Key Paper Summaries Neurostimulation

Key Paper Summaries IDD

Medtronic Publications

Case Studies

Useful Links

• From the time of commencement of intrathecal opioids to the time of follow-up:
  
  Positive
  
  
  • 82% of patients reported overall pain relief of 50% or greater. Mean pain relief was 60%.
• 74% of patients reported increased activity levels.
• Oral medication intake was significantly reduced.
• Patient satisfaction with treatment was high with 88% of patients reporting satisfaction.

Less positive/complication

• There was no significant change in work status.
• There were frequent reports of opioid side effects including sexual dysfunction and menstrual disturbances.
• Technical complications occurred in 40% of patients, most often catheter related.
• 93% of patients were initially treated with morphine. Mean morphine dosage increased from 9.95 ± 1.49 mg/day at 6 months to 15.26 ± 2.52 mg/day at 36 months.
• Drug administration systems were permanently removed in 6% of patients,

• In this group of patients with chronic intractable non-cancer pain for an average of 12 years, infusion of opioids via an implanted DAS for a mean duration of >3 years was associated with improved analgesia, self-reported activity levels, reduction in medication intake and high levels of patient satisfaction.
  
  
• In line with other studies of intrathecal opioids, there was no significant change in work status associated with treatment. It has previously been suggested that successful return to work may not be a realistic outcome in patients with very severe non-cancer pain and high levels of disability and dysfunction.
  
  
• Therapy does not seem to be significantly inhibited by the development of tolerance.
  
  
• Intrathecal opioid therapy using implanted drug administration systems appears to have a place in the management of chronic non-cancer pain.

• Opioids have a demonstrated use in treating chronic pain. However there are many myths about the use of these drugs, which limit or preclude their use by many physicians, particularly in non-cancer patients.
  
  
• Historically, the need to increase the dose of opioid has usually been attributed to the development of tolerance. However, this may well have other origins, such as disease progression, changes in affective state or underdosing.
  
  
• Clinical data suggest that the need for dose increases rarely compromises effective therapy, and is no more of a problem in intrathecal than during systemic therapy. Thus, concerns about the possible development of tolerance should not be the basis for withholding opioid therapy.
  
  
• Patients requiring dose escalation because of increasing pain should be investigated for the source of this increase, which may be a change in disease state, psychological state or a problem with the drug-delivery system. If a dose increase is warranted, this should be made, although at high doses the potential for hyperalgesia should be recognised.
  
  
• Addiction to opioid medications used in pain therapy is rare in individuals with no history of addictive disorders. Moreover, it seems possible that the likelihood of addition would be even smaller when using intrathecal than oral systemic therapy, as systemic exposure to the opioids is much smaller.
  
  
• Opioids are stigmatised drugs and their underuse, and therefore undertreatment, is a significant problem. To address this, education is needed at all levels: clinicians, policy makers and patients.
  

• This is an introduction to a supplement on this subject.
  In an effort to explore the evolving clinical consensus and ongoing disagreements that characterise the controversy of the use of intrathecal therapy in non-cancer patients, a closed roundtable meeting of pain specialists was convened. The supplement reports on that meeting.

• A total of 26 patients were followed up for an average of 23 months (range 16-17 months).
  
  
• Average pain rating decreased from 8.9 (out of 10) before treatment to 5.5 at 6 months and 4.9 at 12 months. The average subjective rating of improvement in pain was 59%.
  
  
• The average functional level was 4.0 (out of 6) before surgery and decreased (improved) to 2.8 afterwards. Average improvement in daily functioning was 50%.

• Pain was reduced from a mean of 93.6 (maximum 100) to 30.5 on a visual analogue scale after 6 months. This was accompanied by a marked reduction in patients' social withdrawal, and improvements in their mood and quality of life. 92% of the patients were satisfied with the therapy and 81% reported an improvement of their quality of life.
  
  
• The dose of opiate required generally increased throughout the treatment period. Tolerance developed in seven patients, which was managed by drug holidays in four patients, but required explantation of the pump in the other three.
  
  
• Most common side-effects could be managed pharmacologically, and decreased as treatment continued. A total of 25 pumps had to be removed for various reasons.