Articles: pain-management.
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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.
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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).
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Due to successful use of intrathecal drug delivery in the management of refractory pain and spasticity, new agents and indications are now being investigated. Preclinical studies of neurotrophic factors, molecules necessary for neuroneal survival and development, suggest that these agents may be beneficial for patients with neurologic disorders. ⋯ Treatment of other neurologic disorders, such as brain tumors and HIV-related viral infections, also may be optimized by methods of local drug delivery, including intratumoral and intraparenchymal administration of potentially effective agents. Intraspinal, intratumoral, and intraparenchymal routes of administration are speculated to become critical components of treatment for a variety of neurological indications.
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Advances in cancer pain research and management are an example of the advances that have occurred within the field of neuro-oncology, the medical discipline that includes the diagnosis and treatment of primary central nervous system neoplasms, metastatic and nonmetastatic neurological complications of cancer originating outside the nervous system, and pain associated with cancer. Progress in the diagnosis and treatment of cancer, coupled with advances in our understanding of the anatomy, physiology, pharmacology, and psychology of pain perception, has led to improved care of the patient with pain of malignant origin. Currently, specialized methods of cancer diagnosis and treatment provide the most direct approach to treating cancer pain by treating the cause of the pain. Yet, before the introduction of successful antitumor therapy, when treatment of the cause of the pain has failed or when injury to bone, soft tissue, or nerve has occurred as a result of therapy, appropriate pain management is essential.