Ceasing intrathecal therapy in chronic non-cancer pain: an invitation to shift from biomedical focus to active management.

Abstract

OBJECTIVE: To report long term experience (1997-2009) of intrathecal (IT) therapy for chronic non-cancer pain in the context of our team's increasing emphasis on active management.

DESIGN: Descriptive case series.

SETTING: Australian tertiary multidisciplinary pain center, Hunter Integrated Pain Service (HIPS).

INTERVENTION: This case series reports the changing use of IT implanted drug delivery systems (IDDSs) for chronic non-cancer pain over 13 years. Initially IT therapy was used selectively following multidisciplinary assessment and double blind IT trial. Typical therapy combined opioid with clonidine. Multidimensional management was offered. Treatment strategy changed in 2003 due to HIPS experience of limited therapeutic gains and equivocal support for IT therapy in the literature. Subsequently IT therapy was no longer initiated for non-cancer pain and those on established regimes were encouraged to shift to oral/transdermal opioids with greater emphasis on active management. Patient education and consultation were key elements. Where IT cessation was elective gradual dose reduction commenced as an outpatient. In elective and urgent cases ketamine infusion and oral clonidine were used during hospital admissions to cover the switch to oral/transdermal opioids. Over the study period transition occurred to a broader management framework in which IT therapy for chronic non-cancer pain was no longer supported by HIPS.

RESULTS: 25 patients were managed using IDDSs; 8 implanted by HIPS and 17 by other teams. Dose escalation and adverse effects were common. 24 of 25 patients ceased IT therapy; 7 (29%) with urgent IDDS related complications, 16 (67%) electively and 1 due to an unrelated death. The remaining patient returned to her original team to continue IT therapy. One post-explantation patient transferred to another team to recommence IT therapy. The remainder were successfully maintained on oral/transdermal opioids combined with active management.