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

https://doi.org/10.1111/j.1525-1403.2012.00476.xGet rights and content

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.

Methods

The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain.

Results

After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain.

Conclusions

The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.

Section snippets

INTRODUCTION

The use of intraspinal (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. Thus far, research has not kept pace with the growing need for innovative pain management; therefore, a consensus opinion is needed to clarify the current research and address deficiencies in the data.

The Polyanalgesic Consensus Conference (PACC) panel first convened

METHODS

A broad literature search was conducted to identify preclinical and clinical data on IT therapy published from January 15, 2007, through March 1, 2011. MEDLINE®, BioMed Central®, Current Contents Connect®, Embase, International Pharmaceutical Abstracts®, and Web of Science® data bases were searched for publications on a range of medications that are either currently in use or potentially useful for the IT treatment of chronic pain. Search terms included intrathecal, intraspinal, morphine,

RECOMMENDATIONS OF PACC 2012 FOR IT THERAPY

Since the publication of the third PACC report in 2007 (3), the published literature on IT therapy has expanded, and the 2012 updated version of the PACC treatment algorithm is based on the best available evidence from published reports and on panel discussions. The current algorithm for drug selection provides clinical practice guidelines for the optimization of IT therapy with single-drug treatments and drug combinations in a rational and prioritized order. Unlike the previous PACC

ANALYSIS OF THE CONSENSUS PANEL

The 2012 PACC panelists closely examined the published literature, their own clinical experiences, and other anecdotal reports from colleagues regarding the use of IT analgesic drugs and formulated several consensus opinions and recommendations regarding key issues of IT therapy. These opinions are offered to lend guidance and to improve patient safety and are not intended to promote or recommend off-label use of medications. Physicians should consult their national approval processes when

Opioids

Preclinical data on IT opioids published between January 15, 2007, and March 1, 2011, are summarized in Table 9(14,15,56., 57., 58., 59., 60., 61., 62., 63., 64., 65., 66., 67., 68., 69., 70., 71., 72., 73., 74., 75., 76., 77., 78., 79., 80.).

Results from a preliminary study of the effects of IT opioids on pain control and cytokine levels suggest that an inverse correlation exists between pain intensity and plasma concentrations of interleukin (IL)-10 and IL-6 in patients with chronic pain who

CONCLUSIONS

The previous PACC work has led to improved patient safety and efficacy and advanced the questions that have led to additional IT drug research. In that spirit, this manuscript presents the next step in algorithmic thought. The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care

Acknowledgements

William Stuart, RPh; Audrey Suh, PharmD. Special acknowledgement: Christopher Bernards, MD.

Authorship Statements

Drs. Allen Burton, Eric Buchser, David Caraway, Michael Cousins, José De Andrés, Sudhir Diwan, Michael Erdeck, Eric Grigsby, Marc Huntoon, Marilyn Jacobs, Philip Kim, Krishna Kumar, Michael Leong, Liong Liem, Gladstone McDowell, Nagy Mekhail, Sunil Panchal, Richard Rauck, Michael Saulino, Peter Staats, Michael Stanton-Hicks, Lisa Stearns, B. Todd Sitzman, Mark Wallace, K. Dean Willis, William Witt, and

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    For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http://www.wiley.com/bw/submit.asp?ref=1094-7159&site=1

    Sources of financial support: This project was supported by grants from Medtronic, Inc. (Minneapolis, Minnesota, USA) and Azur Pharma Ltd (Dublin, Ireland).

    1

    Because IT methadone is associated with possible spinal cord toxicity, it is not endorsed for routine usage by the PACC panel.

    2

    Because IT ketamine is associated with possible spinal cord toxicity, it is not endorsed for routine usage by the PACC panel.

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    Copyright © 2012 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.