Pharmaceutical care for a patient with refractory cancer pain treated by intrathecal infusion of hydromorphone

Background: Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function. Study Design: A systematic review of intrathecal infusion devices for chronic non-cancer pain. Objective: To determine the efficacy, utilization, safety, and complications associated with the use of intrathecal infusion devices for long-term management of chronic non-cancer pain. Methods: Literature search was performed through EMBASE, Medline, Cochrane databases, and systematic reviews identified from 1966 to December 2008. Studies were then reviewed and assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Outcome Measures: The primary outcome measure was pain relief (short-term relief ≤ one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were also utilized. Results: The level of evidence for intrathecal infusion systems indicated either Level II-3 or Level III (limited) based on U.S. Preventive Services Task Force (USPSTF) criteria. Limitations: The limitations of this study include the paucity of literature, lack of quality evidence, and lack of randomized trials. Conclusion: This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain. Key words: Intrathecal infusion, intraspinal infusion, programmable infusion systems, spinal infusion, intra-spinal infusion devices, baclofen infusion, intrathecal opiates

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Pharmaceutical Care Applied to the Hospice Setting: A Cancer Pain Model

The Hospice Journal ◽

10.1080/0742-969x.1996.11882827 ◽

1996 ◽

Vol 11 (3) ◽

pp. 55-69

Author(s):

Pamela L. Burch ◽

Kimberly A. Hunter

Keyword(s):

Cancer Pain ◽

Pharmaceutical Care ◽

Pain Model

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Intrathecal Infusions for Intractable Cancer Pain: A Qualitative Study of the Impact on a Case Series of Patients and Caregivers

Pain Research and Management ◽

10.1155/2009/538675 ◽

2009 ◽

Vol 14 (5) ◽

pp. 371-379 ◽

Cited By ~ 9

Author(s):

Philippa Hawley ◽

Elizabeth Beddard-Huber ◽

Cameron Grose ◽

William McDonald ◽

Daphne Lobb ◽

...

Keyword(s):

Palliative Care ◽

Cancer Pain ◽

Case Series ◽

Palliative Care Unit ◽

Intractable Pain ◽

Management Service ◽

Palliative Care Setting ◽

Intractable Cancer Pain ◽

The Impact ◽

Intrathecal Infusion

BACKGROUND: The need for intrathecal infusion in a palliative care setting is infrequent. Despite established efficacy, safety and cost effectiveness, this is considered an ‘extraordinary measure’ in Canada. Patients requiring this approach are not typical palliative care patients, having shorter and more uncertain life expectancies.OBJECTIVES: The present study is a qualitative exploration of the impact of intrathecal pump implantation on cancer patients, and also the impact of the intervention on the staff caring for those patients.METHODS: Palliative care unit patients who received an implanted intrathecal pump or dome catheter for intractable cancer pain participated in multiple semistructured interviews. Doctors and nurses caring for each patient were also interviewed. Interviews were recorded and analyzed for themes. The study terminated when saturation was reached.RESULTS: Six patients participated, with up to three interviews each. Twenty-four staff interviews took place. Patients’ hopes and expectations were not always fully met, but the infusions had a profound positive effect on quality of life. Patients expressed anxiety about dependence on the device, and also on a few highly skilled individuals. Staff interviews revealed a significant impact on the ‘culture’ of the palliative care unit. Clear communication of the rationale for infusion was very important, as was regular education about infusion management.CONCLUSIONS: Implanted intrathecal infusion devices are a necessary part of a tertiary level cancer pain management service for the unfortunate minority with intractable pain. Practical recommendations for care are made for palliative care programs contemplating offering intrathecal infusions.

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Intrathecal Infusion Systems for Long-Term Management of Chronic Non-Cancer Pain: An Update of Assessment of Evidence

January 2018 - Pain Physician ◽

10.36076/ppj.2013/16/se185 ◽

2013 ◽

Vol 2s;16 (2s;4) ◽

pp. SE185-SE216

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Systematic Review ◽

Cancer Pain ◽

Quality Assessment ◽

Outcome Measures ◽

Observational Studies ◽

Randomized Trials ◽

Infusion Systems ◽

Term Management ◽

Intrathecal Infusion

Background: Intrathecal infusion systems are often used for patients with intractable pain when all else fails, including surgery. There is, however, some concern as to the effectiveness and safety of this treatment. Study Design: A systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. Objective: To evaluate and update the effect of intrathecal infusion systems in managing chronic non-cancer pain. Methods: The available literature on intrathecal infusion systems in managing chronic pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventative Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief with short-term relief < 12 months and long-term relief ≥ 12 months. Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: There were 28 studies identified for this systematic review. Of these, 21 were excluded from further review. A total of 7 non-randomized studies met inclusion criteria for methodological quality assessment. No randomized trials met the inclusion requirements. The evidence is limited based on observational studies. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: The evidence is limited for intrathecal infusion systems. Key words: Spinal pain, chronic low back pain, intrathecal infusion, intrathecal infusion systems, intrathecal drug delivery systems, intrathecal pumps, chronic non-cancer pain, chronic non-malignant pain, morphine, bupivacaine, ziconotide

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