Targeted Drug Delivery for Chronic Nonmalignant Pain: Longitudinal Data From the Product Surveillance Registry

Intrathecal Drug Delivery for Intractable Pain: Identified Patient Satisfaction Survey Study Comparing Intrathecal Dose With Satisfaction, Pain Relief, and Side Effects

OBJECTIVES

Past studies have shown the efficacy of spinal targeted drug delivery (TDD) in pain relief, reduction in opioid use, and cost-effectiveness in long-term management of complex chronic pain. We conducted a survey to determine treatment variables associated with patient satisfaction.

MATERIALS AND METHODS

Patients in a single pain clinic who were implanted with Medtronic pain pumps to relieve intractable pain were identified from our electronic health record. From November 2021 to February 2023, 973 patients with active TDD were identified; 564 completed the 23-question survey, and 560 were included in analyses. Most patients (96.4%) had intrathecal (IT) infusion admixtures containing bupivacaine and opioid. The survey compared satisfaction with IT medication dosages, pain relief, pain diagnosis, catheter tip location, side effects, mental clarity, physical functioning, and healthcare utilization. Outcomes were reported as proportions; p < 0.05 was considered significant.

RESULTS

Most respondents reported good-to-excellent pain relief (63.8%), high satisfaction with TDD (80.7%), improvement in physical functioning (75.0%), and better quality of life (89.7%); 78.5% of respondents reported complete discontinuation or substantial reductions in systemic opioid use. There was a statistically significant relationship between satisfaction and IT medication dose (p = 0.02), with the average dose increasing with higher satisfaction groups. We found that patients on higher doses of IT opioids did not have more bothersome side effects (p = 0.05).

CONCLUSIONS

Our data show that the most satisfied respondents had higher IT doses, fewer side effects, and longer duration of TDD therapy. This suggests that higher dose IT admixtures are safe and effective at relieving pain and improving quality of life in patients with complex chronic pain whose condition has failed to respond adequately to other treatments. TDD may be an effective alternative to long-term systemic opioids for well-selected patients willing to accept the risks of invasive procedures.

Rise of implantable drugs: A chronicle of breakthroughs in drug delivery systems

In recent years, implantable drug delivery systems (IDDSs) have undergone significant advancements because they offer many advantages to patients and health care professionals. Miniaturization has reduced the size of these devices, making them less invasive and easier to implant. Remote control provides more precise medication delivery and dosage. Biodegradable implants are an additional advancement in implantable drug delivery systems that eliminate the need for surgical removal. Smart implants can monitor a patient's condition and adjust their drug doses. Long-acting implants also provide sustained drug delivery for months or even years, eliminating the need for regular medication dosing, and wireless power and data transmission technology enables the use of devices that are more comfortable and less invasive. These innovations have enhanced patient outcomes by enabling more precise administration, sustained drug delivery, and improved health care monitoring. With continued research and development, it is anticipated that IDDSs will become more effective and provide patients with improved health outcomes. This review categorizes and discusses the benefits and limitations of recent novel IDDSs for their potential therapeutic use.

The Polyanalgesic Consensus Conference (PACC)®: Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant.

RESULTS

The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Management of Cancer-Related Pain With Intrathecal Drug Delivery: A Systematic Review and Meta-Analysis of Clinical Studies

BACKGROUND

Despite increased attention paid to assessment and management, pain continues to be a prevalent and undertreated symptom in patients with cancer. Intrathecal drug delivery (IDD) is a therapeutic option that allows targeted delivery of analgesics to the intrathecal space.

OBJECTIVE

The aim of this review was to examine the efficacy of managing cancer-related pain with IDD. Secondary objectives included the effects of IDD on systemic opioid use and infection rates.

EVIDENCE REVIEW

A systematic search of the literature published between 1990 and 2019 was performed to identify studies evaluating the efficacy and/or safety of IDD with external or implanted pumps in patients with cancer-related pain. Data were extracted and meta-analyses performed to determine the mean changes in pain levels at short-, mid-, and long-term intervals; changes in opioid (oral morphine equivalent [OME]) daily dose; and infection rates. Changes were assessed compared with baseline.

FINDINGS

Pain levels were decreased from baseline: On a 0 to 10 scale, mean differences were -4.34 (95% CI [-4.93 to -3.75], p < 0.001) at 4 to 5 weeks; -4.34 (95% CI [-5.07 to -3.62], p < 0.001) at 6 to 12 weeks; and -3.32 (95% CI [-4.60 to -2.04], p < 0.001) at >6 months. Weighted mean OME consumption was reduced by 308.24 (SE = 22.72) mg/d. Weighted mean infection rates were ∼3% for external and implanted pumps.

CONCLUSIONS

Meta-analyses show a statistically significant and sustained decrease in cancer pain with IDD, compared with baseline. Systemic opioid consumption was reduced on average by >50% after IDD. Infection rates were comparable with other indications.