David Caraway

Polyanalgesic consensus conference 2007: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel.

Background.  Expert panels of physicians and nonphysicians in the field of intrathecal therapies convened in 2000 and 2003 to make recommendations for the rational use of intrathecal analgesics based on the preclinical and clinical literature known up to those times. An expert panel of physicians convened in 2007 to update previous recommendations and to form guidelines for the rational use of intrathecal opioid and nonopioid agents.

Polyanalgesic Consensus Conference 2012: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel: INTRATHECAL THERAPY CONSENSUS

Introduction:  The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences.

The Appropriate Use of Neurostimulation of the Spinal Cord and Peripheral Nervous System for the Treatment of Chronic Pain and Ischemic Diseases: The Neuromodulation Appropriateness Consensus Committee

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

Clinical experience with intrathecal bupivacaine in combination with opioid for the treatment of chronic pain related to failed back surgery syndrome and metastatic cancer pain of the spine

BACKGROUND CONTEXT Bupivacaine is a local anesthetic agent of the amide class. This drug has been used in many clinical situations including intrathecal infusion. The literature regarding intrathecal bupivacaine is limited to small case studies, and anecdotal reports. This article examines a large patient group receiving bupivacaine with opioids over an extended period of time and analyzes efficacy and safety. The patients had pain related to failed back surgery syndrome or metastatic cancer to the spine. PURPOSE The purpose of this study was to determine the efficacy and safety of intrathecal bupivacaine combined with opioids for treatment of pain of spinal origin when opioids alone were inadequate. The secondary purpose of this study was to determine if the combination of bupivacaine and opioids created a neurological safety risk. STUDY DESIGN/SETTING The study design was retrospective, and involved consecutive medical records review by a disinterested third party. PATIENT SAMPLE One hundred nine consecutive patients were studied for a total of 6,780 patient weeks of bupivacaine/opioid infusion. These data were compared with a comparable time in the opioid alone treatment arm. The population included 84 noncancer patients and 25 cancer patients. OUTCOME MEASURES The primary outcome measure was pain relief obtained by a group of patients with a combination of bupivacaine and opioids as compared with opioid alone when delivered by intrathecal infusion. The visual analog scale was used to measure pain levels. Secondary objectives included measuring the amount of oral and transdermal medication required (opioid and nonopioid), emergency visits, routine office visits and patient satisfaction. These secondary objectives give a measure of health-care utilization. We also reviewed neurological complications during the combined arm of treatment. METHODS The study was done retrospectively with 109 consecutive patients. Patient chart reviews were used to determine the visual analog scales, amount of oral opioids, oral nonopioid adjuvant and patient satisfaction ratings. Patient satisfaction and pain rating was measured by a visual analog scale. Other factors recorded were emergency room visits, doctors visits (other than the primary pain physician) and pain center visits. We also reviewed records for neurological deficits in the opioid arm and the combined arm. The t test was used to analyze statistical significance. RESULTS The findings suggested that in the combination arm the pain relief was significantly better (p=.008), the number of oral opioids used were significantly less (p=.008), the number of oral nonopioid adjuvants were reduced, the number of doctors visits were less in the combined arm (p=.008), the number of pain clinic visits were less (p=.03), the number of emergency visits were significantly less (p=.01) and patient satisfaction was better (p=.003). The total dose of morphine was reduced by 23% in the combined arm (p=.005). During the course of treatment with intrathecal bupivacaine, there were no irreversible complications. CONCLUSION Bupivacaine, when used in combination with opioids, is a helpful and safe method of treatment in a select population of patients who have not responded to intrathecal opioids alone.

Polyanalgesic Consensus Conference--2012: recommendations to reduce morbidity and mortality in intrathecal drug delivery in the treatment of chronic pain.

Introduction:  Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality.

Polyanalgesic Consensus Conference--2012: recommendations on trialing for intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel.

Introduction:  Trialing for intrathecal pump placement is an essential part of the decision‐making process in placing a permanent device. In both the United States and the international community, the proper method for trialing is ill defined.

Best practices for intrathecal drug delivery for pain.

The objective of this study was to identify best practices and provide guidance to clinicians to ensure safety and optimize intrathecal drug delivery for chronic intractable pain.

Polyanalgesic Consensus Conference—2012: Consensus on Diagnosis, Detection, and Treatment of Catheter‐Tip Granulomas (Inflammatory Masses)

Introduction:  Continuous intrathecal infusion of drugs to treat chronic pain and spasticity has become a standard part of the algorithm of care. The use of opioids has been associated with noninfectious inflammatory masses at the tip of the intrathecal catheter, which can result in neurologic complications.

Management of Intrathecal Catheter‐Tip Inflammatory Masses: An Updated 2007 Consensus Statement From An Expert Panel

Background.  Expert panel of physicians and nonphysicians, all expert in intrathecal (IT) therapies, convened in the years 2000 and 2003 to make recommendations for the rational use of IT analgesics based on the preclinical and clinical literature known up to those times, presentations of the expert panel, discussions on current practice and standards, and the result of surveys of physicians using IT agents. An expert panel of physicians and convened in 2007 to review previous recommendations and to form recommendations for the rational use of IT agents as they pertain to new scientific and clinical information regarding the etiology, prevention and treatment for IT granuloma.