1
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Díaz-Rodríguez D, Fontán-Atalaya IM, Peralta-Espinosa E, Fernández-Torres B. Differences in efficacy and safety between intrathecal infusion devices in cancer pain. Pain Pract 2024; 24:42-51. [PMID: 37493072 DOI: 10.1111/papr.13279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Intrathecal infusion therapy is widely accepted for cancer pain patients when conventional analgesic treatments are not sufficient. There are different types of devices for carrying out this therapy: partially externalized devices (PED), used when life expectancy is under 3 months, and totally implanted devices (TID), when it is larger. Our objective is to compare the efficacy, functionality, and complication rate in both types. METHODS We included 132 patients with mild-severe cancer pain, treated with intrathecal infusion therapy by fixed flow devices, PED, or TID, during the study time. Demographic, physical oncologic, and pain control data of the patients were recorded prior to starting therapy and at months 1, 3, and 6. Functionality status and complications were also collected from the patient's medical records and clinical files. RESULTS Pain control improved after starting therapy, with an overall reduction of 4.75 points in VAS score at 1 month in the both groups, without significant differences between them, keeping it at 3 months and 6. 33.3% of the patients developed complications and were more frequent in the PED group, being catheter dislocation the most common. Patients with TID required more often hospital admission to solve the complication. CONCLUSIONS Intrathecal infusion therapy has been shown to be a very effective and safe therapy for the treatment of moderate to severe oncologic pain. There are no significant differences between PED and TID in terms of degree of pain control, therapeutic success, efficacy on episodic or nocturnal pain, or the presence of serious complications.
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Affiliation(s)
- Diego Díaz-Rodríguez
- Anesthesiology and Reanimation, Pain Unit, Complejo Hospitalario Universitario, A Coruña, Spain
| | | | | | - Bartolomé Fernández-Torres
- Anesthesiology and Reanimation, Hospital Universitario Virgen Macarena, Seville, Spain
- Department of Surgery, Faculty of Medicine, University of Seville, Seville, Spain
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2
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Hsieh YL, Chen HY, Lin CR, Wang CF. Efficacy of epidural analgesia for intractable cancer pain: A systematic review. Pain Pract 2023; 23:956-969. [PMID: 37455298 DOI: 10.1111/papr.13273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Epidural analgesia is a common technique for managing perioperative and obstetric pain. Patients with cancer who cannot tolerate opioids or not responding to conventional treatment may benefit from epidural analgesia. Therefore, this systematic review aimed to analyze the efficacy and safety of epidural analgesia in patients with intractable cancer pain. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify studies on patients with cancer who received epidural analgesia. We assessed the quality of all included studies using the risk-of-bias tool or Newcastle-Ottawa scale. The primary outcome was pain relief after epidural analgesia, and the secondary outcome was quality of life, analgesic consumption, and adverse events. The studies were grouped based on the medications used for epidural analgesia. A descriptive synthesis was performed following the Synthesis Without Meta-analysis reporting guideline. RESULTS Our systematic review included nine randomized controlled trials (n = 340) and 15 observational studies (n = 926). Two randomized controlled trials suggested that epidural opioids were not superior to systemic opioids in relieving pain. Epidural opioids combined with local anesthetics or adjuvants, including calcitonin, clonidine, ketamine, neostigmine, methadone, and dexamethasone, offered better analgesic effects. No significant difference in pain relief between an intermittent bolus and a continuous infusion of epidural morphine was observed. Epidural opioids had more analgesic effects on nociceptive pain than neuropathic pain. The methods used to evaluate the quality of life and the corresponding results were heterogeneous among studies. Six observational studies demonstrated that some patients could have decreased opioid consumption after epidural analgesia. Adverse events, including complications and drug-related side effects, were reported in 23 studies. Five serious complications, such as epidural abscess and hematoma, required surgical management. The heterogeneity and methodological limitations of the studies hindered meta-analysis and evidence-level determination. CONCLUSION Coadministration of epidural opioids, local anesthetics, and adjuvants may provide better pain relief for intractable cancer pain. However, we must assess the patients to ensure that the benefits outweigh the risks before epidural analgesia. Therefore, further high-quality studies are required.
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Affiliation(s)
- Yu-Lien Hsieh
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Yu Chen
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Ren Lin
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Fei Wang
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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3
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Thepsuwan A, Tontisirin N, Euasobhon P, Pannangpetch P, Leerapan B, Pattanaprateep O, Cohen SP. Cost-Effectiveness and Cost-Utility Analyses in Thailand of Continuous Intrathecal Morphine Infusion Compared with Conventional Therapy in Cancer Pain: A 10-year Multicenter Retrospective Study. Can J Pain 2023; 7:2225564. [PMID: 37533506 PMCID: PMC10392764 DOI: 10.1080/24740527.2023.2225564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023]
Abstract
Background Because of the high initial cost of intrathecal drug delivery (ITDD) therapy, this study investigated the cost-effectiveness and cost-utility of ITDD therapy in refractory cancer pain management in Thailand over the past 10 years. Methods The retrospective study was conducted in patients with cancer pain who underwent ITDD therapy from January 2011 to 2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale, and the EQ-5D. The direct medical and nonmedical as well as indirect costs were also recorded. Cost-effectiveness and cost-utility analyses were performed comparing ITDD therapy with conventional therapy (extrapolated from costs of the same patient before ITDD therapy) from a societally oriented economic evaluation. Results Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT port; n = 15) or programmable intrathecal pump (IT pump; n = 5) were included. The median survival time was 78 (interquartile range = 121-54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/pain reduction of an IT port (US$2065.36 (CA$2829.54)/2-point NRS reduction/lifetime) was lower than for patients with an IT pump (US$5479.26 (CA$7506.58)/2-point NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALYs) gained for an IT port compared with conventional treatment was US$93,999.31(CA$128,799.06)/QALY gained, which is above the cost-effectiveness threshold for Thailand. Conclusion The cost-effectiveness and cost-utility of IT port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD therapy with devices over a range of prices are warranted.
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Affiliation(s)
- Arpawan Thepsuwan
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nuj Tontisirin
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pramote Euasobhon
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patt Pannangpetch
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Borwornsom Leerapan
- Chakri Naruebodindra Medical Institute, Mahidol University, Samut Prakan, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Steven P. Cohen
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Departments of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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4
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Whitaker CD, Stone BK, Gregorczyk JA, Alsoof D, Hardacker K, Diebo BG, Daniels A, Basques B. Nonsurgical Interventional Spine Pain Procedures: Outcomes and Complications. JBJS Rev 2023; 11:01874474-202304000-00003. [PMID: 37058581 DOI: 10.2106/jbjs.rvw.22.00235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. » Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. » Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. » Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. » Medial branch blocks and facet joint injections were found to be useful diagnostic tools.
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Affiliation(s)
- Colin D Whitaker
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Benjamin K Stone
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kyle Hardacker
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bryce Basques
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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5
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Nursey F, Gillett K. Intrathecal drug delivery for cancer pain at the end of life: a case study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S16-S22. [PMID: 36913330 DOI: 10.12968/bjon.2023.32.5.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Two-thirds of patients with advanced cancer have pain and, of these, approximately 10-20% do not respond to conventional pain management approaches. This case study concerns a hospice patient who received intrathecal drug delivery for intractable cancer pain at the end of life. This involved working in partnership with a hospital-based interventional pain team. Despite side-effects and complications associated with intrathecal drug delivery and the requirement for inpatient nursing care, intrathecal drug delivery was the best option for the patient. The case identifies the importance of a patient-centred approach to decision-making, effective partnerships between hospice and acute hospital teams, and nurse education as key factors contributing to the provision of safe and effective intrathecal drug delivery.
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6
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Giglio M, Preziosa A, Mele R, Brienza N, Grasso S, Puntillo F. Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study. Cancer Control 2022; 29:10732748221133752. [PMID: 36281899 PMCID: PMC9607974 DOI: 10.1177/10732748221133752] [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: 11/16/2022] Open
Abstract
BACKGROUND In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain. METHODS Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC). RESULTS Fifty patients, (16 F/34 M) were enrolled (age 69 ± 12). All had advanced cancer with metastasis. The median daily VASPI score was 75, the median depression score was 6, and the median anxiety score was 4, median PSQI was 16. At 28 days, a significant reduction in VASPI score was registered as well as in depression and anxiety item. Also, PSQI decreased significantly. The EQ-5D-5 L showed a significant improvement in all components at 14 and 28 days. Patient Global Impression of Change scores showed high level of satisfaction. A low incidence of adverse events and a reduction in BTCP episodes were also registered. CONCLUSION Intrathecal combination therapy delivered by an IDDS-SP could ensure adequate control of cancer related symptoms, such as pain, depression, anxiety and sleep disturbances. These effects, with low rate of AEs and reduced BTcP episodes, could explain the improvement in QoL and the overall high levels of patients' satisfaction.
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Affiliation(s)
- Mariateresa Giglio
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Angela Preziosa
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Roberta Mele
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro”, Bari, Italy
| | - Filomena Puntillo
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy,Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy,Filomena Puntillo, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”. Anaesthesia, Intensive Care and Pain Unit, Piazza G. Cesare 11, 70124 Bari, Italy.
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7
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Perruchoud C, Dupoiron D, Papi B, Calabrese A, Brogan SE. Management of Cancer-Related Pain With Intrathecal Drug Delivery: A Systematic Review and Meta-Analysis of Clinical Studies. Neuromodulation 2022:S1094-7159(21)06969-5. [PMID: 35088743 DOI: 10.1016/j.neurom.2021.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite increased attention paid to assessment and management, pain continues to be a prevalent and undertreated symptom in patients with cancer. Intrathecal drug delivery (IDD) is a therapeutic option that allows targeted delivery of analgesics to the intrathecal space. OBJECTIVE The aim of this review was to examine the efficacy of managing cancer-related pain with IDD. Secondary objectives included the effects of IDD on systemic opioid use and infection rates. EVIDENCE REVIEW A systematic search of the literature published between 1990 and 2019 was performed to identify studies evaluating the efficacy and/or safety of IDD with external or implanted pumps in patients with cancer-related pain. Data were extracted and meta-analyses performed to determine the mean changes in pain levels at short-, mid-, and long-term intervals; changes in opioid (oral morphine equivalent [OME]) daily dose; and infection rates. Changes were assessed compared with baseline. FINDINGS Pain levels were decreased from baseline: On a 0 to 10 scale, mean differences were -4.34 (95% CI [-4.93 to -3.75], p < 0.001) at 4 to 5 weeks; -4.34 (95% CI [-5.07 to -3.62], p < 0.001) at 6 to 12 weeks; and -3.32 (95% CI [-4.60 to -2.04], p < 0.001) at >6 months. Weighted mean OME consumption was reduced by 308.24 (SE = 22.72) mg/d. Weighted mean infection rates were ∼3% for external and implanted pumps. CONCLUSIONS Meta-analyses show a statistically significant and sustained decrease in cancer pain with IDD, compared with baseline. Systemic opioid consumption was reduced on average by >50% after IDD. Infection rates were comparable with other indications.
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8
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Chou CZ, Hopkins TJ, Badiola I, Gazelka HM, Gohil S, Kitt A, Luke WR, Vaughan CL, Jones CA, Varhabhatla N. Top Ten Tips Palliative Care Clinicians Should Know About Interventional Pain and Procedures. J Palliat Med 2020; 23:1386-1391. [PMID: 32865443 DOI: 10.1089/jpm.2020.0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pain is a common symptom for patients with advanced illness. Palliative care (PC) clinicians are experts in pharmacologic and nonpharmacologic treatment of pain and other symptoms for these patients. True multimodal pain control should include consideration of interventional procedures and pumps to improve difficult-to-manage pain. This article, written by clinicians with expertise in interventional pain and PC, outlines and explains many of the adjunctive and interventional therapies that can be considered for patients with pain in the setting of serious illness. Only by understanding and considering all available options can we ensure that our patients are receiving optimal care.
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Affiliation(s)
- Claudia Z Chou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J Hopkins
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | - Ignacio Badiola
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharmil Gohil
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arthur Kitt
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Whitney R Luke
- Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christina L Vaughan
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher A Jones
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Narayana Varhabhatla
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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9
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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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10
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Chen GH, Spiegel MA, Magram YC, Baig E, Clement K, Laufer I, Gulati A. Evaluation of Fixed Intrathecal Bupivacaine Infusion Doses in the Oncologic Population. Neuromodulation 2020; 23:984-990. [PMID: 32343025 DOI: 10.1111/ner.13161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/12/2020] [Accepted: 03/30/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Intrathecal drug delivery systems (IDDS) are an important method of pain control for patients with refractory oncologic pain. Local anesthetics such as bupivacaine have been infused either alone or with opioids. While effective, bupivacaine can cause adverse effects such as numbness, weakness, and urinary retention. This study looks to establish a safe and efficacious fixed bupivacaine dosing algorithm in intrathecal pumps for cancer patients. MATERIALS AND METHODS A bupivacaine dosing algorithm was developed using data from 120 previous patients who underwent IDDS placement at Memorial Sloan Kettering Cancer Center. The outcomes were then evaluated for 43 subsequent patients who were treated with bupivacaine IDDS according to our aforementioned algorithm. RESULTS Our data show that in patients treated with our bupivacaine guideline, visual analog pain scale scores decreased by 59% and oral morphine equivalence decreased by 70% from the period between IDDS implantation until discharge from the MSKCC hospital. However, 16.3% of our patients had bupivacaine-related side effects. CONCLUSIONS For oncological patients, our data and experience support the initiation of intrathecal bupivacaine at the following doses: 5 mg/day for catheter tips in the cervical spine, 8 mg/day for catheter tips at T1-4, and 10 mg/day for catheter tips at T5-8. Given the higher likelihood of adverse effects in catheters at T9-12 and the lumbar spine, we start at 8 mg/day with close follow-up of the patient. Initiating these doses allow our patients to safely reach adequate analgesia faster, with a shorter hospitalization and quicker return to anti-cancer therapy.
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Affiliation(s)
- Grant H Chen
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew A Spiegel
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Yan C Magram
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Ehtesham Baig
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Keith Clement
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ilya Laufer
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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11
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Abstract
This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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12
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Dupoiron D, Leblanc D, Demelliez-Merceron S, Bore F, Seegers V, Dubois PY, Pechard M, Robard S, Delorme T, Jubier-Hamon S, Carvajal G, Lebrec N. Optimizing Initial Intrathecal Drug Ratio for Refractory Cancer-Related Pain for Early Pain Relief. A Retrospective Monocentric Study. PAIN MEDICINE 2019; 20:2033-2042. [DOI: 10.1093/pm/pnz096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Objective
Intrathecal (IT) drug delivery has shown its efficiency in treating refractory cancer pain, but switching opioids from the systemic to the intrathecal route is a challenging phase. Moreover, associations are widely used and recommended. Few data deal with the initial dosage of each drug. Analyzing conversion factors and initial dosages used in intrathecal therapy seems essential to decreasing the length of titration and to delivering quick pain relief to patients.
Methods
We retrospectively analyzed data from consecutive adult patients implanted with an intrathecal device for cancer pain and treated at the Institut de Cancérologie de l’Ouest, in Angers, France, for four years. The main goal was to identify factors associated with early pain relief after intrathecal drug delivery system (IDDS) implantation.
Results
Of the 220 IDDS-treated patients, 70 (32%) experienced early pain relief (EaPR) and 150 (68%) delayed pain relief (DePR). Performance Status stage and initial IT ropivacaine:IT morphine ratio were the variables independently associated with EaPR. The best IT ropivacaine:IT morphine ratio to predict EaPR was 5:1, with a 73% (95% confidence interval [CI] = 64.8% to 79.6%) sensitivity and a 67.1% (95% CI = 54.9% to 77.9%) specificity. EaPR subjects experienced better pain relief (–84% vs –60% from baseline pain score, P < 0.0001), shorter length of hospitalization (7 vs 10 days, P < 0.0001), and longer survival (155 vs 82 days, P = 0.004).
Conclusions
Local anesthetic:morphine ratio should be considered when starting IDDS treatment. EaPR during the IT analgesia titration phase was associated with better pain relief and outcomes in patients with refractory cancer-related pain.
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Affiliation(s)
- Denis Dupoiron
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Damien Leblanc
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | | | - Francois Bore
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Valerie Seegers
- Research and Statistics Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Pierre Yves Dubois
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Marie Pechard
- Anesthesiology and Pain Department, Institut Curie, Paris, France
| | - Serge Robard
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest R. Gauducheau, St Herblain, France
| | - Thierry Delorme
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Sabrina Jubier-Hamon
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Gabriel Carvajal
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Nathalie Lebrec
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
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13
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Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations. Scand J Pain 2017; 17:150-151. [PMID: 28950244 DOI: 10.1016/j.sjpain.2017.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Breivik H, Stubhaug A. Cancer-pain intractable to high-doses systemic opioids can be relieved by intraspinal local anaesthetic plus an opioid and an alfa 2-adrenoceptor agonist. Scand J Pain 2017; 16:158-159. [PMID: 28850396 DOI: 10.1016/j.sjpain.2017.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Harald Breivik
- Department of Pain Management and Research, Oslo University Hospital, Norway; Department of Anaesthesiology, Oslo University Hospital, Norway; University of Oslo, Faculty of Medicine, Oslo, Norway.
| | - Audun Stubhaug
- Department of Pain Management and Research, Oslo University Hospital, Norway; University of Oslo, Faculty of Medicine, Oslo, Norway
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