Intrathecal Drug Delivery

30 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: INTRATHECAL DRUG DELIVERY THERAPIES

Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations. Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies. Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.

The opioid-dependent patient (ODP) not uncommonly presents a significant treatment challenge to physicians. Opioids are increasingly being used for managing both malignant and nonmalignant pain. Opioids are a cost-effective, straightforward therapy for some people with persistent pain, and this property fits well into current pain management practice in many settings. However, because long-term opioid therapy may have declining or adverse effects in some patients, alternative modalities are some-times sought. There exist limitations of long-term opioid therapy alone in some patients, and adopting a multimodal approach to long-term pain management may better address long-term outcomes. This chapter will focus on the use of adjunctive and alternative modalities in the management of chronic nonmalignant pain of patients on chronic opioid therapy with suboptimal out-comes. Of course, many of the management strategies discussed may be employed as well in patients with malignant pain.

Intrathecal delivery of analgesic drugs by implantable pump systems has been recognized as a treatment option for patients with chronic pain of benign or malignant origin that is resistant to oral or parenteral medication. Patients with chronic back and leg pain (CBLP), a benign but severely disabling condition of the lumbar spine with multifactorial genesis, have been demonstrated in a number of retrospective and in some prospective clinical studies to benefit from intrathecal delivery of opioid and/or non-opioid substances, either as single drugs or in combinations. In addition, intrathecal therapy for CBLP has been proven safe and less expensive that conventional medical therapy. This chapter summarizes the clinical and experimental evidence and the personal experience of the authors with long-term intrathecal infusion therapy for CBLP. It discusses important clinical issues such as drug selection, drug combinations, and side effects and complications of intrathecal infusion. It is concluded that further clinical research is needed in order to provide stronger evidence for the usefulness of a number of drugs currently used for intrathecal therapy on a mostly empirical basis.

Case Scenario: Self-extraction of Intrathecal Pump Medication with a Concomitant Intrathecal Granulomatous Mass

The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy

Persistent pain has been defined as pain lasting beyond the normal time of healing (up to six months), often in the absence of observable tissue pathology. it includes a range of conditions which are likely to present in the dental setting including temporomandibular disorders, burning mouth syndrome, persistent dentoalveolar pain, trigeminal nerve injury, trigeminal neuralgia and atypical facial pain.<br/> This article reviews psychological interventions for pain. this includes interventions that have been researched in a range of persistent pain settings, including but not limited to those that have been directly applied to persistent orofacial pain (POFP).<br/> All current psychological interventions for persistent pain are underpinned by a biopsychosocial understanding of the complex and multifactorial nature of pain. the main currently applied interventions are described, along with their rationale and selected relevant research. To date, psychological treatments which have been shown to persistent pain demonstrate small but consistent improvements in pain, disability and quality of life compared to standard care.<br/> A stepped care approach to service provision is outlined, with practical ideas for administering routine psychological measures to help stratify patients towards the appropriate care pathway.

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. 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. 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). 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.

Persistent anterolateral ankle pain is a debilitating condition often associated with soft tissue impingement following inversion injuries. It can lead to significant limitations in daily activities and overall quality of life, particularly in individuals with chronic ankle instability. This systematic review examines the efficacy and safety of minimally invasive arthroscopic decompression techniques in managing anterolateral ankle impingement syndrome. A total of 246 cases from nine studies were reviewed, involving 135 males with a mean age of 29.6 years and an average follow-up period of 29.5 months (range: 15-83.7 months). Outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scores and Meislen criteria. The AOFAS scores improved significantly from a mean of 40.75 preoperatively to 84.2 postoperatively, reflecting substantial functional recovery. Based on the Meislen criteria, 124 cases (50%) were rated as excellent, 71 (29%) as good, 14 (6%) as fair, and three (1%) as poor. Postoperative mobility was restored to normal in 130 cases, with complications reported in 24 cases (9.8%), including hypoesthesia, infections, intra-articular haemarthrosis, scar tissue formation, nerve irritation, and persistent pain or numbness. Patient satisfaction was high, with most patients reporting significant improvements in pain relief and functional capacity. Arthroscopic decompression is a safe, minimally invasive, and effective intervention for managing persistent anterolateral ankle impingement, offering substantial improvements in pain, mobility, and overall function with low morbidity and a manageable complication rate. This approach is an invaluable option for patients unresponsive to conservative treatments.

Exploring beliefs and practice of opioid prescribing for persistent non-cancer pain by general practitioners

Intrathecal Analgesia

Future Directions for Intrathecal Pain Management: A Review and Update From the Interdisciplinary Polyanalgesic Consensus Conference 2007

acute burn pain management has advanced significantly, yet little is known about long-term pain outcomes after severe burn injury. Even less is known about patient satisfaction with pain management after burn injury. This study examined the long-term pain and psychological outcomes of burn survivors who were treated at the Burns Service of Western Australia between 1994 and 2005. of 2114 burn survivors who were mailed standardized self-report measures of pain, depressive, and posttraumatic stress symptoms, 492 returned completed questionnaires. Of these, 18%reported persistent burn-related pain, and 27% and 14% reported clinically significant depressive and posttraumatic stress symptoms, respectively. Those with persistent pain reported significantly more severe depressive and posttraumatic stress symptoms compared with those with no pain. Interestingly, respondents with persistent burn-related pain recalled significantly higher levels of procedural and dressing change acute pain than those without pain symptoms. Linear multiple regression analyses revealed that the extent to which pain treatment expectations were met predicted overall satisfaction with pain treatment, beyond the effects of perceived pain improvement, current burn pain intensity, depression and posttraumatic stress symptoms, age, sex, and total burn surface area. collectively, these findings suggest a significant proportion of severely injured burn survivors continue to experience persistent pain and point to the need to identify and treat persistent pain more effectively. Moreover, assessing and managing pain treatment expectations during the early phase of recovery postburn may yield improved levels of patient satisfaction with treatment received

Failed back surgery syndrome (FBSS) is a well-recognized complication of spinal surgery and remains a challenge for surgeons. Intrathecal morphine therapy has been increasingly utilized in patients with malignant or non-malignant intractable pain who failed to respond to conventional treatment or could not tolerate these side effects of morphine, but has never been used for treatment of failed back surgery syndrome before in Taiwan. Consequently, this is the first study to use implanted intrathecal morphine infusion for treatment of failed back surgery syndrome in Taiwan. The clinical data of this first case were recorded and analyzed retrospectively to evaluate the efficiency and safety of implanted intrathecal morphine pump for the treatment of failed surgery syndrome. This patient demonstrated significant pain relief and functional status improvement without serious side effects. Although intrathecal morphine infusion was helpful in this first patient with failed back surgery syndrome, long-term efficacy, effectiveness, complication must be evaluated

Background Opioids offer limited long-term benefits and carry significant risks. We developed the PROMPPT intervention to address challenges in implementing effective person-centred review and safe opioid tapering in UK primary care. PROMPPT comprises a primary care review, led by clinical pharmacists working in general practices as part of the multidisciplinary team, and an associated training package. This trial will evaluate (1) the effectiveness of PROMPPT in supporting people with persistent non-cancer pain to safely reduce opioids, where appropriate, without increasing pain/pain-related interference, and (2) cost-effectiveness compared with usual primary care. Methods Design and setting: cluster randomised controlled trial, with internal pilot, in 38 general practices across England. Participants: patients &ge;18&nbsp;years prescribed one or more opioids &ge;6&nbsp;months for persistent pain who consent to participate in a questionnaire study. Exclusions: acute pain, cancer pain, end-of-life care, dementia, severe mental illness or otherwise vulnerable, and current substance misuse treatment. Practices are randomly allocated (1:1) to either: invite participants for a PROMPPT review with a trained practice pharmacist, and follow-up as needed, or continue usual primary care review for patients who are prescribed opioids. Co-primary outcomes, measured at 12&nbsp;months, are (1) reduction in self-reported opioid use (&ge;25% reduction in daily morphine equivalent dose from their baseline) and (2) non-inferiority of the Brief Pain Inventory total score. The trial includes an economic evaluation (within trial and longer-term cost-utility analyses) and a mixed methods process evaluation. Analysis of consultation audio-recordings, case report forms (including an intervention delivery template), acceptability questionnaires and semi-structured interviews will explore how PROMPPT was delivered and received, and how context affected implementation and outcomes. Conclusion The PROMPPT trial will assess whether review by trained clinical pharmacists working in general practices can support safe opioid reduction without compromising pain management and quality of life. Trial registration ISRCTN 45616481, 13/05/2022 https://doi.org/10.1186/ISRCTN45616481