Neuraxial (epidural and intrathecal) opioids for intractable pain

Summary Points 1. Neuraxial opioids are considered for use in patients who have resistant intractable pain that fails to respond to other treatment options or pain that responds to analgesia but for which the doses required result in unacceptable side-effects. 2. Neuraxial opiods can be considered for both chronic non-malignant pain and chronic cancer-related pain. 3. Effectiveness in chronic non-malignant pain and cancer pain is exerted through the use of either single-agent drugs (opioids) or a combination of drugs: opioids, local anaesthetics and other drugs such as clonodine and ziconotide. 4. Complications of long-term continuous infusion therapy are related to the insertion process (haematoma), the mechanical device (both pump and catheter) and the long-term effects of the drugs. 5. Patients will require ongoing ambulatory monitoring and supportive care.

[1]  L. Lynch.  Intrathecal drug delivery for cancer pain , 2014 .

[2]  M. Saulino,et al.  Polyanalgesic Consensus Conference 2012: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel , 2012, Neuromodulation : journal of the International Neuromodulation Society.

[3]  S. Kaasa,et al.  Spinal opioids in adult patients with cancer pain: A systematic review: A European Palliative Care Research Collaborative (EPCRC) Opioid Guidelines Project , 2011, Palliative medicine.

[4]  N. Morton,et al.  Best practice in the management of epidural analgesia in the hospital setting , 2010 .

[5]  Z. Merza,et al.  Chronic Use of Opioids and the Endocrine System , 2010, Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme.

[6]  Jeff Myers,et al.  Intraspinal techniques for pain management in cancer patients: a systematic review , 2010, Supportive Care in Cancer.

[7]  C. Rochlitz,et al.  Serious Complications Associated with External Intrathecal Catheters Used in Cancer Pain Patients: A Systematic Review and Meta-analysis , 2009, Anesthesiology.

[8]  S. Hassenbusch,et al.  Polyanalgesic Consensus Conference 2007: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel , 2007, Neuromodulation : journal of the International Neuromodulation Society.

[9]  D. Munday,et al.  Provision for advanced pain management techniques in adult palliative care: a national survey of anaesthetic pain specialists , 2007, Palliative medicine.

[10]  J. Behar,et al.  Anaesthesia: Regional anaesthesia , 2007, BMJ.

[11]  J. Raphael,et al.  Placebo-controlled single blind study of short-term efficacy of spinal morphine in chronic non-malignant pain: 118. , 2006, Regional Anesthesia & Pain Medicine.

[12]  T. Yaksh,et al.  Opiate Pharmacology of Intrathecal Granulomas , 2006, Anesthesiology.

[13]  J. Rathmell,et al.  Infectious Risks of Chronic Pain Treatments: Injection Therapy, Surgical Implants, and Intradiscal Techniques , 2006, Regional Anesthesia & Pain Medicine.

[14]  P. Rawlins,et al.  The diagnosis of intrathecal infusion pump system failure. , 2005, Pain physician.

[15]  P. Staats,et al.  An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug-related toxicity, and possibly better survival compared with comprehensive medical management (CMM). , 2005, Annals of oncology : official journal of the European Society for Medical Oncology.

[16]  P. B. Hanson,et al.  Neuraxial Anesthesia and Low-Molecular-Weight Heparin Prophylaxis in Major Orthopedic Surgery in the Wake of the Latest American Society of Regional Anesthesia Guidelines , 2005, Anesthesia and analgesia.

[17]  K. Simpson,et al.  Nerve Blocks in Palliative Care , 2004 .

[18]  J. Peragut,et al.  Intrathecal Morphine Infusion for Chronic Non‐Malignant Pain: A Multiple Center Retrospective Survey , 2004, Neuromodulation : journal of the International Neuromodulation Society.

[19]  K. Simpson,et al.  Spinal drug delivery , 2004 .

[20]  K. Simpson,et al.  Philosophy behind the use of interventional pain management techniques in palliative care , 2004 .

[21]  D. Dickson.  Risks and benefits of long‐term intrathecal analgesia , 2004, Anaesthesia.

[22]  E. Kravitz,et al.  Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study , 2004, Pain.

[23]  J. Drake,et al.  Prevention and Management of Intrathecal Drug Delivery and Spinal Cord Stimulation System Infections , 2004, Anesthesiology.

[24]  M. Byas-Smith,et al.  Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. , 2004, JAMA.

[25]  P. Peng,et al.  Spinal Cord Compression From Intrathecal Catheter-Tip Inflammatory Mass: Case Report and a Review of Etiology , 2003, Regional anesthesia and pain medicine.

[26]  S. Hassenbusch,et al.  Management of intrathecal catheter-tip inflammatory masses: a consensus statement. , 2002, Pain medicine.

[27]  S. Hassenbusch,et al.  Inflammatory masses associated with intrathecal drug infusion: a review of preclinical evidence and human data. , 2002, Pain medicine.

[28]  R. Wheatley,et al.  Safety and efficacy of postoperative epidural analgesia. , 2001, British journal of anaesthesia.

[29]  S. Chapman,et al.  Spinal anatomy and the use of epidurals. , 2001, Professional nurse.

[30]  M. Kelly,et al.  Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: long-term benefits and efficacy. , 2001, Surgical neurology.

[31]  J. Eisenach,et al.  Spinal anesthesia: Mechanisms, agents, methods, and safety☆ , 1998 .

[32]  T. Horlocker,et al.  Spinal and epidural blockade and perioperative low molecular weight heparin: smooth sailing on the Titanic. , 1998, Anesthesia and analgesia.

[33]  F. Mosteller,et al.  Comparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer. , 2013, The Cochrane database of systematic reviews.

[34]  J. Eisenach,et al.  Epidural clonidine analgesia for intractable cancer pain , 1995, Pain.

[35]  I. Curelaru,et al.  Complications of Intrathecal Opioids and Bupivacaine in the Treatment of “Refractory” Cancer Pain , 1995, The Clinical journal of pain.

[36]  J. Vermylen,et al.  Anticoagulants and Spinal‐Epidural Anesthesia , 1994, Anesthesia and analgesia.

[37]  Harris Lg.  Epidural and intrathecal analgesia. , 1993 .

[38]  J. Neary,et al.  Epidural and intrathecal analgesia in a rural setting. , 1993, AANA journal.

[39]  S. Walker,et al.  Acute Pain Management: Scientific Evidence , 2010 .

[40]  L. Malysh,et al.  Intrathecal infusions for intractable cancer pain: a qualitative study of the impact on a case series of patients and caregivers. , 2009, Pain research & management.

[41]  K. Grady,et al.  Intrathecal drug delivery for the management of pain and spasticity in adults ; recommendations for best clinical practice , 2008 .

[42]  L. Cohen,et al.  Pain and Pain Management , 2008 .

[43]  L. Dougherty,et al.  The Royal Marsden Hospital manual of clinical nursing procedures , 2007 .

[44]  S. Walker,et al.  Acute pain management: scientific evidence, fourth edition, 2015 , 2016, The Medical journal of Australia.

[45]  Kathleen M. Stacy,et al.  Thelan's critical care nursing : diagnosis and management , 2002 .

[46]  Williams Je,et al.  Intrathecal pumps for giving opioids in chronic pain: a systematic review. , 2000, Health technology assessment.

[47]  J. Eisenach,et al.  Epidural clonidine analgesia for intractable cancer pain. The Epidural Clonidine Study Group. , 1995, Pain.