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Introduction: interspinal drug delivery for chronic pain (part I)∗
Seminars in Pain Medicine Vol. 1 No. 4 2003
Introduction: Interspinal Drug Delivery for Chronic Pain (Part I)* The discovery of spinal opiate receptors in the early 1970s opened the gate for a multitude of basic and clinical research on the use of neuraxial opiates for pain control. Advances in technology of infusion pumps (programmable and nonprogrammable) have allowed for further development in the field of pain medicine. Interspinal drug delivery for management of cancer pain and spasticity is well accepted. With regard to interspinal administration of opiates for the management of chronic nonmalignant pain, although it remains controversial, it offers several advantages over systemic administration in properly selected patients. Use of baclofen to manage intractable spasticity is an excellent way to manage complex patients with multiple sclerosis and spinal cord injuries. The use of polyanalgesic therapy to manage complicated neuropathic pain syndromes offers great potential for minimizing suffering and improving the quality of life for this patient population. In this issue of the journal, various basic and clinical issues related to interspinal drug delivery are discussed. An overview of general considerations concerning the methodology of the trials for devices used in interspinal drug delivery, and patient selection is followed by several studies discussing the anatomy and physiology of interspinal drug-delivery routes. Special emphasis is given to the pharmacology of various interspinally administered agents, which is followed a discussion of practical approaches to opiate dose conversion. Interspinal polyanalgesic therapy and guidelines are also addressed, followed by a discussion of various complications and other considerations of long-term management of patients. Intrathecal granuloma, as a major and relatively rare complication of interspinal drug delivery, is addressed with an emphasis on risk factors and recommendations. Special clinical circumstances, such as cancer pain and intractable spasticity, are discussed in detail. With the accelerating costs of health care, it is very important to address the cost-effectiveness of this invasive therapy. Finally, psychologic and addiction issues related to interspinal administration of opiates for chronic pain are discussed. Nagy A. Mekhail, MD, PhD Chairman, Department of Pain Management The Cleveland Clinic Foundation Cleveland, OH Guest Editor
*Some of the articles referred to here will be included in Part II of this topic, which will be featured in the March 2004 issue. © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.spmd.2004.02.003
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Introduction: Interspinal Drug Delivery for Chronic Pain (Part I)* The discovery of spinal opiate receptors in the early 1970s opened the gate for a multitude of basic and clinical research on the use of neuraxial opiates for pain control. Advances in technology of infusion pumps (programmable and nonprogrammable) have allowed for further development in the field of pain medicine. Interspinal drug delivery for management of cancer pain and spasticity is well accepted. With regard to interspinal administration of opiates for the management of chronic nonmalignant pain, although it remains controversial, it offers several advantages over systemic administration in properly selected patients. Use of baclofen to manage intractable spasticity is an excellent way to manage complex patients with multiple sclerosis and spinal cord injuries. The use of polyanalgesic therapy to manage complicated neuropathic pain syndromes offers great potential for minimizing suffering and improving the quality of life for this patient population. In this issue of the journal, various basic and clinical issues related to interspinal drug delivery are discussed. An overview of general considerations concerning the methodology of the trials for devices used in interspinal drug delivery, and patient selection is followed by several studies discussing the anatomy and physiology of interspinal drug-delivery routes. Special emphasis is given to the pharmacology of various interspinally administered agents, which is followed a discussion of practical approaches to opiate dose conversion. Interspinal polyanalgesic therapy and guidelines are also addressed, followed by a discussion of various complications and other considerations of long-term management of patients. Intrathecal granuloma, as a major and relatively rare complication of interspinal drug delivery, is addressed with an emphasis on risk factors and recommendations. Special clinical circumstances, such as cancer pain and intractable spasticity, are discussed in detail. With the accelerating costs of health care, it is very important to address the cost-effectiveness of this invasive therapy. Finally, psychologic and addiction issues related to interspinal administration of opiates for chronic pain are discussed. Nagy A. Mekhail, MD, PhD Chairman, Department of Pain Management The Cleveland Clinic Foundation Cleveland, OH Guest Editor
*Some of the articles referred to here will be included in Part II of this topic, which will be featured in the March 2004 issue. © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.spmd.2004.02.003
227