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Intrathecal Drug Therapy for Cancer Pain: Time for a Boost!

Medical management of cancer pain remains poor despite the presence of good management guidelines, increased physician and patient awareness of available therapies, and significant emphasis on the problem from advocacy groups. In the previous issue of Pain Practice, Trentman and colleagues discuss an unfortunate occurrence of a hemorrhagic pontine metastatic mass in which diagnosis was delayed because of attribution of signs and symptoms including gait unsteadiness, dizziness, difficulty concentrating, tinnitus, sedation, and ataxia to the recent implantation of an intrathecal drug-delivery system (IDDS). Many of the early symptoms and signs in this patient could easily have been attributed to a post-dural puncture headache, which can, in turn, rarely lead to subdural fluid collection. Fortunately, Trentman and colleagues obtained imaging that demonstrated the hemorrhage, and no brain descent indicative of low cerebrospinal fluid pressure. The first use of intrathecal opioids was about 30 years ago, and predicted the future potential for multiple human applications. However, in the three decades hence, a single multicenter randomized, prospective trial on the subject of intrathecal drug delivery for cancer patients has been performed. Specific outcomes from the Smith et al. study of 202 patients were that opioid-induced toxicities such as fatigue, sedation, and cognitive slowing were improved compared with patients receiving comprehensive medication management. Pain scores were also improved with respect to baseline and compared with the scores in patients receiving comprehensive medication management, with nearly 2/3 of IDDS patients, having scores in the target range of less than 4/10. Although that study supported the use of IDDS in the cancer patient population, the number of pumps being implanted for cancer has not been sufficiently impacted since that time. Implanting physicians expect IDDS therapy to decrease analgesic side effects. Why then was diagnosis delayed in the Trentman et al. case? First, in spite of the aforementioned study, conversion ratios of the various agents are not known, and patient factors and genetic variability are present, thus side effects still occur. These problems confound one’s ability to manage these patients. To emphasize this point, a recent article on the topic of opioid dose conversion stated: “Consensus guidelines for intraspinal (epidural or intrathecal) conversions to systemic or oral opioids regimens and vice versa do not exist.” Other complications or shortfalls of IDDS therapy are, perhaps, ubiquitous to the entire country: (1) A significant concentrated longitudinal care experience is lacking, meaning there are few “super-implanters” to guide others. (2) The number of drug choices are actually quite minimal and although they should be guided by consensus guidelines, it is apparent to those in tertiary referral centers that the guidelines are not universally applied. (3) Procedural complication rates remain unacceptably high, including not only drug errors, pump failures, disconnections and other equipment Address correspondence and reprint requests to: Marc A. Huntoon, MD, Mayo Clinic—Anesthesiology, 200 1st St SW, Rochester, MN 55905, U.S.A. E-mail: huntoon.marc@mayo.edu. DOI. 10.1111/j.1533-2500.2009.00306.x