Citation

Saulino M, Kim PS, Shaw E. J. Pain Res. 2014; 7: 627-638.

Copyright

(Copyright © 2014, Dove Press)

DOI

10.2147/JPR.S65441

PMID

unavailable

Abstract

Chronic pain continues to pose substantial and growing challenges for patients, caregivers, health care professionals, and health care systems. By the time a patient with severe refractory pain sees a pain specialist for evaluation and management, that patient has likely tried and failed several nonpharmacologic and pharmacologic approaches to pain treatment. Although relegated to one of the interventions of "last resort", intrathecal drug delivery can be useful for improving pain control, optimizing patient functionality, and minimizing the use of systemic pain medications in appropriately selected patients. Due to its clinical and logistical requirements, however, intrathecal drug delivery may fit poorly into the classic pain clinic/interventional model and may be perceived as a "critical mass" intervention that is feasible only for large practices that have specialized staff and appropriate office resources. Potentially, intrathecal drug delivery may be more readily adopted into larger practices that can commit the necessary staff and resources to support patients' needs through the trialing, initiation, monitoring, maintenance, and troubleshooting phases of this therapy. Currently, two agents - morphine and ziconotide - are approved by the United States Food and Drug Administration for long-term intrathecal delivery. The efficacy and safety profiles of morphine have been assessed in long-term, open-label, and retrospective studies of >400 patients with chronic cancer and noncancer pain types. The efficacy and safety profiles of ziconotide have been assessed in three double-blind, placebo-controlled trials of 457 patients, and safety has been assessed in 1,254 patients overall, with severe chronic cancer, noncancer, and acquired immunodeficiency syndrome pain types. Both agents are highlighted as first-line intrathecal therapy for the management of neuropathic or nociceptive pain. The purpose of this review is to discuss practical considerations for intrathecal drug delivery, delineate criteria for the identification and selection of candidates for intrathecal drug delivery, and consider which agent may be more appropriate for individual patients. © 2014 Saulino et al.

Language: en

Keywords

human; Review; decision making; Chronic pain; suicidal ideation; depression; psychosis; chronic pain; helplessness; suicide attempt; medical error; cognitive defect; dose calculation; health care access; headache; somnolence; patient referral; opiate; morphine; myoclonus; urine retention; practice guideline; confusion; drug safety; drug efficacy; drug tolerability; nausea; cost effectiveness analysis; hypotension; patient satisfaction; lung disease; side effect; withdrawal syndrome; morphine sulfate; analgesia; cancer pain; drug approval; drug contraindication; nystagmus; nausea and vomiting; respiration depression; drug indication; patient selection; nervousness; infection risk; baclofen; monotherapy; diplopia; dizziness; fluid retention; reimbursement; hypogonadism; consciousness disorder; bacterial infection; speech disorder; medical history; drug substitution; bupivacaine; hyperalgesia; gait disorder; Intrathecal; meningitis; omega conotoxin MVIIA; peripheral edema; catheter infection; drug delivery system; sleep disordered breathing; granuloma; medical device complication; catheter; catheter complication; catheter leakage; catheter migration; catheter tip granuloma; Drug delivery; inappropriate prescribing; intrathecal drug delivery; Patient selection; Polyanalgesic Consensus Conference; programming error; pump; transient spinal headache