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Qin W, Zhao L, Liu B, Yang Y, Mao P, Xu L, Li P, Shang Y, Zhang L, Fan B. Comparison of external system and implanted system in intrathecal therapy for refractory cancer pain in China: A retrospective study. Brain Behav 2023; 13:e2851. [PMID: 36545706 PMCID: PMC9847588 DOI: 10.1002/brb3.2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intrathecal therapy (ITT) via an implanted system was demonstrated for the treatment of refractory cancer pain for decades. Recently, the dissemination of ITT is enhanced in an external system way in Asia for a lower implantation cost. This study compares the efficacy, safety, and cost of the two ITT systems in refractory cancer pain patients in China. METHODS One hundred and thirty-nine cancer pain patients who underwent implantation of the ITT system were included. One hundred and three patients received ITT via the external system (external group), while 36 patients received ITT via the implanted system (implanted group). A 1:2 propensity score matching procedure was used to yield a total of 89 patients for the final analysis. Medical records of included patients were retrospectively reviewed and pain scores, incidences of complications, and costs were compared. RESULTS ITT via the external system provided pain relief as potent as ITT via the implanted system but was less time-consuming in the implantation phase (13 vs. 19 days, p < .01). Nausea/vomiting and urinary retention were the most frequent adverse events in both external and implanted groups (32.14%, 16.07% vs. 36.36%, 21.21%). No significant difference was found in the incidences of all kinds of complications. Compared to the implanted group, the external group cost less for the initial implantation (7268 vs. 26,275 US dollar [USD], p < .001) but had a significant higher maintenance cost (606.62 vs. 20.23 USD calculated monthly, p < .001). CONCLUSIONS ITT via the external system is as effective and safe as that via the implanted system and has the advantage of being cheap in the upfront implantation but costs more during the maintenance process in China.
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Affiliation(s)
- Wangjun Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhao
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Botao Liu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Yang Yang
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Peng Mao
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Liyuan Xu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Yongguang Shang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Lei Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Bifa Fan
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
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Strategies for interventional therapies in cancer-related pain-a crossroad in cancer pain management. Support Care Cancer 2019; 27:3133-3145. [PMID: 31093769 DOI: 10.1007/s00520-019-04827-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/23/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Interventional therapies are important to consider when facing cancer pain refractory to conventional therapies. The objective of the current review is to introduce these effective strategies into dynamic interdisciplinary pain management, leading to an exhaustive approach to supportive oncology. METHODS Critical reflection based on literature analysis and clinical practice. RESULTS Interventional therapies act on the nervous system via neuromodulation or surgical approaches, or on primitive or metastatic lesions via interventional radiotherapy, percutaneous ablation, or surgery. Interventional therapies such as neuromodulations are constantly evolving with new technical works still in development. Nowadays, their usage is better defined, depending on clinical situations, and their impact on quality of life is proven. Nevertheless their availability and acceptability still need to be improved. To start with, a patient's interdisciplinary evaluation should cover a wide range of items such as patient's performance and psychological status, ethical considerations, and physiochemical and pharmacological properties of the cerebrospinal fluid for intrathecal neuromodulation. This will help to define the most appropriate strategy. In addition to determining the pros and cons of highly specialized interventional therapies, their relevance should be debated within interdisciplinary teams in order to select the best strategy for the right patient, at the right time. CONCLUSIONS Ultimately, the use of the interventional therapies can be limited by the requirement of specific trained healthcare teams and technical support, or the lack of health policies. However, these interventional strategies need to be proposed as soon as possible to each patient requiring them, as they can greatly improve quality of life.
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Ahmad I, Ahmed MM, Ahsraf MF, Naeem A, Tasleem A, Ahmed M, Farooqi MS. Pain Management in Metastatic Bone Disease: A Literature Review. Cureus 2018; 10:e3286. [PMID: 30443456 PMCID: PMC6235631 DOI: 10.7759/cureus.3286] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/11/2018] [Indexed: 11/29/2022] Open
Abstract
Cancer means an uncontrolled division of abnormal cells in the body. It is a leading cause of death today. Not only the disease itself but its complications are also adding to the increase in mortality rate. One of the major complications is the pain due to metastasis of cancer. Pain is a complex symptom which has physical, psychological, and emotional impacts that influence the daily activities as well as social life. Pain acts as an alarm sign, telling the body that something is wrong. Pain can manifest in a multitude fashion. Management of bone pain due to metastasis involves different modes with some specific treatments according to the type of primary cancer. Over the years various treatment modalities have been tried and tested to improve the pain management including the use of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, bisphosphonates, tricyclic antidepressants, corticosteroids, growth factors and signaling molecules, ET-1 receptor antagonists, radiotherapy as well as surgical management. The topic of discussion will cover each one of these in detail.
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Affiliation(s)
- Imama Ahmad
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Munis M Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | | | - Anika Naeem
- Graduate, Allama Iqbal Medical College, Lahore, Pakistan, Lahore, PAK
| | - Azka Tasleem
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Moeed Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Muhammad S Farooqi
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
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Duarte RV, Lambe T, Raphael JH, Eldabe S, Andronis L. Intrathecal Drug Delivery Systems for the Management of Chronic Noncancer Pain: A Systematic Review of Economic Evaluations. Pain Pract 2017; 18:666-686. [DOI: 10.1111/papr.12650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/08/2017] [Accepted: 10/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rui V. Duarte
- Liverpool Reviews and Implementation Group; Department of Health Services Research; University of Liverpool; Liverpool U.K
| | - Tosin Lambe
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
| | - Jon H. Raphael
- Faculty of Health; Birmingham City University; Birmingham U.K
- Department of Pain Management; Russells Hall Hospital; Dudley U.K
| | - Sam Eldabe
- Department of Pain and Anaesthesia; The James Cook University Hospital; Middlesbrough U.K
| | - Lazaros Andronis
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
- Populations; Evidence and Technologies Group; Division of Health Sciences; University of Warwick; Coventry U.K
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Liu HJ, Li WY, Chen HF, Cheng ZQ, Jin Y. Long-Term Intrathecal Analgesia With a Wireless Analgesia Pump System in the Home Care of Patients With Advanced Cancer. Am J Hosp Palliat Care 2017; 34:148-153. [PMID: 26537661 DOI: 10.1177/1049909115615110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intrathecal analgesia is more effective than conservative delivery methods such as drugs administered orally or intravenously. Programmable devices such as Medtronic's SynchroMed systems have often been applied for long-term intrathecal analgesia. However, the totally implanted systems are very expensive in China. Considering cost-effectiveness, a reliable transmission protocol for a ZigBee-Based wireless analgesia pump system was used for long-term intrathecal analgesia in the home care of patients. METHODS We retrospectively investigated the efficacy, side effects, and complications of long-term intrathecal analgesia in the home care of patients via the wireless analgesia pump system. Follow-up visits occurred monthly for the initial 3 months after implantation and then every 3 months until patient death, withdrawal from the study, or removal of the device by a designated staff. At each follow-up visit, daily average pain score, pain frequency, satisfaction level, Spitzer Quality of Life Index, and side effects for every patient were recorded. RESULTS Pain intensity and frequency were significantly decreased by intrathecal analgesia via a wireless analgesia pump system. There were no significant differences in the satisfaction levels between hospitalization and each follow-up visit. The Spitzer Quality of Life Indexes were improved compared with patients who were hospitalized. No serious side effects were observed in this study. CONCLUSION Intrathecal analgesia is an effective and safe method for control of refractory cancer pain, and wireless analgesia pump systems can be safely and effectively used for long-term intrathecal analgesia management in the home care of patients with advanced cancer.
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Affiliation(s)
- Hong-Jun Liu
- 1 Department of Anesthesiology, Jinling Hospital, Nanjing, Peoples Republic of China, Nanjing, China
| | - Wei-Yan Li
- 1 Department of Anesthesiology, Jinling Hospital, Nanjing, Peoples Republic of China, Nanjing, China
| | - Hao-Fei Chen
- 1 Department of Anesthesiology, Jinling Hospital, Nanjing, Peoples Republic of China, Nanjing, China
| | - Zhu-Qiang Cheng
- 1 Department of Anesthesiology, Jinling Hospital, Nanjing, Peoples Republic of China, Nanjing, China
| | - Yi Jin
- 1 Department of Anesthesiology, Jinling Hospital, Nanjing, Peoples Republic of China, Nanjing, China
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Bhatnagar S, Gupta M. Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain. Indian J Palliat Care 2015; 21:137-47. [PMID: 26009665 PMCID: PMC4441173 DOI: 10.4103/0973-1075.156466] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Onco-Anaesthesia, Pain and Palliative Care, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Maynak Gupta
- Department of Anaesthesia, Shri Guru Rai Institute of Medical and Health Sciences, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India
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Abstract
Advances in intrathecal analgesia and intrathecal drug delivery systems have allowed for a range of medications to be used in the control of pain and spasticity. This technique allows for reduced medication doses that can decrease the side effects typically associated with oral or parenteral drug delivery. Recent expert panel consensus guidelines have provided care paths in the treatment of nociceptive, neuropathic, and mixed pain syndromes. While the data for pain relief, adverse effect reduction, and cost-effectiveness with cancer pain control are compelling, the evidence is less clear for noncancer pain, other than spasticity. Physicians should be aware of mechanical, pharmacological, surgical, and patient-specific complications, including possible granuloma formation. Newer intrathecal drug delivery systems may allow for better safety and quality of life outcomes.
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Affiliation(s)
- Michael M Bottros
- Division of Pain Medicine, Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Heo BH, Pyeon TH, Lee HG, Kim WM, Choi JI, Yoon MH. Epidural Infusion of Morphine and Levobupivacaine through a Subcutaneous Port for Cancer Pain Management. Korean J Pain 2014; 27:139-44. [PMID: 24748942 PMCID: PMC3990822 DOI: 10.3344/kjp.2014.27.2.139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/10/2014] [Accepted: 02/19/2014] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND To manage intractable cancer pain, an alternative to systemic analgesics is neuraxial analgesia. In long-term treatment, intrathecal administration could provide a more satisfactory pain relief with lower doses of analgesics and fewer side-effects than that of epidural administration. However, implantable drug delivery systems using intrathecal pumps in Korea are very expensive. Considering cost-effectiveness, we performed epidural analgesia as an alternative to intrathecal analgesia. METHODS We retrospectively investigated the efficacy, side effects, and complications of epidural morphine and local anesthetic administration through epidural catheters connected to a subcutaneous injection port in 29 Korean terminal cancer patients. Patient demographic data, the duration of epidural administration, preoperative numerical pain rating scales (NRS), side effects and complications related to the epidural catheterization and the drugs, and the numerical pain rating scales on the 1st, 3rd, 7th and 30th postoperative days were determined from the medical records. RESULTS The average score for the numerical pain rating scales for the 29 patients decreased from 7 ± 1.0 at baseline to 3.6 ± 1.4 on postoperative day 1 (P < 0.001). A similar decrease in pain intensity was maintained for 30 days (P < 0.001). Nausea and vomiting were the most frequently reported side effects of the epidural analgesia and two patients (6.9%) experienced paresthesia. CONCLUSIONS Epidural morphine and local anesthetic infusion with a subcutaneous pump seems to have an acceptable risk-benefit ratio and allows a high degree of autonomy to patients with cancer pain.
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Affiliation(s)
- Bong Ha Heo
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Tae Hee Pyeon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyung Gon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Woong Mo Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jeong Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Ha Yoon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
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9
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Joshi M, Chambers WA. Pain relief in palliative care: a focus on interventional pain management. Expert Rev Neurother 2014; 10:747-56. [DOI: 10.1586/ern.10.47] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Krames E, Poree L, Deer T, Levy R. Implementing the SAFE Principles for the Development of Pain Medicine Therapeutic Algorithms That Include Neuromodulation Techniques. Neuromodulation 2013; 12:104-13. [PMID: 22151283 DOI: 10.1111/j.1525-1403.2009.00197.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Currently accepted chronic pain treatment algorithms have positioned therapies according to levels of invasiveness and up-front costs. After reviewing updated literature on efficacy and cost outcomes of care for patients with chronic pain that include interventional implantable technologies, we offer a new model of thinking when formulating algorithms of care that might include more invasive and costly interventions such as spinal cord stimulation, the SAFE principles. These SAFE principles include "safety,""appropriateness,""fiscal neutrality," and "efficacy."
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Affiliation(s)
- Elliot Krames
- Pacific Pain Treatment Centers, San Francisco, CA, USA; Pain Clinic of Monterey Bay, Aptos, CA, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA; Center for Pain Relief Inc., Charleston, WV, USA; West Virginia University School of Medicine, Morgantown, WV, USA; Departments of Neurologic Surgery and Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Brogan SE, Winter NB, Abiodun A, Safarpour R. A cost utilization analysis of intrathecal therapy for refractory cancer pain: identifying factors associated with cost benefit. PAIN MEDICINE 2013; 14:478-86. [PMID: 23461787 DOI: 10.1111/pme.12060] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Intrathecal therapy (ITT) for cancer pain is characterized by high initial cost followed by low maintenance costs. Non-ITT pain management is associated with steadily increasing cumulative cost that can equal the cost of ITT over time. The intent of this modeling project is to identify factors associated with relatively rapid achievement of cost-benefit with ITT. DESIGN A retrospective chart review was performed on 36 patients with cancer pain who underwent ITT and survived beyond 4 weeks. METHODS Data on the cost of conventional opioid therapy prior to ITT and at 4-6 weeks were collected and projected over time. ITT costs included all intrathecal pump implantation and maintenance costs. Pre-ITT opioid regimens were stratified into high-cost conventional (HCC-high-dose, nongeneric, or use of intravenous patient-controlled analgesia, N = 12) and low-cost conventional (low-dose or generic, N = 24) regimens. RESULTS The median daily cost of opioid medications pre-ITT was $21.26 (25th-75th percentile $10.31-78.85, range 0-$971.97) vs $0 (25th-75th percentile $0-0.70), P = 0.007, post-ITT. In the HCC group, the median daily cost was $172.47 (25th-75th percentile $67.29-406.20). The median daily cost of ITT medications was $16.01 (25th-75th percentile $9.52-23.23).When these data were used to model costs over the long term, including pump implantation costs, cost-benefit for all patients compared with conventional therapy was predicted at 344 months but at 7.4 months in the HCC group. Seven patients (19%) achieved cost equivalence within 6 months and three of these within the first 3 months. CONCLUSIONS In selected patients on high-cost opioid regimens, ITT may become cost-beneficial within 6 months. Factors associated with earlier attainment of ITT cost-benefit include the use of parenteral therapy, high-dose opioids, and the use of nongeneric opioid products.
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Affiliation(s)
- Shane E Brogan
- Department of Anesthesiology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84132, USA.
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Poree L, Krames E, Pope J, Deer TR, Levy R, Schultz L. Spinal cord stimulation as treatment for complex regional pain syndrome should be considered earlier than last resort therapy. Neuromodulation 2013; 16:125-41. [PMID: 23441988 DOI: 10.1111/ner.12035] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 10/30/2012] [Accepted: 11/26/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach. METHODS We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care. RESULTS AND CONCLUSION Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed.
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Affiliation(s)
- Lawrence Poree
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
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Deer T, Winkelmüller W, Erdine S, Bedder M, Burchiel K. Intrathecal therapy for cancer and nonmalignant pain: patient selection and patient management. Neuromodulation 2012; 2:55-66. [PMID: 22151109 DOI: 10.1046/j.1525-1403.1999.00055.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. Patient selection criteria for cancer and nonmalignant pain are similar; however, a more comprehensive psychological and social assessment is required for patients with nonmalignant pain. In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
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Affiliation(s)
- T Deer
- The Center for Pain Relief, Charleston, West Virginia, USA; Gemeinschaftspraxis für Neurochirurgie, Hannover, Germany; Department of Algology, Medical Faculty of Istanbul, Istanbul, Turkey; Advanced Pain Management Group, Inc., Portland, Oregon, USA; Oregon Health Sciences University, Portland, Oregon, USA
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Hamza M, Doleys D, Wells M, Weisbein J, Hoff J, Martin M, Soteropoulos C, Barreto J, Deschner S, Ketchum J. Prospective Study of 3-Year Follow-Up of Low-Dose Intrathecal Opioids in the Management of Chronic Nonmalignant Pain. PAIN MEDICINE 2012; 13:1304-13. [DOI: 10.1111/j.1526-4637.2012.01451.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Singh M, Cugati G, Singh P, Singh AK. Programmable morphine pump (an intrathecal drug delivery system) - A promising option for pain relief and palliation in cancer patients. Indian J Med Paediatr Oncol 2012; 33:58-9. [PMID: 22754212 PMCID: PMC3385282 DOI: 10.4103/0971-5851.96974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Manish Singh
- Department of Neurosurgery, JIPMER, Puducherry, India E-mail:
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Jeon YS, Lee JA, Choi JW, Kang EG, Jung HS, Kim HK, Shim BY, Park JH, Joo JD. Efficacy of epidural analgesia in patients with cancer pain: a retrospective observational study. Yonsei Med J 2012; 53:649-53. [PMID: 22477012 PMCID: PMC3343439 DOI: 10.3349/ymj.2012.53.3.649] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Pain in terminal cancer patients may be refractory to systemic analgesics or associated with adverse drug reactions to analgesics. Epidural analgesia has been effectively used in such patients for pain control. However, this method does not provide pain relief to all patients. The efficacy and complications of continuous epidural analgesia were evaluated for expanding efficacy in terminal cancer patients. MATERIALS AND METHODS The charts of patients who received epidural analgesia for over 5 years for the control of terminal cancer pain were reviewed retrospectively. RESULTS Ninety-six patients received 127 epidural catheters. The mean duration for epidural catheterization was 31.5±55.6 (5-509) days. The dose of epidural morphine increased by 3.5% per day. The efficacy of epidural analgesia at 2 weeks follow up revealed improved pain control (n=56), as the morphine equivalent drug dose dropped from 213.4 mg/day to 94.1 mg/day (p<0.05) at 2 weeks follow up. Accordingly, after 2 weeks institution of epidural analgesia, there was a significant reduction in the proportion of patients with severe pain, from 78.1% to 19.6% (p<0.05). CONCLUSION Epidural analgesia was an effective pain control method in patients with terminal cancer pain, however, a systematized algorithm for the control of cancer-related pain in needed.
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Affiliation(s)
- Yeon Soo Jeon
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jung Ah Lee
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jin Woo Choi
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Eu Gene Kang
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hoon Kyo Kim
- Department of Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Byoung Yong Shim
- Department of Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae Hee Park
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Krames ES. A History of Intraspinal Analgesia, a Small and Personal Journey. Neuromodulation 2012; 15:172-93; discussion 193. [DOI: 10.1111/j.1525-1403.2011.00414.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Upadhyay SP, Mallick PN. Intrathecal drug delivery system (IDDS) for cancer pain management: a review and updates. Am J Hosp Palliat Care 2011; 29:388-98. [PMID: 22089523 DOI: 10.1177/1049909111426134] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cancer pain remains undertreated and a significant number of patients with cancer pain die from severe untreated pain. With increasing survival rate in cancer, the prevalence of cancer pain is also increasing in number. Though majority of patients with cancer pain can be effectively treated with conventional medical management, still a significant portion of patients required some form of interventional pain management techniques. Among the interventional techniques, intrathecal drug delivery is increasingly used in cancer pain management. Our objective of this article is to review literatures and clinical studies on intrathecal drug delivery system (IDDS) in cancer pain management and to provide updates on its use, precautions, contraindications, side effects and its management, socioeconomic consideration, and management of IDDS in difficult or uncommon situations.
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Affiliation(s)
- Surjya Prasad Upadhyay
- Department of Anaesthesiology, Critical care and Pain management, Al Jahra Hospital, Ministry of Health, State of Kuwait, Kuwait.
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19
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de Courcy J. Interventional Techniques for Cancer Pain Management. Clin Oncol (R Coll Radiol) 2011; 23:407-17. [DOI: 10.1016/j.clon.2011.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/13/2010] [Accepted: 04/05/2011] [Indexed: 12/11/2022]
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20
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Krames ES, Monis S, Poree L, Deer T, Levy R. Using the SAFE Principles When Evaluating Electrical Stimulation Therapies for the Pain of Failed Back Surgery Syndrome. Neuromodulation 2011; 14:299-311; discussion 311. [DOI: 10.1111/j.1525-1403.2011.00373.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Schuchard M, Lanning R, North R, Reig E, Krames E. Neurologic Sequelae of Intraspinal Drug Delivery Systems: Results of a Survey of American Implanters of Implantable Drug Delivery Systems. Neuromodulation 2010; 1:137-48. [DOI: 10.1111/j.1525-1403.1998.tb00007.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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24
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25
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Tay W, Ho KY. The Role of Interventional Therapies in Cancer Pain Management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.
Key words: Intractable pain, Intrathecal analgesia, Neurolysis
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Intrathecal Analgesics, Choice of System. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00035-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Abstract
Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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30
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Abstract
Most patients with cancer pain achieve good analgesia using traditional analgesics and adjuvant medications; however, an important minority of patients (2% to 5%) suffers from severe and refractory cancer pain. For these individuals, spinal analgesics (intrathecal or epidural) provide significant hope for pain relief over months or years of treatment to help improve quality of life. Spinal analgesics have been suggested as the fourth step in the World Health Organization guidelines in the management of cancer pain, and thus the pain physician should be familiar with principles of use. Most patients achieve pain relief using spinal analgesics, with a minimum of complications that are easily managed at home. A variety of opioids, local anesthetics, clonidine, ketamine, and other analgesics are available for the spinal route of administration and should be titrated to clinical effect or intolerable side effect. This article discusses the appropriate selection of patients for spinal analgesics, reviews current recommended infusion systems and current spinal analgesics, discusses possible complications, and includes practical suggestions for patient management.
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Affiliation(s)
- Paul A Sloan
- University of Kentucky Medical Center, Lexington, KY 40536, USA.
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31
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Likar R, Ilias W, Kloimstein H, Kofler A, Kress HG, Neuhold J, Pinter MM, Spendel MC. Stellenwert der intrathekalen Schmerztherapie. Schmerz 2007; 21:15-8, 20-4, 26-7. [PMID: 17109113 DOI: 10.1007/s00482-006-0515-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intraspinal drug infusion using implantable pumps and catheter systems is a safe and effective therapy for selected pain patients with severe chronic pain. It improves pain relief, reduces drug-related side effects, decreases the need for oral analgesia and enhances quality of life in a segment of chronic pain patients whose pain has not been controlled with more conservative therapies. Intrathecal drug therapy has therefore established its role in the treatment of malignant pain, benign pain and severe spasticity.Careful patient selection and management as well as a multidisciplinary approach are determinants of successful treatment. Current practices for patient selection and management, screening, drug selection, dosing and implantation for intrathecal drug delivery systems are discussed.
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Affiliation(s)
- R Likar
- Landeskrankenhaus, Klagenfurt.
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32
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Hong D, Andrén-Sandberg A. Punctate midline myelotomy: a minimally invasive procedure for the treatment of pain in inextirpable abdominal and pelvic cancer. J Pain Symptom Manage 2007; 33:99-109. [PMID: 17196911 DOI: 10.1016/j.jpainsymman.2006.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 06/27/2006] [Accepted: 06/27/2006] [Indexed: 10/23/2022]
Abstract
The midline of the dorsal column contains a pathway that may be more important for transmitting visceral nociceptive signals than the spinothalamic tract. Punctate midline myelotomy, a neuroablative operation with the intent of interrupting the midline of the dorsal column, has demonstrated efficacy in the treatment of otherwise intractable abdominal and pelvic cancer pain. The indications, technical procedure, outcomes, and complications of all published clinical studies of punctate midline myelotomy are reviewed. The lesion level of the spinal cord and the depth of the incision are discussed, with the focus on the feasibility of this technique.
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Affiliation(s)
- Dun Hong
- Department of Spine Surgery, Taizhou Hospital, Whenzhou University, Taizhou, China
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33
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Thai V, Fainsinger RL. Pain. Palliat Care 2007. [DOI: 10.1016/b978-141602597-9.10007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lou L, Orbegozo M, King CL. Rationale and technique for single and multiple drug combinations in long-term intrathecal infusions. Pain Pract 2006; 1:68-78; quiz 79-80. [PMID: 17129286 DOI: 10.1046/j.1533-2500.2001.01010.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- L Lou
- International Pain Institute, Texas Tech University Health Sciences Center, Lubbock, Texas 79413, USA
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Abstract
Inadequately managed cancer pain continues to be a significant problem despite increased awareness, improved knowledge and understanding of pain pathophysiology, and standardized treatment guidelines of this distressing and debilitating symptom complex. Small subsets of patients who are refractory to optimal medical management because of drug toxicity or unsatisfactory analgesia may be candidates for exteriorized or implantable intrathecal drug delivery systems. By delivering opioids and other agents directly to the central nervous system, intrathecal drug administration can offer superior pain relief with less toxicity at a fraction of the systemic dose. With adjuncts such as local anesthetics and clonidine, intrathecal therapy also allows for broader therapeutic options in the most difficult of cases. In general, intrathecal therapy is underused despite evidence of its efficacy, safety, and cost-effectiveness.
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Affiliation(s)
- Shane E Brogan
- University of Utah, Department of Anesthesiology, Salt Lake City, UT 84132, USA.
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36
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Abstract
This article provides information regarding treatments for the management of moderate to severe pain in patients who are at the end of life. Discussion focuses on the use of strong opioids and adjuvant analgesics. Special attention also is given to the most frequently used forms of interventional pain management. Although pain in terminally ill patients is not always related to cancer, many of the studies cited in this article were performed in cancer patients, a model that informs much of what is presented.
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Affiliation(s)
- Mario De Pinto
- Department of Anesthesiology, University of Washington Harborview Medical Center, Box 356540, 325 9th Avenue, Seattle, WA 98104, USA.
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Smith TJ, Coyne PJ. Implantable drug delivery systems (IDDS) after failure of comprehensive medical management (CMM) can palliate symptoms in the most refractory cancer pain patients. J Palliat Med 2005; 8:736-42. [PMID: 16128647 DOI: 10.1089/jpm.2005.8.736] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A randomized clinical trial of implantable drug delivery system (IDDS) plus comprehensive medical management (CMM) versus CMM alone in 200 patients with refractory cancer pain showed better clinical success with IDDS. The objective of this study was to evaluate whether IDDS could help the most refractory patients failed by expert CMM. PATIENTS AND METHODS This was a planned longitudinal prospective analysis of 30 of 99 (30%) patients for whom CMM failed who crossed over to IDDS by 6 months, as part of the randomized clinical trial. Patients had a pain visual analogue scale (VAS) score of 5 or more despite CMM with 320 mg or morphine-equivalent opioids and adjunct drugs for 1 month. The intervention was an implantable intrathecal programmable pump with opioids and local anesthetics. Clinical success was measured as a 20% change in pain VAS score and NCI CTEP drug toxicity scales. RESULTS Clinical success was achieved with pain scores and drug toxicity scores significantly reduced by 27% (p = 0.011) and 51% (p < 0.0001). Median survival was 103 days after IDDS implant, similar to IDDS patients who received implantation as part of the initial randomization. CONCLUSIONS CMM patients who crossed over to IDDS for the most refractory pain had significant reductions in pain and drug toxicity. The survival time of 3 months may be long enough for the IDDS implant to be cost effective. In this prospective longitudinal study, patients with refractory cancer pain despite comprehensive medical management derived benefit from IDDS.
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Affiliation(s)
- Thomas J Smith
- Thomas Palliative Care Unit, Division of Hematology/Oncology and Palliative Care, Virginia Commonwealth University, MCV Box 980230, Richmond, VA 23298-0230, USA.
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38
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Abstract
Epidural and intrathecal catheters have increasingly become a part of acute and chronic pain management over the past 25 years. Externalized systems include temporary, permanent exteriorized, and permanent port systems for use over weeks to months of expected therapy. Implanted, completely internalized systems are available for conditions expected to require many months or years of therapy. Expert care includes routine management as well as advanced troubleshooting. Prevention of infection is a key priority for nurses managing these devices.
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Affiliation(s)
- Anna Du Pen
- Peninsula Pain Clinic, 2601 Cherry Avenue #304, Bremerton, WA 98310, USA.
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39
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Abstract
Interventional pain therapies play a critical role in palliation of severe cancer pain. Anesthesiologists specializing in cancer pain management have developed minimally invasive techniques to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients. A thorough understanding of the pathophysiology of the cancer pain is needed to implement interventional therapies. It is also important to understand the prognosis of the patient, associated comorbidities, and expectations of the patient and family. Interventional pain therapies are minimally invasive techniques that can be divided into direct drug delivery, neuroablation and neural blockade, and neurostimulation.
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Affiliation(s)
- Philip S Kim
- St. Francis Pain Center, Center for Pain Medicine, Bryn Mawr, PA 19010, USA.
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40
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Smith TJ, Coyne PJ, Staats PS, Deer T, Stearns LJ, Rauck RL, Boortz-Marx RL, Buchser E, Català E, Bryce DA, Cousins M, Pool GE. An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug-related toxicity, and possibly better survival compared with comprehensive medical management (CMM). Ann Oncol 2005; 16:825-33. [PMID: 15817596 DOI: 10.1093/annonc/mdi156] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The randomized clinical trial of implantable drug delivery systems (IDDS) plus comprehensive medical management (CMM) versus CMM alone showed better clinical success at 4 weeks for IDDS patients. This 'as treated' analysis assessed if improvements in pain control, drug toxicity and survival were maintained over time. PATIENTS AND METHODS We compared those who received IDDS with those who did not receive IDDS (non-IDDS). All patients had Visual Analogue Scores (VAS) for pain > or =5/10 on at least 200 mg morphine or equivalent daily. RESULTS At 4 weeks, 46 of 52 (88.5%) IDDS patients achieved clinical success compared with 65 of 91 (71.4%; P=0.02) non-IDDS patients, and more often achieved > or =20% reduction in both pain VAS and toxicity [35 of 52 (67.3%) versus 33 of 91 patients (36.3%); P=0.0003]. By 12 weeks, 47 of 57 (82.5%) IDDS patients had clinical success compared with 35 of 45 (77.8%; P=0.55) non-IDDS patients, and more often had a > or =20% reduction in both pain VAS and toxicity [33 of 57 (57.9%) versus 15 of 45 patients (33.3%); P=0.01]. At 12 weeks the IDDS VAS pain scores decreased from 7.81 to 3.89 (47% reduction) compared with 7.21 to 4.53 for non-IDDS patients (42% reduction; P=0.23). The 12 week drug toxicity scores for IDDS patients decreased from 6.68 to 2.30 (66% reduction), and for non-IDDS patients from 6.73 to 4.13 (37% reduction; P=0.01). All individual drug toxicities improved with IDDS at both 4 and 12 weeks. At 6 months, only 32% of the group randomized to CMM and who did not cross over to IDDS were alive, compared with 52%-59% for patients in those groups who received IDDS. CONCLUSIONS IDDS improved clinical success, reduced pain scores, relieved most toxicity of pain control drugs, and was associated with increased survival for the duration of this 6 month trial.
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Affiliation(s)
- T J Smith
- Massey Cancer Center of Virginia Commonwealth University and other institutions, Richmond, VA 23298, USA.
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41
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Burton AW, Rajagopal A, Shah HN, Mendoza T, Cleeland C, Hassenbusch SJ, Arens JF. Epidural and intrathecal analgesia is effective in treating refractory cancer pain. PAIN MEDICINE 2004; 5:239-47. [PMID: 15367301 DOI: 10.1111/j.1526-4637.2004.04037.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.
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Affiliation(s)
- Allen W Burton
- Department of Anesthesiology, University of Texas M.D.Anderson Cancer Center, Houston, Texas 77030, USA.
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42
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de Leon-Casasola OA. Interventional Procedures for Cancer Pain Management: When Are They Indicated? Cancer Invest 2004; 22:630-42. [PMID: 15565820 DOI: 10.1081/cnv-200027166] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Non-invasive pharmacological management of patients with cancer related pain has resulted in pain control in 90-95% of the patients. Thus, 5-10% of patients still experience inadequate pain control despite aggressive combined pharmacological therapy. Moreover, patients may not tolerate an aggressive program of titration of medications and fail this approach because of side effects. In these patients interventional techniques have been very useful. This article discusses the alternative therapies, as well as the pitfalls in implementing these therapies, to achieve the highest possible success while minimizing potential complications and side effects.
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43
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Abstract
Intraspinal analgesia can be helpful in some patients with intractable pain. Over 15 years palliative care professionals evolved their spinals policy through a repeated series of evaluations, discussions and literature reviews. One hundred intraspinal lines were then reviewed. Notable changes in policy were the switch from epidurals to intrathecals, and the insertion of lines during working hours rather than as emergencies. Our efficacy, and frequency of adverse effects, is equal or better to published studies. Key issues in reducing adverse effects were the improved care of the spinal line exit site, a change from bolus administration to continuous infusions, and modifying line insertion techniques. Current policy is to use continuous infusions of diamorphine and bupivacaine in a 1:5 ratio through externalized intrathecal lines. The lines are effective in approximately two thirds of patients and can be kept in place for up to 18 months. The policy continues to be updated and common documentation is now in place.
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Affiliation(s)
- Lisa Baker
- St. Oswald's Hospice, Newcastle upon Tyne, UK.
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44
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Nguyen H, Hassenbusch SJ. Cost-effectiveness of intraspinal drug delivery for chronic pain. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.spmd.2004.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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45
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Fortner BV, Okon TA, Portenoy RK. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. THE JOURNAL OF PAIN 2003; 3:38-44. [PMID: 14622852 DOI: 10.1054/jpai.2002.27136] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pain is a common problem for cancer patients and can result in substantial medical costs, but little is known about the characteristics of pain that may predict these costs. This study applied telephone survey methodology to investigate the relationship between breakthrough pain (BTP) and the use of medical resources in a cancer population with pain. A nonrandom sample of 1,000 cancer patients was contacted by using standard telephone survey techniques. Eligible patients were questioned about the occurrence of BTP and pain-related hospitalizations, emergency department visits, and physician office visits. Patients who indicated that they had experienced BTP were compared with similar patients who had not experienced BTP by using cost estimations derived from patient reports of health care use. The analysis indicated that BTP patients were more likely to have experienced pain-related hospitalizations and physician office visits. When statistical control was made for patient ratings of the effectiveness of scheduled analgesics, BTP had higher costs associated with pain-related hospitalizations and physician office visits. The total cost of pain-related hospitalizations, emergency visits, and physician office visits was 12,000 US dollars/yr per BTP patient and 2,400 US dollars/yr per non-BTP patient. Cancer patients with BTP may sustain higher direct medical costs than patients without BTP. Implications and limitations of the study are discussed, and studies that will further clarify the relationship between BTP and medical costs are encouraged.
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46
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Affiliation(s)
- Thomas J. Smith
- Virginia Commonwealth University, Division of Hematology/Oncology and Palliative Care, Richmond, VA
| | - Peter Staats
- Virginia Commonwealth University, Division of Hematology/Oncology and Palliative Care, Richmond, VA
| | - Patrick J. Coyne
- Virginia Commonwealth University, Division of Hematology/Oncology and Palliative Care, Richmond, VA
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47
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Peverini M, Lo Presti C, Romeo M. Infusional Devices for Cancer Pain. Neuromodulation 2003. [DOI: 10.1046/j.1525-1403.2003.03027_9.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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48
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49
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Fortner BV, Demarco G, Irving G, Ashley J, Keppler G, Chavez J, Munk J. Description and predictors of direct and indirect costs of pain reported by cancer patients. J Pain Symptom Manage 2003; 25:9-18. [PMID: 12565184 DOI: 10.1016/s0885-3924(02)00597-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to describe direct and indirect costs associated with pain in cancer patients and to examine potential predictors of these costs. The study surveyed cancer outpatients about direct costs resulting from pain-related hospitalizations, emergency department visits, physician office visits, and use of analgesic medications and indirect costs related to money spent on pain-related transportation, complementary methods to improve pain management, educational materials, over-the counter medication, domestic support, and childcare. Furthermore, the study examined age, marital status, race, income level, pain severity, pain interference, and presence of breakthrough pain as predictors of direct and indirect costs. Three hundred and seventy-three cancer outpatients were sampled. One hundred and forty-four cancer patients (39%) reported experiencing cancer-related pain and completed the study questionnaires. Seventy-six percent (76%) of the patients had experienced at least one pain-related cost, resulting in an average monthly direct cost of US$ 891/month per patient. Sixty-nine percent (69%) of patients had experienced some type of direct medical cost due to pain, resulting in an average total direct pain-related cost of US$ 825/month per patient. Fifty-seven percent (57%) of patients reported incurring at least one indirect pain-related expense for an average indirect cost of US$ 61/month per patient. Higher pain intensity, greater pain interference, and presence of breakthrough pain predicted higher direct and indirect medical expenses. Younger age and lower income level also predicted higher direct medical expenses.
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Abstract
The cost of chronic benign spinal pain is large and growing. The costs of interventional treatment for spinal pain were at a minimum of $13 billion (U.S. dollars) in 1990, and the costs are growing at least 7% per year. Medical treatment of chronic pain costs $9000 to $19,000 per person per year. The costs of interventional therapy is calculated. Methods of evaluating differential treatments in terms of costs are described. Cost-minimization versus cost-effectiveness approaches are described. Spinal cord stimulation and intraspinal drug infusion systems are alternatives that can be justified on a cost basis. Cost minimization analysis suggests that epidural injections under fluoroscopy may not be justified by the current literature.
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