scholarly journals Drug-Related Side Effects of Long-term Intrathecal Morphine Therapy

2007 ◽  
Vol 2;10 (3;2) ◽  
pp. 357-365
Author(s):  
Xiulu Ruan
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Opioid Receptors ◽  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Pump Therapy ◽  
Morphine Administration ◽  
Opioid Administration ◽  
Morphine Therapy

Background: The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage. Objectives: To review the literature on side effects due to long-term intrathecal morphine therapy with discussions of alternate treatment options. Design: English-language publications were identified through MEDLINE search and the bibliographies of identified articles were reviewed. Results: Most side effects of intrathecal morphine therapy are dose dependent and mediated by opioid receptors. Common ones include nausea, vomiting, pruritus, urinary retention, constipation, sexual dysfunction, and edema. Less common ones include respiratory depression, and hyperalgesia. Catheter tip inflammatory mass formation is a less common complication that may not be mediated by opioid receptors. Conclusion: The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with longterm intrathecal morphine administration prior to placement of a permanent morphine infusion pump. Key words: side effects, intrathecal morphine, opioid receptors

Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study

2017 ◽  
Vol 17 (1) ◽  
pp. 37-40 ◽  
Author(s):  
Kehua Zhou ◽  
Sen Sheng ◽  
Gary G. Wang
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Pain Control ◽  
Intrathecal Morphine ◽  
Management Approach ◽  
Intractable Pain ◽  
Pump Therapy ◽  
Pump Implantation ◽  
Morphine Therapy

AbstractBackground and aimsThe use of intrathecal morphine therapy has been increasing. Intrathecal morphine therapy is deemed the last resort for patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions. However, effective treatments for patients with CNCP who “failed” this last resort because of severe side effects and lack of optimal pain control remain unclear.Methods and resultsHere we report two successfully managed patients (Ms. S and Mr. T) who had intractable pain and significant complications years after the start of intrathecal morphine therapy. The two patients had intrathecal morphine pump implantation due to chronic consistent pain and multiple failed surgical operations in the spine. Years after morphine pump implantation, both patients had significant chronic pain and compromised function for activities of daily living. Additionally, Ms. S also had four episodes of small bowel obstruction while Mr. T was diagnosed with end stage severe “dementia”. The successful management of these two patients included the simultaneous multidisciplinary approach for pain management, opioids tapering and discontinuation.ConclusionThe case study indicates that for patients who fail to respond to intrathecal morphine pump therapy due to side effects and lack of optimal pain control, the simultaneous multidisciplinary pain management approach and opioids tapering seem appropriate.

Long Term Intrathecal Administration of Morphine: A Comparison of Bolus Injection via Reservoir with Continuous Infusion by Implanted Pump

Neurosurgery ◽  
1987 ◽  
Vol 21 (4) ◽  
pp. 484-491 ◽  
Author(s):  
Graeme Alexander Brazenor
Keyword(s):  
Complication Rate ◽  
Subarachnoid Space ◽  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Intrathecal Administration ◽  
Morphine Administration ◽  
Spinal Subarachnoid Space ◽  
Temporal Horn ◽  
The Cost

Abstract Twenty-six cases of chronic intrathecal morphine administration are described: 19 cases utilizing the Spinalgesic injectable subcutaneous reservoir and 7 cases utilizing the Infusaid implanted infusion pump. In 25 cases, the morphine was delivered into the spinal subarachnoid space, and in 1 case of thalamic pain it was delivered into the temporal horn of the ipsilateral cerebral ventricle. The average duration of usage of the system was 132 days. The efficacy of the method was excellent: 23 of 26 patients used no other analgesics or only minor ones such as aspirin, paracetamol, or dextropropoxyphene. The complication rate was low, with no infections under the author's care, and only 4 catheter blockages (1 by tumor). There have been no complications in the 7 patients with implanted pumps. From this experience, the author concludes that the implanted pump is now the method of choice in all patients who can afford it and for whom the life expectancy outside an institution is in excess of 60 days. A special and relatively absolute indication for the pump is the situation of pain in the arm, head, or neck areas, in which case the constant morphine levels likely to be achieved with the pump may prevent failure of the method due to intractable nausea or emesis. The subcutaneous reservoir is otherwise to be preferred if the patient's disease is progressing rapidly, if the patient is already institutionalized and likely to remain so, or where the cost of the implanted pump would cause hardship. Either method of delivery of morphine to the subarachnoid space can provide incomparable analgesia without clouding of consciousness, with a very low complication rate. (Neurosurgery 21:484-491, 1987)

scholarly journals POST-OPERATIVE PAIN RELIEF FOR LOWER ABDOMINAL SURGERY

2005 ◽  
Vol 12 (03) ◽  
pp. 340-345
Author(s):  
ROBINA FIRDOUS
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Pain Relief ◽  
Abdominal Surgery ◽  
Opioid Receptors ◽  
Acute Pain ◽  
Alternate Route ◽  
Parenteral Route ◽  
Group I ◽  
Post Operative Pain

The severity of post-operative pain and the lack of efforts in relievingit have led to the involvement of Anaesthesiologists in the management of post-operative and acute pain. Parenteralopiates have been utilized for post-operative pain management. The identification of the opioid receptors on substantiagelatinosa has provided an alternate route i.e 1 the epidural route - for administering opiates. Objectives: To evaluateand compare the efficacy and side effects of parenteral Buprenorphine with those of Extradural Buprenorphine.Setting: Department of Anaesthesia, District Headquarter Hospital, Faisalabad. Period: The data was collected duringthe last three and a half years. Materials and Methods: Sixty adult patients of either sex and ages ranging from 35-45years, who underwent lower abdominal surgery, were randomly selected for the study. They were equally divided intotwo groups. Group I patients were administered Buprenorphine 0.3 mg through the epidural catheter in extraduralspace. Group II patients were given Buprenorphine 0.3 mg intramuscularly. Results: Buprenorphine through theepidural route gives better analgesia with fewer side effects as compared with the parenteral route.

Persistent Hiccup Associated with Intrathecal Morphine Infusion Pump Therapy

2007 ◽  
Vol 86 (12) ◽  
pp. 1019-1022 ◽  
Author(s):  
Xiulu Ruan ◽  
John Patrick Couch ◽  
Rinoo Shah ◽  
Frank Wang ◽  
Hai Nan Liu
Keyword(s):  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Pump Therapy ◽  
Morphine Infusion

scholarly journals Long Term Treatment of Intractable Reflex Sympathetic Dystrophy With Intrathecal Morphine

1995 ◽  
Vol 22 (2) ◽  
pp. 153-159 ◽  
Author(s):  
W.J. Becker ◽  
D.P. Ablett ◽  
C.J. Harris ◽  
O.N. Dold
Keyword(s):  
Reflex Sympathetic Dystrophy ◽  
Intrathecal Morphine ◽  
Symptom Control ◽  
Term Treatment ◽  
Leg Pain ◽  
Medical Treatments ◽  
Autonomic Changes ◽  
Long Term Treatment ◽  
Morphine Therapy

AbstractBackground:Some patients with reflex sympathetic dystrophy (RD) develop intractable symptoms unresponsive to conventional therapy. Recently, intrathecal morphine therapy has been used with some success in such patients.Methods:The clinical course of two patients with intractable reflex sympathetic dystrophy (RSD) is described. Both patients developed intractable leg pain, swelling and autonomic changes after a leg injury. Numerous medical treatments and surgical sympathectomies failed to provide long term relief.Results:Relatively satisfactory symptom control was achieved only with the use of long term intrathecal morphine therapy delivered by subcutaneously implanted infusion pumps. Exacerbations of the RSD continued to occur, at times in association with further leg trauma, but these could be controlled by a temporary escalation of the intrathecal morphine dose. Complications of morphine therapy were relatively minor. A red rash appearing over the pump site was the first sign that a drug catheter break had occurred, necessitating surgical catheter revision.Conclusion:Long term intrathecal morphine therapy is a useful treatment option for patients with intractable severe RSD who have failed other therapies and remain markedly disabled.

Persistent Pain Associated With Long-term Intrathecal Morphine Administration

1996 ◽  
Vol 89 (4) ◽  
pp. 417-419 ◽  
Author(s):  
WINSTON C. V. PARRIS ◽  
PIOTR K. JANICKI ◽  
BENJAMIN JOHNSON ◽  
JANICE LIVENGOOD ◽  
LETHA MATHEWS
Keyword(s):  
Intrathecal Morphine ◽  
Persistent Pain ◽  
Morphine Administration

scholarly journals Peripherally Acting μ-Opioid Receptor Antagonists for the Treatment of Opioid-Related Side Effects: Mechanism of Action and Clinical Implications

2017 ◽  
Vol 31 (6) ◽  
pp. 658-669 ◽  
Author(s):  
John M. Streicher ◽  
Edward J. Bilsky
Keyword(s):  
Side Effects ◽  
Opioid Receptor ◽  
Opioid Receptors ◽  
Mechanism Of Action ◽  
Bowel Dysfunction ◽  
Cardiac Risk ◽  
Common Side Effect ◽  
Receptor Antagonists ◽  
Opioid Receptor Antagonists ◽  
Opioid Administration

Opioid receptors are distributed throughout the central and peripheral nervous systems and on many nonneuronal cells. Therefore, opioid administration induces effects beyond analgesia. In the enteric nervous system (ENS), stimulation of µ-opioid receptors triggers several inhibitory responses that can culminate in opioid-induced bowel dysfunction (OBD) and its most common side effect, opioid-induced constipation (OIC). OIC negatively affects patients’ quality of life (QOL), ability to work, and pain management. Although laxatives are a common first-line OIC therapy, most have limited efficacy and do not directly antagonize opioid effects on the ENS. Peripherally acting µ-opioid receptor antagonists (PAMORAs) with limited ability to cross the blood-brain barrier have been developed. The PAMORAs approved by the U S Food and Drug Administration for OIC are subcutaneous and oral methylnaltrexone, oral naloxegol, and oral naldemedine. Although questions of cost-effectiveness and relative efficacy versus laxatives remain, PAMORAs can mitigate OIC and improve patient QOL. PAMORAS may also have applications beyond OIC, including reducing the increased cardiac risk or potential tumorigenic effects of opioids. This review discusses the burden of OIC and OBD, reviews the mechanism of action of new OIC therapies, and highlights other potential opioid-related side effects mediated by peripheral opioid receptors in the context of new OIC therapies.

scholarly journals Respiratory Failure Following Delayed Intrathecal Morphine Pump Refill: A Valuable, but Costly Lesson

2010 ◽  
Vol 4;13 (4;7) ◽  
pp. 337-341
Author(s):  
Xiulu Ruan
Keyword(s):  
Drug Delivery ◽  
Respiratory Failure ◽  
Side Effects ◽  
Respiratory Depression ◽  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Opioid Tolerance ◽  
Intrathecal Catheter ◽  
Patient Reported ◽  
Preservative Free

Background: Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. Objective: To describe a severe adverse event, i.e., respiratory failure, following delayed intrathecal morphine pump refill. Case Report: A 65-year-old woman with intractable chronic low back pain, due to degenerative disc disease, and was referred to our clinic for an intraspinal drug delivery evaluation, after failing to respond to multidisciplinary pain treatment. Following a psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine infusion trial. The infusion trial lasted 12 days and was beneficial in controlling her pain. The patient reported more than 90% pain reduction with improved distance for ambulation. She subsequently consented and was scheduled for permanent intrathecal morphine pump implantation. The intrathecal catheter was inserted at right paramedian L3-L4, with catheter tip advanced to L1, confirmed under fluoroscopy. Intrathecal catheter placement was confirmed by positive CSF flow and by myelogram. A non-programmable Codman 3000 constant-flow rate infusion pump was placed in the right mid quandrant between right rib cage and right iliac crest. The intrathecal infusion consisted of preservative free morphine, delivering 1.0 mg / day. Over the following 6 months, the dosage was gradually titrated up to 4 mg/day with satisfactory pain control without significant side effects. However, the patient was not able to return to the clinic for pump refill until 12 days later than the previously scheduled pump-refill date. Her pump was accessed and was noted to be empty. Her intrathecal pump was refilled with preservative free morphine, delivering 4 mg/day (the same daily dose as her previous refill). However, on the night of pump refill, 10 hours after the pump refill, the patient was found to be unresponsive by her family members. 911 was called. Upon arriving, paramedics found her in respiratory failure, with shallow breathing at a rate of 5/min, pulse oxymetry showing oxygen saturation about 55-58%. She was emergently intubated on site and rushed to local hospital ER. The on call physician for our clinic was immediately contacted, and advised the administration of intravenous Naloxone. Her respiratory effort improved dramatically after receiving a total of 0.6 mg IV Naloxone IV over 25 minutes. Her intrathecal pump was immediately accessed by clinic on call physician and the remainder of the medication in the catheter space was aspirated. The pump infusate was immediately diluted with preservative free normal saline, to deliver preservative free morphine at 1mg/day. She was transferred to the intensive care unit and extubated the next morning. She recovered fully without any sequelae. Conclusion: Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type. Key words: intraspinal drug delivery pump, intrathecal morphine, respiratory depression, opioid tolerance

Intraperitoneal Versus Interpleural Morphine or Bupivacaine for Pain after Laparoscopic Cholecystectomy 

1995 ◽  
Vol 82 (3) ◽  
pp. 634-640 ◽  
Author(s):  
Hans Schulte-Steinberg ◽  
Ernst Weninger ◽  
Dominik Jokisch ◽  
Bernhard Hofstetter ◽  
Axel Misera ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Side Effects ◽  
Shoulder Pain ◽  
Opioid Receptors ◽  
Saline Group ◽  
Morphine Group ◽  
Opioid Administration ◽  
Intravenous Morphine ◽  
Intravenous Saline ◽  
Intraperitoneal Bupivacaine

Background Opioids can produce peripheral analgesic effects by activation of opioid receptors on sensory nerves. This study was designed (1) to examine a novel route of opioid administration, the intraperitoneal injection; (2) to compare this to interpleural application, and (3) to compare opioid with local anesthetic effects under both conditions. Methods At the end of laparoscopic cholecystectomy, 110 patients received the following injections in a double-blind, randomized manner: Group 1 (n = 18) was given intraperitoneal morphine (1 mg in 20 ml saline) and 20 ml intravenous saline. Group 2 (n = 17) received intraperitoneal saline and 1 mg intravenous morphine. Group 3 (n = 15) received 20 ml 0.25% intraperitoneal bupivacaine and intravenous saline. Group 4 (n = 20) received interpleural morphine (1.5 mg in 30 ml saline) and 30 ml intravenous saline. Group 5 (n = 20) received interpleural saline and 1.5 mg intravenous morphine. Group 6 (n = 20) received 30 ml 0.25% interpleural bupivacaine and intravenous saline. Postoperative pain was assessed using a visual analog scale, a numeric rating scale, and the McGill pain questionnaire. Pain localization, supplemental analgesic consumption, vital signs, and side effects were recorded for 24 h. Results Neither intraperitoneal nor interpleural morphine produced significant analgesia after laparoscopic cholecystectomy (P > 0.05, Kruskal-Wallis test), whereas interpleural bupivacaine was effective (P < 0.05, Kruskal-Wallis test, up to 6 h postoperatively) but not intraperitoneal bupivacaine (P > 0.05, Kruskal-Wallis test). Shoulder pain was not prevalent in the majority of patients during the first 6 h. By 24 h, about half of the patients complained of shoulder pain, which was rated "low" by about one-third of all patients. No significant side effects occurred. Conclusions Interpleural bupivacaine (0.25%) produces analgesia after laparoscopic cholecystectomy. We attribute the lack of effect of intraperitoneal injections to the small dose and to a rapid dilution within the peritoneal cavity. The fact that interpleural morphine (0.005%) is ineffective may be due to an intact perineurial barrier in the noninflamed pleural cavity, which restricts the transperineurial passage of morphine to opioid receptors on intercostal nerves.

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