Skip to main content

Medications in Intrathecal Pumps

  • Chapter
  • First Online:
Essentials of Interventional Cancer Pain Management
  • 1552 Accesses

Abstract

Intrathecal (IT) pumps are a critical part of cancer pain treatment. While there are currently three medications (morphine, ziconotide, and baclofen) approved by the Food and Drug Administration (FDA) for intrathecal drug use, there are other medications that can help provide pain relief. The location and characteristics of the pain should always be used in determining which drug(s) to use. Side effects and interaction of IT drugs with other medications should also be investigated prior to initiation of treatment. Starting and adjustment doses can be effectively titrated based on the individual patient’s needs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 149.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Bottros MM, Christo PJ. Current perspectives on intrathecal drug delivery. J Pain Res. 2014;7:615–26.

    PubMed  PubMed Central  Google Scholar 

  2. Wang JK, Nauss LA, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979;50(2):149–51.

    Article  CAS  PubMed  Google Scholar 

  3. Deer TR, Prager J, Levy R, et al. Polyanalgesic consensus conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012;15(5):436–64.

    Article  PubMed  Google Scholar 

  4. Hassenbusch SJ, Pillay PK, Magdinec M, et al. Constant infusion of morphine for intractable cancer pain using an implanted pump. J Neurosurg. 1990;73(3):405–9.

    Article  CAS  PubMed  Google Scholar 

  5. Atli A, Theodore BR, Turk DC, et al. Intrathecal opioid therapy for chronic nonmalignant pain: a retrospective cohort study with 3-year follow-up. Pain Med. 2010;11(7):1010–6.

    Article  PubMed  Google Scholar 

  6. Reig E, Abejon D. Continuous morphine infusion: a retrospective study of efficacy, safety, and demographic variables. Neuromodulation. 2009;12(2):122–9.

    Article  PubMed  Google Scholar 

  7. Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040–9.

    Article  CAS  PubMed  Google Scholar 

  8. Rauck RL, Cherry D, Boyer MF, et al. Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain. J Pain. 2003;4(8):441–7.

    Article  CAS  PubMed  Google Scholar 

  9. Sjöberg M, Appelgren L, Einarsson S, et al. Long-term intrathecal morphine and bupivacaine in “refractory” cancer pain. I. Results from the first series of 52 patients. Acta Anaesthesiol Scand. 1991;35(1):30–43.

    Article  PubMed  Google Scholar 

  10. Sjöberg M, Nitescu P, Appelgren L, et al. Long-term intrathecal morphine and bupivacaine in patients with refractory cancer pain. Results from a morphine: bupivacaine dose regimen of 0.5:4.75 mg/ml. Anesthesiology. 1994;80(2):284–97.

    Article  PubMed  Google Scholar 

  11. Mitchell A, McGhie J, Owen M, et al. Audit of intrathecal drug delivery for patients with difficult-to-control cancer pain shows a sustained reduction in pain severity scores over a 6-month period. Palliat Med. 2015;29(6):554–63.

    Article  PubMed  Google Scholar 

  12. Mercadante S, Intravala G, Villari P, et al. Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids. Clin J Pain. 2007;23(9):793–8.

    Article  PubMed  Google Scholar 

  13. Yaksh TL, Onofrio BM. Retrospective consideration of the doses of morphine given intrathecally by chronic infusion in 163 patients by 19 physicians. Pain. 1987;31(2):211–23.

    Article  CAS  PubMed  Google Scholar 

  14. Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth. 1995;42:891–903.

    Article  CAS  PubMed  Google Scholar 

  15. Ruan X. Drug-related side effects of long-term intrathecal morphine therapy. Pain Physician. 2007;10(2):357–66.

    PubMed  Google Scholar 

  16. Malhotra VT, Root J, Kesselbrenner J, et al. Intrathecal pain pump infusions for intractable cancer pain: an algorithm for dosing without a neuraxial trial. Anesth Analg. 2013;116(6):1364–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Veizi E, Tornero-Bold M, Hayek SM. Resolution of intrathecal hydromorphone or morphine-induced peripheral edema by opioid rotation to fentanyl: a case series. Pain Pract. 2016;16(6):E94–8.

    Article  PubMed  Google Scholar 

  18. Olivera B, Gray WR, Zikus R, et al. Peptide neurotoxins from fish-hunting cone snails. Science. 1985;230(4732):1338–43.

    Article  CAS  PubMed  Google Scholar 

  19. Bowersox SS, Gadbois T, Singh T, et al. Selective N-type neuronal voltage-sensitive calcium channel blocker, SNX-111, produces spinal antinociception in rat models of acute, persistent and neuropathic pain. J Pharmacol Exp Ther. 1996;279:1243–9.

    CAS  PubMed  Google Scholar 

  20. Alicino I, Giglio M, Manca F, et al. Intrathecal combination of ziconotide and morphine for refractory cancer pain: a rapidly acting and effective choice. Pain. 2012;153(1):245–9.

    Article  CAS  PubMed  Google Scholar 

  21. Staats PS, Yearwood T, Charapata SG, et al. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. JAMA. 2004;291(1):63–70.

    Article  CAS  PubMed  Google Scholar 

  22. Prilat. Ziconotide intrathecal infusion. [prescribing information]. San Diego: Jazz Pharmaceuticals, Inc.; 2016.

    Google Scholar 

  23. Maier C, Cockel HH, Gruhn K, et al. Increased risk of suicide under intrathecal ziconotide treatment? – a warning. Pain. 2011;152(1):235–7.

    Article  CAS  PubMed  Google Scholar 

  24. Malmberg AB, Yaksh TL. Effect of continuous intrathecal infusion of omega-conopeptides, N-type calcium-channel blockers, on behavior and antinociception in the formalin and hot-plate tests in rats. Pain. 1995;60(1):83–90.

    Article  CAS  PubMed  Google Scholar 

  25. Prialt (ziconotide) Solution, Intrathecal Infusion [package insert]. Palo Alto: Jazz Pharmaceuticals, Inc.; 2013.

    Google Scholar 

  26. Fishman S, Ballantyne J, Rathmell JP, Bonica JJ. Bonica’s management of pain. 4th ed. Baltimore: Lippincott, Williams & Wilkins; 2010.

    Google Scholar 

  27. Gulati A, Puttanniah V, Hung J, et al. Considerations for evaluating the use of intrathecal drug delivery in the oncologic patient. Curr Pain Headache Rep. 2014;18(2):391.

    Article  PubMed  Google Scholar 

  28. Sloan PA. Neuraxial pain relief for intractable cancer pain. Curr Pain Headache Rep. 2007;11(4):238–9.

    Article  Google Scholar 

  29. Graf BM, Abraham I, Eberbach N, et al. Differences in cardiotoxicity of bupivacaine and ropivacaine are the result of physicochemical and stereoselective properties. Anesthesiology. 2002;96(6):1427–34.

    Article  CAS  PubMed  Google Scholar 

  30. Eisenach JC, DuPen S, Dubois M, et al. Epidural clonidine analgesia for intractable cancer pain. Pain. 1995;61:391–9.

    Article  CAS  PubMed  Google Scholar 

  31. Klimscha W, Tong C, Eisenach JC. Intrathecal α2-adrenergic agonists stimulate acetylcholine and norepinephrine release from the spinal cord dorsal horn in sheep. An in vivo microdialysis study. Anesthesiology. 1997;87(1):110–6.

    Article  CAS  PubMed  Google Scholar 

  32. Feng X, Zhang F, Dong R, et al. Intrathecal administration of clonidine attenuates spinal neuroimmune activation in a rat model of neuropathic pain with existing hyperalgesia. Eur J Pharmacol. 2009;614(1–3):38–43.

    Article  CAS  PubMed  Google Scholar 

  33. Yaksh TL. Pharmacology of spinal adrenergic systems which modulate spinal nociceptive processing. Pharmacol Biochem Behav. 1985;22:845–58.

    Article  CAS  PubMed  Google Scholar 

  34. Hassenbusch SJ, Gunes S, Wachsman S, et al. Intrathecal clonidine in the treatment of intractable pain: a phase I/II study. Pain Med. 2002;3(2):85–91.

    Article  PubMed  Google Scholar 

  35. Hassenbusch SJ, Portenoy RK. Current practices in intraspinal therapy – a survey of clinical trends and decision making. J Pain Symptom Manag. 2000;20(2):S4–11.

    Article  CAS  Google Scholar 

  36. Ugur F, Gulcu N, Boyaci A. Intrathecal infusion therapy with dexmedetomidine-supplemented morphine in cancer pain. Acta Anaesthesiol Scand. 2007;51(3):388.

    Article  CAS  PubMed  Google Scholar 

  37. Konakci S, Adanir T, Yilmax G, et al. The efficacy and neurotoxicity of dexmedetomidine administered via the epidural route. Eur J Anaesthesiol. 2008;25(5):403–9.

    Article  CAS  PubMed  Google Scholar 

  38. Coffey RJ, Cahil D, Steers W, et al. Intrathecal baclofen for intractable spasticity of spinal origin: results of a long-term multicenter study. J Neurosurg. 1993;78:226–32.

    Article  CAS  PubMed  Google Scholar 

  39. Albright AL, Gilmartin R, Swift D, et al. Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin. J Neurosurg. 2003;98:291–5.

    Article  CAS  PubMed  Google Scholar 

  40. Koulousakis A, Kuchta J. Intrathecal antispastic drug application with implantable pumps: results of a 10 year follow-up study. Acta Neurochir Suppl. 2007;97.(Pt 1:181–4.

    CAS  PubMed  Google Scholar 

  41. Heetla HW, Staal MJ, Kliphuis C, et al. The incidence and management of tolerance in intrathecal baclofen therapy. Spinal Cord. 2009;47(10):751–6.

    Article  CAS  PubMed  Google Scholar 

  42. Coffey RJ, Edgar TS, Francisco GE, et al. Abrupt withdrawal from intrathecal baclofen: recognition and management of a potentially life-threatening syndrome. Arch Phys Med Rehabil. 2002;83:735–41.

    Article  PubMed  Google Scholar 

  43. Ginsburg GM, Lauder AJ. Progression of scoliosis in patients with spastic quadriplegia after the insertion of an intrathecal baclofen pump. Spine (Phila Pa 1976). 2007;32(24):2745–50.

    Article  Google Scholar 

  44. Yaksh TL, Tozier N, Horais KA, et al. Toxicology profile of N-methyl-D-aspartate antagonists delivered by intrathecal infusion in the canine model. Anesthesiology. 2008;108(5):938–49.

    Article  CAS  PubMed  Google Scholar 

  45. Wang C, Sadovova N, Fu X, et al. The role of the N-methyl-d-aspartate receptor in ketamine-induced apoptosis in rat forebrain culture. Neuroscience. 2005;132:967–77.

    Article  CAS  PubMed  Google Scholar 

  46. Vranken JH, Troost D, Wegener JT, et al. Neuropathological findings after continuous intrathecal administration of S(+)-ketamine for the management of neuropathic cancer pain. Pain. 2005;117(1–2):231–5.

    Article  CAS  PubMed  Google Scholar 

  47. Yang CY, Wong CS, Chang JY, et al. Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain. Can J Anaesth. 1996;43(4):379–83.

    Article  CAS  PubMed  Google Scholar 

  48. Osenbach RK. Intrathecal drug delivery in the management of pain. In: Fishman S, Ballantyne J, Rathmell J, editors. Bonica’s management of pain. Philadelphia: Lippencott, Williams, & Wilkins; 2010. p. 1437–57.

    Google Scholar 

  49. Pope JE, Deer TR. Intrathecal pharmacology update: novel dosing strategy for intrathecal monotherapy ziconotide on efficacy and sustainability. Neuromodulation. 2015;18(5):414–20.

    Article  PubMed  Google Scholar 

  50. Medtronic Inc. http://professional.medtronic.com/pt/neuro/idd/prod/myptm-personal-therapy-manager/features-specifications/index.htm#.V9CNejf2ZaQ. September 7, 2016.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Grant H. Chen .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Chen, G.H. (2019). Medications in Intrathecal Pumps. In: Gulati, A., Puttanniah, V., Bruel, B., Rosenberg, W., Hung, J. (eds) Essentials of Interventional Cancer Pain Management. Springer, Cham. https://doi.org/10.1007/978-3-319-99684-4_32

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-99684-4_32

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-99682-0

  • Online ISBN: 978-3-319-99684-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics