Neuromodulation : journal of the International Neuromodulation Society
-
Spasticity can affect individuals with spinal injury, spinal disease, or multiple sclerosis. In most cases, spasticity is useful because it helps compensate for motor deficits. Oral medication is ineffective or produces intolerable side effects in ≅ 30% of patients with severe spasticity and surgeries can sometimes have effects inappropriate for patients requiring some degree of spasticity for function. ⋯ Although complications are relatively uncommon, most involve mechanical compromise of the catheter. Cost analysis shows that there is an overall savings associated with intrathecal baclofen therapy, primarily due to a reduction in required hospitalizations and medical care for conditions resulting from spasticity. Intrathecal baclofen is a safe, efficacious, titratable, reversible, and cost-effective treatment for severe spinal origin spasticity, including spinal cord injury, spinal cord disease, and multiple sclerosis.
-
Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. ⋯ In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
-
Although opioid therapy has been accepted for the treatment of patients with cancer pain, its use for nonmalignant pain is still regarded as controversial due to concerns about the development of tolerance and psychological dependence. However, recent studies indicate that there is a low incidence of addiction in patients who do not have a history of addictive disorders, and opioid use is increasing for long-term treatment in patients with nonmalignant pain. ⋯ These studies demonstrate that intrathecal opioid delivery produces short-term relief of specific symptoms and improves long-term outcomes such as patient functioning (measured by increases in activities of daily living [ADLs] and capacity to work), mood, treatment satisfaction, and quality of life, as well as decreases in oral opioid use. Furthermore, these studies showed there was no development of tolerance or addiction in patients who received long-term intrathecal opioid delivery.
-
Intrathecal drug delivery is effective for the treatment of cancer and nonmalignant pain in patients who do not respond well to oral opioids, in patients who cannot tolerate the side effects associated with opioids, or in patients who show a large, permanent increase in dosage. Although intrathecal drug delivery is associated with pharmacological side effects and complications, its benefits far outweigh its risks. There are three main categories of potential adverse events associated with intrathecal drug delivery: pharmacologic side effects, surgical complications, and device-related complications. ⋯ Many adverse events either resolve on their own or can be managed with dosage or device adjustment. More serious complications may require surgical intervention or discontinuation of therapy. This paper will provide an overview of adverse events and complications, their origins, detection, manifestations, and management.
-
Successful management of chronic cancer and nonmalignant pain remains a challenge to clinicians, and cost effectiveness is an important consideration for clinical decision making. Although the oral route was previously considered the optimal method of chronic opioid administration, emerging evidence demonstrates a therapeutic advantage to intrathecal opioid delivery compared to alternative modalities. ⋯ Although the initial costs of surgical implantation of an intrathecal pump appear to be substantial, maintenance costs of intrathecal drug delivery over time are significantly lower than other routes of administration, including oral and intravenous drug delivery. Cost analyses of alternate routes of opioid administration indicate that intrathecal delivery is the most cost-effective route of opioid administration for patients who require long-term management of cancer (≥ 3-6 months) or nonmalignant pain (≥ 11-22 months).