Neuromodulation : journal of the International Neuromodulation Society
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There is a need to develop alternative agents for intrathecal pain therapy for patients who either cannot tolerate the side effects of or who no longer obtain sufficient analgesia with opioids. The experimental use of several compounds in intrathecal drug delivery is currently in progress, with the development of clonidine as the single most important advance in the improvement of pain treatment. ⋯ Other possible effective agents for intrathecal delivery include bupivacaine, octreotide, and SNX-111. The preclinical and clinical profiles for these promising new intrathecal pain medications are discussed.
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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. ⋯ 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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Although opioid therapy has been accepted for the treatment of patients with cancer pain, its use for nonmalignant pain is still regarded as controversial due to concerns about the development of tolerance and psychological dependence. However, recent studies indicate that there is a low incidence of addiction in patients who do not have a history of addictive disorders, and opioid use is increasing for long-term treatment in patients with nonmalignant pain. ⋯ These studies demonstrate that intrathecal opioid delivery produces short-term relief of specific symptoms and improves long-term outcomes such as patient functioning (measured by increases in activities of daily living [ADLs] and capacity to work), mood, treatment satisfaction, and quality of life, as well as decreases in oral opioid use. Furthermore, these studies showed there was no development of tolerance or addiction in patients who received long-term intrathecal opioid delivery.
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Successful management of chronic cancer and nonmalignant pain remains a challenge to clinicians, and cost effectiveness is an important consideration for clinical decision making. Although the oral route was previously considered the optimal method of chronic opioid administration, emerging evidence demonstrates a therapeutic advantage to intrathecal opioid delivery compared to alternative modalities. ⋯ Although the initial costs of surgical implantation of an intrathecal pump appear to be substantial, maintenance costs of intrathecal drug delivery over time are significantly lower than other routes of administration, including oral and intravenous drug delivery. Cost analyses of alternate routes of opioid administration indicate that intrathecal delivery is the most cost-effective route of opioid administration for patients who require long-term management of cancer (≥ 3-6 months) or nonmalignant pain (≥ 11-22 months).