AAPM 2009: Specialists Endorse Intrathecal Pain Therapies but Urge Caution

Allison Gandey

January 29, 2009

January 29, 2009 (Honolulu, Hawaii) — Intrathecal therapies can relieve pain and improve long-term function, report specialists, but there are risks that should be taken into consideration. Speakers presented during a plenary session on the benefits and potential complications associated with intrathecal analgesic strategies here at the American Academy of Pain Medicine 25th Annual Meeting.

Drs. Leonardo Kapural, Todd Sitzman, and Timothy Deer taking questions at the plenary session.

Presenter Timothy Deer, MD, from the Center for Pain Relief in Charleston, West Virginia, discussed the problem of off-label use of various analgesics with this strategy. "It is important to use an approved catheter with an approved drug," he told the meeting. "Clinicians are putting drugs in the pumps with absolutely no reasoning for it and are doing some outrageous things."

There are currently only 2 drugs approved by the US Food and Drug Administration for use in intrathecal pumps — morphine and ziconotide.

"Regulation can be a good thing," moderator Leonardo Kapural, MD, from the Cleveland Clinic in Ohio told Medscape Neurology & Neurosurgery. He also voiced concern over widespread off-label use and urged clinicians to base therapeutic decisions on available evidence.

Dr. Kapural suggested that intrathecal therapies should be considered a last step in the treatment of cancer and noncancer pain. The drug-delivery systems consist of an implantable pump and catheter that deliver small quantities of analgesic into the intrathecal space in the spine. They are indicated for the management of chronic, intractable pain and for the treatment of severe spasticity of cerebral or spinal origin.

Know the Pharmacology and Toxicology

"When you've been practicing long enough, it's not a question of if but when you are going to see complications" associated with intrathecal treatment, Todd Sitzman, MD, from the Forrest General Cancer Center, in Hattiesburg, Mississippi, said during his talk.

Dr. Sitzman pointed out that pump complications can range from infection to death. Other potential adverse events include the development of an inflammatory mass, respiratory depression, and neurologic injury or paralysis.

Catheter complications can also pose a problem, he noted. They can disconnect, fracture, leak, or migrate, or kinks can form. Granulomas can also become a serious problem.

Start low and go slow.

To reduce postoperative mortality associated with intrathecal pain treatment, Dr. Sitzman urged clinicians to "start low and go slow." Titrate drug doses slowly, he emphasized, to reduce the risk for adverse events and "avoid systemic opioids and sedatives, if you can." He recommended frequent respiratory checks and encouraged clinicians to add respiratory depression orders to patient charts.

Dr. Sitzman said the postoperative opioid dose must not exceed the trial dose, and all pump program changes should be verified by 2 staff members.

"Programming changes are the most avoidable errors," Dr. Sitzman emphasized at the meeting. "Review each line," he said, "and provide patients with a printout of pump settings that they can keep in their wallet." He also recommended that doctors schedule a return date to refill pumps before patients leave, to avoid emergencies.

Dr. Sitzman said that clinicians should know the recommendations from the Polyanalgesic Consensus Conference 2007. They should also read the Medtronic Clinical Reference Guide from May 2007 and review all FDA-approved product information.

Nonopioid Therapy

During his presentation on nonopioid therapy, Dr. Kapural was enthusiastic about the potential of new combinations. "We might be able to improve results and decrease granulomas. We might also be able to avoid opioid tolerance and opioid-induced hyperalgesia," he said.

"This is just the beginning," Dr. Kapural added during an interview. "We are still a long way away, but looking at our practice at the Cleveland Clinic, we believe there are many benefits of using nonopioid therapies."

Dr. Kapural says he looks forward to new evidence evaluating these options and subsequent regulatory review.

Dr. Deer added, "Hopefully, 5 years from now, our algorithms will evolve so much that we will be disappointed to see that we once used opioids at all."

Dr. Timothy Deer reports that he is a consultant for Codman and St. Jude Medical as well as a researcher for Bioness. Dr. Leonardo Kapural has disclosed that he is a speaker for Baylis Medical Company. Dr. Todd Sitzman reports that he is a speaker for Eli Lilly and Cephalon and takes part in an advisory board for Codman.

American Academy of Pain Medicine 25th Annual Meeting. Plenary session 112. Presented January 28, 2009.

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