A panel released guidelines to help clinicians identify patients experiencing cancer-related pain who would benefit from an implanted intrathecal (IT) drug delivery systems.
A panel of pain management specialists recently released consensus guidelines intended to help clinicians identify patients experiencing cancer-related pain who would benefit from receiving medication through implanted intrathecal (IT) drug delivery systems, and endorsed “a much wider application” of such therapies.
The group consisted of 10 clinicians from university and pain specialty facilities in the United States and 1 from Australia whose findings were published in the May/ June issue of Pain Physician.
The authors said randomized trials and observational studies have shown that IT systems are viable treatment options that can deliver improved pain relief when compared with conventional therapies, but that patients should be carefully evaluated to determine whether they are candidates for such systems.
IT systems involve positioning a catheter in the cerebral spinal fluid, necessitating the surgical placement of a pump for long-term therapy.
“With careful consideration of the patient’s medical comorbidities and prior therapies, communication with the oncologist, proper psychological evaluation, and appropriate trialing technique, clinicians can effectively optimize the use of IT therapy for cancer pain,” the paper said.
Regarding the prevalence, impact, and need for better treatment for cancer-related pain, the authors reported:
Adverse effects associated with IT drug therapy include opioid-induced hyperalgesia, hypotension, sedation, respiratory depression, inflammatory mass, hypogonadotropic hypogonadism, and immunologic compromise.
Other dangers associated with this approach to pain management include increased mortality risk from rapid and improperly monitored dose escalation. To guard against adverse events, the panel recommended that “therapy be initiated at low doses, with slow titration upward, as necessary, based on patient response.”
Recommendations for selecting patients for treatment with IT drug therapy include:
Because it “may be difficult to overstate” the role that psychological factors and emotional stresses play in patients’ response to pain and pain treatment, clinicians should consider conducting a preimplantation psychological evaluation based on the status of the patient’s disease. The authors identified 3 levels of need:
Although IT drug therapy trials prior to permanent device implantation can be used to “determine patient response to therapy and establish a baseline measurement from which potential improvement can be assessed,” research has not yet established “a direct correlation between a patient’s response during an IT trial and subsequent effects of therapy.”
Thus, the panel reminds that “it is up to the implanting clinician to weigh the benefi ts and limitations of each trialing method and decide which technique—if any—is best suited for the patient.” The panel also recommends against the use of mandatory IT drug trials, especially for patients near the end of life.
Deer TR, Smith HS, Burton AW, et al. Comprehensive consensus based guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain. Pain Physician. 2011;14(3):E283-E312. http://tiny.cc/o7wrf