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Abstract
PURPOSE OF REVIEW To provide an overview on drug targets and emerging pharmacological treatment options for chronic pain. RECENT FINDINGS Chronic pain poses an enormous socioeconomic burden for the more than 30% of people who suffer from it, costing over $600 billion per year in the USA. In recent years, there has been a surge in preclinical and clinical research endeavors to try to stem this epidemic. Preclinical studies have identified a wide array of potential targets, with some of the most promising translational research being performed on novel opioid receptors, cannabinoid receptors, selective ion channel blockers, cytokine inhibitors, nerve growth factor inhibitors, N-methyl-D-aspartate receptor antagonists, glial cell inhibitors, and bisphosphonates. SUMMARY There are many obstacles for the development of effective medications to treat chronic pain, including the inherent challenges in identifying pathophysiological mechanisms, the overlap and multiplicity of pain pathways, and off-target adverse effects stemming from the ubiquity of drug target receptor sites and the lack of highly selective receptor ligands. Despite these barriers, the number and diversity of potential therapies have continued to grow, to include disease-modifying and individualized drug treatments.
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Abdolmohammadi S, Hétu PO, Néron A, Blaise G. Efficacy of an intrathecal multidrug infusion for pain control in older adults and in end-stage malignancies: A report of three cases. Pain Res Manag 2015; 20:118-22. [PMID: 25996762 PMCID: PMC4447152 DOI: 10.1155/2015/405630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of the present study was to explore the effectiveness of an alternative method to manage pain based on a time-limited intrathecal (IT) infusion of an analgesic medication mixture. Three patients (69, 64 and 94 years of age) with intractable and poorly controlled pain due to bed sores, pelvic metastatic mass, and thoracic vertebra and rib fractures, respectively, were treated. Daily doses of opioids could not be increased due to side effects. An IT catheter (20 G) was placed by percutaneous approach in the lumbar area while advancing toward the thoracic region, and was then tunnelled and fixed subcutaneously. It was connected to an external infusion pump with a mixture of bupivacaine 1 mg⁄mL, naloxone 0.02 ng⁄mL, ketamine 100 µg⁄mL, morphine 0.01 mg⁄mL and clonidine 0.75 µg⁄mL. The starting rate was 1 mL⁄h. The pain was mostly controlled at a rate of <1 mL⁄h. Opioid consumption was reduced dramatically. The catheter was kept in place for one month in the first and third patients, and for six months in the second patient, until his death. Major side effects, such as hypotension, constipation, muscle weakness, sphincter dysfunction, and cognitive or mood deterioration, were not observed with this approach. One patient experienced a urinary tract infection followed by sepsis and meningitis, which was cured by antibiotics. The catheter was removed in this patient. IT infusion with a low-concentration multidrug mixture could be considered as an alternative modality for intractable pain relief in older adults or in malignancies.
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Affiliation(s)
- Sadegh Abdolmohammadi
- Department of Anesthesiology and Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Pierre-Olivier Hétu
- Department of Biochemistry, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Andrée Néron
- Department of Pharmacy, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Gilbert Blaise
- Department of Anesthesiology and Medicine, Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
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Ver Donck A, Vranken JH, Puylaert M, Hayek S, Mekhail N, Van Zundert J. Intrathecal drug administration in chronic pain syndromes. Pain Pract 2013; 14:461-76. [PMID: 24118774 DOI: 10.1111/papr.12111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 07/29/2013] [Indexed: 01/01/2023]
Abstract
Chronic pain may recur after initial response to strong opioids in both patients with cancer and patients without cancer or therapy may be complicated by intolerable side effects. When minimally invasive interventional pain management techniques also fail to provide satisfactory pain relief, continuous intrathecal analgesic administration may be considered. Only 3 products have been officially approved for long-term intrathecal administration: morphine, baclofen, and ziconotide. The efficacy of intrathecal ziconotide for the management of patients with severe chronic refractory noncancer pain was illustrated in 3 placebo-controlled trials. A randomized study showed this treatment option to be effective over a short follow-up period for patients with pain due to cancer or AIDS. The efficacy of intrathecal opioid administration for the management of chronic noncancer pain is mainly derived from prospective and retrospective noncontrolled trials. The effect of intrathecal morphine administration in patients with pain due to cancer was compared with oral or transdermal treatment in a randomized controlled trial, which found better pain control and fewer side effects with intrathecal opioids. Other evidence is derived from cohort studies. Side effects of chronic intrathecal therapy may either be technical (catheter or pump malfunction) or biological (infection). The most troublesome complication is, however, the possibility of granuloma formation at the catheter tip that may induce neurological damage. Given limited studies, the evidence for intrathecal drug administration in patients suffering from cancer-related pain is more compelling than that of chronic noncancer pain.
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Deer TR, Levy R, Prager J, Buchser E, Burton A, Caraway D, Cousins M, De Andrés J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic Consensus Conference--2012: recommendations to reduce morbidity and mortality in intrathecal drug delivery in the treatment of chronic pain. Neuromodulation 2012; 15:467-82; discussion 482. [PMID: 22849581 DOI: 10.1111/j.1525-1403.2012.00486.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality. METHODS The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems. RESULTS Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy. CONCLUSIONS Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.
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Prochazka J, Hejcl A, Prochazkova L. Intrathecal midazolam as supplementary analgesia for chronic lumbar pain--15 years' experience. PAIN MEDICINE 2012; 12:1309-15. [PMID: 21914117 DOI: 10.1111/j.1526-4637.2011.01218.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The antinociceptive effect of intrathecal midazolam is based on its affecting spinal gamma-amino butyric acid receptors. OBJECTIVE To evaluate pain relief in patients with chronic low back pain and failed back surgery syndrome after a single-shot intrathecal administration of midazolam. DESIGN A prospective, open-label study. OUTCOME MEASURES The analgesic effect was determined using a patient questionnaire during subsequent visits to the pain therapy service. We classified at least a 50% pain reduction with improved quality of life and improved functional condition as a positive outcome. RESULTS Between 1995 and 2010, we performed 500 administrations: 227 administrations in 57 male patients and 273 administrations in 69 female patients. We performed 81 administrations for chronic low back pain and 419 administrations for failed back surgery syndrome. The average age of our patients was 50 years (range 28 to 86). The dose administered ranged from 2 to 5 mg of midazolam. The analgesic effect lasted 9.7 weeks on average, ranging from 1 week to 3 years; the most common reported duration was between 4 and 12 weeks (3 months). In 65% of patients, we achieved pain relief lasting 4 weeks or longer; in 13%, the administration provided no analgesic effect at all. The incidence of side effects (drowsiness, nausea, headache, or transient worsening of complaints) was rather low. CONCLUSION Intrathecal midazolam is a useful supplement to standard analgesic therapy with opioids, non-opioids, or spinal steroids.
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Affiliation(s)
- Jan Prochazka
- Central ICU and Neurosurgical Pain Relief Service, Masaryk Hospital, Usti nad Labem, Czech Republic.
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Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, Caraway D, Cousins M, De Andrés J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic Consensus Conference-2012: Consensus on Diagnosis, Detection, and Treatment of Catheter-Tip Granulomas (Inflammatory Masses). Neuromodulation 2012; 15:483-95; discussion 496. [DOI: 10.1111/j.1525-1403.2012.00449.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Anitescu M, DaSilva AN, Frim DM. Intrapleural migration of a spinal catheter in a patient with arachnoiditis and extensive epidural scarring after tethered cord release: a case report and review of literature. Neuromodulation 2012; 15:200-3; discussion 203. [PMID: 22329419 DOI: 10.1111/j.1525-1403.2011.00423.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to report a case of new onset refractory pain from intrapleural migration of a spinal catheter five months after the implantation of an intrathecal drug delivery system (IDDS). MATERIALS AND METHODS A 57-year-old man had intractable pain because of multiple intradural spinal explorations for tethered cord release. His pain was effectively treated with intrathecal morphine via an IDDS. Five months after the implantation, the patient developed return of the original pain more than two weeks after intrapleural migration of the intrathecal catheter. RESULTS The migration was documented by computed tomography, and repositioning of the catheter rendered the patient comfortable. The gradual onset of pain may have been due to decreasing delivery of drug to the cerebrospinal fluid as the catheter tip migrated further away from the dura. To our knowledge, this complication has not been reported in the literature. CONCLUSION Physicians and nursing staff that place and manage an IDDS should be aware of this complication.
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Affiliation(s)
- Magdalena Anitescu
- Department of Anesthesia and Critical Care, Pain Management, University of Chicago Medical Center, Chicago, Illinois 60637, USA
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Ruan X, Liu H, Couch JP, Wang F, Chiravuri S. Recurrent Cellulitis Associated with Long-Term Intrathecal Opioid Infusion Therapy: A Case Report and Review of the Literature. PAIN MEDICINE 2010; 11:972-6. [DOI: 10.1111/j.1526-4637.2010.00854.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Vissers K, Besse K, Hans G, Devulder J, Morlion B. Opioid Rotation in the Management of Chronic Pain: Where Is the Evidence? Pain Pract 2010; 10:85-93. [DOI: 10.1111/j.1533-2500.2009.00335.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Rauck R, Deer T, Rosen S, Padda G, Barsa J, Dunbar E, Dwarakanath G. Accuracy and efficacy of intrathecal administration of morphine sulfate for treatment of intractable pain using the Prometra® Programmable Pump. Neuromodulation 2009; 13:102-8. [DOI: 10.1111/j.1525-1403.2009.00257.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nocom G, Ho KY, Perumal M. Interventional Management of Chronic Pain. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n2p150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic non-cancer pain is a common clinical condition affecting a significant part of the population. This article aims to review the interventional options for non-cancer pain. Multiple searches using Medline were carried out and additional searches were made using reference lists of published papers and book chapters. The article discussed procedures ranging from selective nerve root or zygapophyseal (facet) joint block with local anaesthetics to irreversible neurodestruction with radiofrequency energy or neurolytic agents and neuromodulation with spinal cord stimulation. Other techniques include intraspinal delivery of analgesics. There is evidence that these interventional procedures are valuable both diagnostically and therapeutically.
Key words: Intrathecal drug delivery, Neuropathic, Spine
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