The Case for Intrathecal Drug Delivery in 2014: The Winds Are Changing

In the past decade, many interventional pain physicians have been criticized for being opioid phobic, overly interventional, or incorrect in limiting high-dose opioids [1]. When I review the Centers for Disease Control and Prevention (CDC) assessment of overdose deaths, I think the opposite and wonder if we cannot go further in this process of finding opioid alternatives [2]. The patient in this discussion presents an all too familiar dilemma. Issues we should consider are the initial choice to use and then elevate opioids, the indications for fusion and whether it was necessary, and what role physical medicine and psychological counseling should play. Finally, we should review the appropriateness of this patient for an intrathecal drug delivery system [3]. The chance of success with fusion for chronic discogenic back pain is low and should be considered with great trepidation [4]. Once the fusion fails to resolve the issue, the continued elevation of oral or transdermal opioids is usually not the solution. The real question to consider is will the delivery of opioids by an alternative route give a different result. In this case, despite oral opioids, the patient continued to have poor quality of life and limited function. Based on these considerations, I would proceed with great caution to place an intrathecal pump. The reassuring issue for us to consider is that an “intrathecal pump” is a simplification of what is now considered state of the art in neuromodulation. When an implanter decides to move forward with an intrathecal drug delivery system, it is not the same therapy that was offered a decade ago. New options exist for those who are not responsive to high-dose oral opioids. In many cases, the weaning of oral opioids and then the initiation of low-dose basal opioids with patient controlled analgesia can be helpful even in the setting of failure of oral opioids [5]. This bolusing effect can lead to a lower opioid requirement and less tolerance over time. The use of other agents is also an option. In some settings, ziconotide, a drug that is active at the calcium channel, can be successful in both relieving pain and improving function. Because this is a non-opioid, the risks of many associated side effects such as granuloma or respiratory depression are eliminated [6]. In addition to these two options in the setting where morphine or ziconotide fail, there is evidence-based guidance on the proper use of adjuvants such as bupivacaine, clonidine or other admixtures in an off-labeled but algorithmic fashion. The use of adjuvants has been shown to reduce the opioid requirements and improve both pain scores and function [5]. It is also important to remember that once a pump is placed, the therapy is only beginning. In our practice, we prefer to initiate a 12-week land- and water-based rehabilitation program and ongoing psychological counseling to assist with coping and adaption. In closing, in addition to intrathecal therapies evolving, the other significant area of neuromodulation is changing greatly. New options for axial back pain such as dorsal root ganglion spinal cord stimulation (SCS), high-frequency SCS at 10 kHz (HF10), and new programming waveforms such as burst SCS have emerged. These new technologies may lead to a reduction in the number of patients who need opioids and may reduce the overall complexity of this type of patient in the future [7].