreated and a significant number of patients with cancer pain die from severe untreated pain. With increasing survival rate in cancer, the prevalence of cancer pain is also increasing in number. Though majority of patients with cancer pain can be effectively treated with conventional medical management, still a significant portion of patients required some form of interventional pain management techniques. Among the interventional techniques, intrathecal drug delivery is increasingly used in cancer pain management. Our objective of this article is to review literatures and clinical studies on intrathecal drug delivery system (IDDS) in cancer pain management and to provide updates on its use, precautions, contraindications, side effects and its management, socioeconomic consideration, and management of IDDS in difficult or uncommon situations.
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Affiliation(s)
- Surjya Prasad Upadhyay
- Department of Anaesthesiology, Critical care and Pain management, Al Jahra Hospital, Ministry of Health, State of Kuwait, Kuwait.
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Kim D, Saidov A, Mandhare V, Shuster A. Role of pretrial systemic opioid requirements, intrathecal trial dose, and non-psychological factors as predictors of outcome for intrathecal pump therapy: one clinician's experience with lumbar postlaminectomy pain. Neuromodulation 2011; 14:165-75; discussion 175. [PMID: 21992206 DOI: 10.1111/j.1525-1403.2011.00333.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Non-psychological parameters may predict pump success. METHODS Review was performed on 35 implants for gender, age, pretrial/trial dose, baseline visual analog scale (VAS), and pain location. One-year outcomes were % change VAS/intrathecal dose and medication change. Spearman coefficients correlated pretrial/trial dose, age, baseline VAS, and % change in VAS/intrathecal dose. Wilcoxon Rank-Sum tests correlated gender/pain location and % change in VAS/intrathecal dose. Pretrial/trial dose, baseline VAS, and medication change was tested using Wilcoxon Rank-Sums. Chi-square was used to correlate medication change with gender/pain location. A two-sample t-test compared age and medication change. RESULTS Positive correlation between % change VAS and trial dose was noted. Greater age correlated with lower VAS and % dose change. Marginally significant difference in % dose change by pain location was present with higher doses for leg pain. CONCLUSION Trial dose, age, and partially pain location are good predictors of pain relief.
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Affiliation(s)
- David Kim
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI 48202, USA.
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24
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Aldrete JA. Failed Back Surgery Syndrome. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Schuchard M, Lanning R, North R, Reig E, Krames E. Neurologic Sequelae of Intraspinal Drug Delivery Systems: Results of a Survey of American Implanters of Implantable Drug Delivery Systems. Neuromodulation 2010; 1:137-48. [DOI: 10.1111/j.1525-1403.1998.tb00007.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Doleys DM, Coleton M, Tutak U. Use of Intraspinal Infusion Therapy with Non-Cancer Pain Patients: Follow-up and Comparison of Worker's Compensation vs. Non-Worker's Compensation Patients. Neuromodulation 2010; 1:149-59. [DOI: 10.1111/j.1525-1403.1998.tb00008.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dahm P, Nitescu P, Appelgren L, Curelaru I. Continuous Intrathecal Infusion of Opioid and Bupivacaine in the Treatment of Refractory Pain Due to Postherpetic Neuralgia: A Case Report. Neuromodulation 2010; 1:85-9. [DOI: 10.1111/j.1525-1403.1998.tb00021.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schuchard M, Krames ES, Lanning R. Intraspinal Analgesia for Nonmalignant Pain: A Retrospective Analysis for Efficacy, Safety and Feasability in 50 Patients. Neuromodulation 2010; 1:46-56. [DOI: 10.1111/j.1525-1403.1998.tb00029.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Campana G, Sarti D, Spampinato S, Raffaeli W. Long-term intrathecal morphine and bupivacaine upregulate MOR gene expression in lymphocytes. Int Immunopharmacol 2010; 10:1149-52. [PMID: 20609402 DOI: 10.1016/j.intimp.2010.06.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 05/10/2010] [Accepted: 06/21/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies have shown that opioids may suppress the immune system either by binding to mu-opioid receptors (MOR) expressed in immune cells or by activating these receptors within the central nervous system. OBJECTIVE To assess the level of lymphocyte expression of MOR mRNA in patients with chronic non-cancer pain, who were treated with intrathecal morphine or with morphine plus bupivacaine via an intrathecal drug delivery system, and to investigate whether intrathecal morphine and the associated local anesthetic administration influences lymphocyte subpopulations. METHODS In total, 29 people [10 controls (age range 59-85 years) and 19 patients (age range 47-89 years) with various chronic non-malignant pain conditions] were enrolled in the study. MOR mRNA levels were evaluated in peripheral lymphocytes, and lymphocyte subsets were determined by direct immunofluorescence using flow cytometry. RESULTS After 12 months of treatment with intrathecal morphine (1.5-4 mg/day), there was an increase in MOR mRNA levels in lymphocytes of 65% compared with controls and 47% with pretreatment values. Even higher levels (increase of 142% compared with controls and 135% with pretreatment values) were observed in the patients treated with morphine plus bupivacaine (0.2-0.4 mg/day). Elevation of MOR mRNA levels was confirmed in patients after 24 months of treatment. At this time point, the percentage of natural killer cells was significantly decreased. CONCLUSION This preliminary study suggests that opioids must be used with care in patients who are already immunosuppressed by disease or by other, concurrently administered drugs.
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Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010; 2010:CD006605. [PMID: 20091598 PMCID: PMC6494200 DOI: 10.1002/14651858.cd006605.pub2] [Citation(s) in RCA: 308] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Opioid therapy for chronic noncancer pain (CNCP) is controversial due to concerns regarding long-term effectiveness and safety, particularly the risk of tolerance, dependence, or abuse. OBJECTIVES To assess safety, efficacy, and effectiveness of opioids taken long-term for CNCP. SEARCH STRATEGY We searched 10 bibliographic databases up to May 2009. SELECTION CRITERIA We searched for studies that: collected efficacy data on participants after at least 6 months of treatment; were full-text articles; did not include redundant data; were prospective; enrolled at least 10 participants; reported data of participants who had CNCP. Randomized controlled trials (RCTs) and pre-post case-series studies were included. DATA COLLECTION AND ANALYSIS Two review authors independently extracted safety and effectiveness data and settled discrepancies by consensus. We used random-effects meta-analysis' to summarize data where appropriate, used the I(2) statistic to quantify heterogeneity, and, where appropriate, explored heterogeneity using meta-regression. Several sensitivity analyses were performed to test the robustness of the results. MAIN RESULTS We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Opioids were administered orally (number of study treatments groups [abbreviated as "k"] = 12, n = 3040), transdermally (k = 5, n = 1628), or intrathecally (k = 10, n = 231). Many participants discontinued due to adverse effects (oral: 22.9% [95% confidence interval (CI): 15.3% to 32.8%]; transdermal: 12.1% [95% CI: 4.9% to 27.0%]; intrathecal: 8.9% [95% CI: 4.0% to 26.1%]); or insufficient pain relief (oral: 10.3% [95% CI: 7.6% to 13.9%]; intrathecal: 7.6% [95% CI: 3.7% to 14.8%]; transdermal: 5.8% [95% CI: 4.2% to 7.9%]). Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies. Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies. AUTHORS' CONCLUSIONS Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.
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Affiliation(s)
- Meredith Noble
- ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA, USA, 19462
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Tay W, Ho KY. The Role of Interventional Therapies in Cancer Pain Management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.
Key words: Intractable pain, Intrathecal analgesia, Neurolysis
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Dewilde S, Verdian L, Maclaine GDH. Cost-effectiveness of ziconotide in intrathecal pain management for severe chronic pain patients in the UK. Curr Med Res Opin 2009; 25:2007-19. [PMID: 19563256 DOI: 10.1185/03007990903090849] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the cost-effectiveness of using intrathecal ziconotide in the treatment of severe chronic pain compared to best supportive care for patients with intractable chronic pain in the United Kingdom. METHODS Using a simulation model, the analysis evaluated the cost and health economic consequences of using ziconotide as a treatment for severe chronic pain. The modelled population and clinical data were based on a randomised controlled trial in which the main outcome was reduction in pain as measured by the visual analogue scale of pain intensity (VASPI). Resource use data were elicited using a modified Delphi panel and costed using published sources. Utility values were derived from a separate research study. The main outcome measure was the cost per quality-adjusted life-year (QALY). Extensive scenario analysis was conducted to evaluate parameter uncertainty. RESULTS Overall, findings were robust to most assumptions. The cost-effectiveness of ziconotide compared to best supportive care (BSC) was pound 27,443 per QALY (95% CI pound 18,304-38,504). Scenarios were investigated in which discount rates, the time horizon, the threshold for qualifying as a responder, pump-related assumptions, utilities, ziconotide drug dose, and the patient discontinuation rate with ziconotide were varied. The most sensitive parameter was the dosage of ziconotide: using the lower and upper bounds of the average ziconotide dosage observed in the long-term open-label study changed the incremental cost-effectiveness ratio (ICER) to pound 15,500 [pound 8206-25,405] and pound 44,700 [pound 30,541-62, 670]. CONCLUSIONS Ziconotide may offer an economically feasible alternative solution for patients for whom current treatment is inappropriate or ineffective. The main study limitation is that some model inputs, mainly related to resource use, are based on assumptions or expert interviews.
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Affiliation(s)
- S Dewilde
- Services in Health Economics, 1000 Brussels, Belgium.
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Kumar K, Bodani V, Bishop S, Tracey S. Use of Intrathecal Bupivacaine in Refractory Chronic Nonmalignant Pain. PAIN MEDICINE 2009; 10:819-28. [DOI: 10.1111/j.1526-4637.2009.00640.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Reig E, Abejón D. Continuous Morphine Infusion: A Retrospective Study of Efficacy, Safety, and Demographic Variables. Neuromodulation 2009; 12:122-9. [DOI: 10.1111/j.1525-1403.2009.00206.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Seo KS, Han KR, Kim SY, Park KE, Kim C. Implantable Intrathecal Drug Delivery Pump in Complex Regional Pain Syndrome Patient -A case report-. Korean J Pain 2009. [DOI: 10.3344/kjp.2009.22.1.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Kyung Soo Seo
- Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Kyung Ream Han
- Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Sae Young Kim
- Pain Clinic, CHA General Hospital, College of Medicine, Pochon CHA University, Seongnam, Korea
| | - Kyeong Eon Park
- Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Chan Kim
- Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
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Abstract
Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Bianchi F, Ginggen A, Tardy Y. Stability and compatibility of drug mixtures in an implantable infusion system. Anaesthesia 2008; 63:972-8. [DOI: 10.1111/j.1365-2044.2008.05516.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ghafoor VL, Epshteyn M, Carlson GH, Terhaar DM, Charry O, Phelps PK. Intrathecal drug therapy for long-term pain management. Am J Health Syst Pharm 2008; 64:2447-61. [PMID: 18029950 DOI: 10.2146/ajhp060204] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use, safety, and efficacy of intrathecal medication administration with implantable pumps for cancer and chronic pain management are reviewed. SUMMARY Implanted intrathecal drug-delivery systems (IDDSs) are used for long-term management of persistent, severe pain despite a multimodal approach with conventional pain treatment options. Currently, consensus papers published in the literature are used as guidelines for determining patient selection and medication administration, because there is a lack of supporting evidence from randomized, controlled, clinical trials. Pharmacists have a critical role in the safe use of intrathecal medication. Most of the medication concentrations and combinations administered through IDDSs are not commercially available and therefore must be compounded in a pharmacy. Medications commonly administered through IDDSs include opioids, local anesthetics, clonidine, baclofen, and ziconotide. It is important for pharmacists who prepare products for IDDSs to understand the pharmacology, adverse effects, and concentration limitations of each medication in order to prevent adverse events related to postoperative subarachnoid hemorrhage, infection, catheter-tip inflammatory masses, withdrawal, and overdose. Pharmacists play an important role in maintaining quality assurance of intrathecal drug use, including the use of standard procedures for ordering and compounding medications, documentation of patient education, and monitoring of patient outcomes. CONCLUSION The use of long-term intrathecal drug delivery for the treatment of intractable pain or intolerable medication adverse effects has expanded to include the treatment of patients with chronic or cancer-related pain. Important considerations for the use of intrathecal drug therapy include the appropriate selection of patients, delivery systems, and medications, as well as potential complications of therapy and quality-assurance measures necessary to ensure patient safety.
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Affiliation(s)
- Virginia L Ghafoor
- Pain Management, Pharmacy Department, University of Minnesota Medical Center (UMMC), Minneapolis 55454, USA.
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Raffaeli W, Righetti D, Caminiti A, Ingardia A, Balestri M, Pambianco L, Fanelli G, Facondini F, Pantazopoulos P. Implantable Intrathecal Pumps for the Treatment of Noncancer Chronic Pain in Elderly Population: Drug Dose and Clinical Efficacy. Neuromodulation 2007; 11:33-9. [DOI: 10.1111/j.1525-1403.2007.00140.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Since the first use of intrathecal (IT) drug infusion systems in the early 1980s, these delivery systems have undergone numerous revisions making them more tolerable, easier to program, and longer lasting. Concurrent with technological advances, the indications for IT pump placement have also been continuously evolving, to the point where the most common indication is now noncancer pain. This article provides an evidence-based review of the indications, efficacy, and complications of IT drug therapy for the most commonly administered spinal analgesics.
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Affiliation(s)
- Steven P Cohen
- Pain Management Division, Department of Anesthesiology, Johns Hopkins School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA.
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Shaladi A, Saltari MR, Piva B, Crestani F, Tartari S, Pinato P, Micheletto G, Dall'Ara R. Continuous Intrathecal Morphine Infusion in Patients With Vertebral Fractures Due to Osteoporosis. Clin J Pain 2007; 23:511-7. [PMID: 17575491 DOI: 10.1097/ajp.0b013e31806a23d4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QOL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side effects. Continuous intrathecal administration of morphine via an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QOL when compared with conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures. MATERIALS AND METHODS In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QOL, we administered the visual analog scale for pain and the Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side effects and responses to intrathecal therapy. RESULTS Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as quality of daily life, domestic work, ambulation, and perception of health status, before and after 1 year after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28 mg/d, 7.92 mg/d at pump implantation, and 16.32 mg/d at 1-year follow-up. CONCLUSIONS Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QOL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side effects with systemic administration of analgesics.
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Affiliation(s)
- Alì Shaladi
- Pain Unit and Palliative Care, S. Maria Misericordia Hospital, Rovigo, Italy
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Koulousakis A, Kuchta J, Bayarassou A, Sturm V. Intrathecal opioids for intractable pain syndromes. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:43-8. [PMID: 17691355 DOI: 10.1007/978-3-211-33079-1_5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
For more than 20 years intrathecal opioid application with implantable pumps is an option for selected patients with malignant as well as non-malignant pain. In general, most types of pain should be treatable by opioid medication. However, the associated systemic side-effects such as nausea, vomiting, constipation or the risk of suppression of the central nervous system hinder the application of oral or intravenous opioid therapy as a sole, widely applicable treatment. Causes of non-malignant pain that may represent an indication for intrathecal drug-delivery systems include: failed back syndrome, neuropathic pain, axial spinal pain, complex regional pain syndrome, diffuse pain, brachial plexitis, central pain, failed spinal cord stimulation (SCS) therapy, arachnoiditis, poststroke pain, spinal cord injury pain and peripheral neuropathy. Due to the proximity to the receptor sites, the therapeutic effect of intrathecal drug application lasts longer and the rate of systemic side effects is reduced. Before definitive pump implantation, the therapeutic effect of intrathecal opioid therapy is tested with an external pump. If there is no clear and satisfactory effect in this trial application, pump implantation is not indicated. In our patients, with a follow-up exceeding 3 years, the reduction of non-malignant pain (assessed with the Visual Analogue Scale, VAS) was good or excellent (pain decrease >50%) in 71.3% of the patients, fair (VAS 5-6) in 19.8% and poor (VAS 7-10) in 8.9%. After 3 years of continuous treatment, we observed catheter-related technical problems (catheter dislocation, obstruction, kinking, disconnection or rupture) in 17 of 165 patients. Pump malfunctions were very rare (8 of 165 cases) and limited to older pump types. Reversible, specific drug-related side effects of long-term therapy with intrathecal pumps developed in 32 of the 165 patients. In our series, the mean serum/cerebrospinal fluid (CSF) concentration ratio for morphine was 1/3000, which explains the low rate of systemic side effects. Local diffusion difficulties in CSF cause an uneven distribution of morphine in CSF. Therefore the clinical effect is markedly influenced by the position of the catheter tip, a fact that should be kept in mind during catheter implantation. Intrathecal drug application is cost effective and can significantly improve the quality of life in selected patients. An intensive training in this method and awareness of its specific complications is necessary for everyone to participate in the consulting and implanting team. Pumps for chronic intrathecal opioid application should only be implanted in specialized centers.
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Affiliation(s)
- A Koulousakis
- Department of Neurosurgery, Cologne University, Cologne, Germany
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Saltari MR, Shaladi A, Piva B, Gilli G, Tartari S, Dall'Ara R, Bevilacqua M, Micheletto G. The Management of Pain From Collapse of Osteoporotic Vertebrae With Continuous Intrathecal Morphine Infusion. Neuromodulation 2007; 10:167-76. [DOI: 10.1111/j.1525-1403.2007.00106.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Abstract
Since the first use of intrathecal (IT) drug infusion systems in the early 1980s, these delivery systems have undergone numerous revisions making them more tolerable, easier to program, and longer lasting. Concurrent with technological advances, the indications for IT pump placement have also been continuously evolving, to the point where the most common indication is now noncancer pain. This article provides an evidence-based review of the indications, efficacy, and complications of IT drug therapy for the most commonly administered spinal analgesics.
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Affiliation(s)
- Steven P Cohen
- Pain Management Division, Department of Anesthesiology, Johns Hopkins School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA.
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47
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Turner JA, Sears JM, Loeser JD. Programmable intrathecal opioid delivery systems for chronic noncancer pain: a systematic review of effectiveness and complications. Clin J Pain 2007; 23:180-95. [PMID: 17237668 DOI: 10.1097/01.ajp.0000210955.93878.44] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We conducted a systematic review of the literature on the effectiveness and complications of programmable intrathecal opioid and ziconotide drug delivery systems (IDDS) for patients with chronic noncancer pain. METHODS We searched MEDLINE, Cochrane, and other bibliographic databases to identify English-language journal articles reporting programmable IDDS complications or effects on pain or functioning. Additional study methodology criteria were applied for the effectiveness review. Two authors independently abstracted data from each included article. RESULTS Six articles met the inclusion criteria for the effectiveness and complications reviews, and 4 others met the criteria only for the complications review; none were randomized trials or of ziconotide. All 6 articles reviewed for effectiveness reported improvement in pain and functioning on average among patients who received a permanent IDDS. Two articles reported the proportion of patients with > or =50% improvement in pain at 6 months (38%, 56%) and 2 at longer follow-ups (30%, 44%). Intrathecal morphine-equivalent doses increased over time. The most commonly reported permanent IDDS drug side effects were nausea/vomiting (mean rate weighted by sample size=33%), urinary retention (24%), and pruritus (26%). Catheter problems were also reported commonly. Rare but serious complications included intrathecal catheter tip granulomas. CONCLUSIONS The studies reviewed found improvement in pain and functioning on average among patients with chronic noncancer pain who received permanent IDDS. However, their methodologic limitations preclude conclusions concerning the effectiveness of this technology long-term and as compared with other treatments. Drug side effects and hardware complications were common. Suggestions are made for methodologic improvements in future studies.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
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Failed Back Surgery Syndrome. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50093-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Lou L, Orbegozo M, King CL. Rationale and technique for single and multiple drug combinations in long-term intrathecal infusions. Pain Pract 2006; 1:68-78; quiz 79-80. [PMID: 17129286 DOI: 10.1046/j.1533-2500.2001.01010.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- L Lou
- International Pain Institute, Texas Tech University Health Sciences Center, Lubbock, Texas 79413, USA
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Raffaeli W, Andruccioli J, Righetti D, Caminiti A, Balestri M. Intraspinal Therapy for the Treatment of Chronic Pain: A Review of the Literature Between 1990 and 2005 and Suggested Protocol for Its Rational and Safe Use. Neuromodulation 2006; 9:290-308. [DOI: 10.1111/j.1525-1403.2006.00071.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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