Editor’s ChoicePolyanalgesic Consensus Conference 2012: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel
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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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.