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The development and practice of palliative care
Published in John Lombard, Law, Palliative Care and Dying, 2018
Palliative medication may be administered in a number of different ways including injection, oral, suppository or through intrathecal pump. The intrathecal pump functions by delivering ‘small doses of medication directly to the spinal fluid’.192 This has the effect of increasing the ‘relative strength of the drug compared to its oral or intravenous equivalent’.193 This approach can minimise potential side effects of sedative drugs. The control exercised over the administration of sedative drugs is important due to the harmful consequences associated with an excessive dose. Naturally, it follows that sedation should be the ‘lowest necessary to provide adequate relief of suffering’.194 In the context of morphine it appears that when it is administered at such a level there is ‘little data to support the belief that appropriate use of opioids hastens death in patients dying from cancer and other chronic diseases’.195 The challenge which this presents is the identification of what constitutes an appropriate level of sedative. This level will vary over the course of a patient’s care, for example, after the initial sedation the risk of hastening death decreases. This is based on the fact that the ‘risk of respiratory depression is greatest when opioids are first begun’.196 As treatment progresses, the ability of a patient to cope with respiratory side effects increases,197 but over time toxicity may occur.
Intrathecal Pumps
Published in Mark V. Boswell, B. Eliot Cole, Weiner's Pain Management, 2005
Outcomes in patients suffering from severe pain secondary to cancer have been very positive by physician report. Most studies have been retrospective or based on case reports. Smith and colleagues9 report a multicenter, international, randomized, prospective study comparing intrathecal drug delivery versus comprehensive medical management. In this study the patients were randomized to the intent-to-treat group and then underwent a trial for intrathecal pump placement. The trials were performed based on the physician’s normal technique. At 4 weeks after the enrollment of the patient, the data were analyzed based on the initial enrollment group. The results showed a clinically significant advantage of intrathecal pumps in overall toxicity (based on national cancer toxicity criteria), pain relief, fatigue, and level of consciousness. Perhaps the most impressive finding was a trend toward improved survival in the pump group (P = 0.06). This study suggests more patients with moderate to severe cancer pain should be considered for intrathecal drug delivery. In a large retrospective study involving both cancer (32.7%), and noncancer (67.3%) pain, a mean pain reduction of 61% was seen in both groups. In those patients with neuropathic pain, improved efficacy was reported when using drugs such as clonidine or bupivacaine. Minimal long-term adverse drug events occurred in this group.36 One of the earliest outcome studies presented a negative impression of intrathecal infusions in patients with cancer. In this study, Commbs and colleagues37 found in a small group of 14 patients that there was no difference in patients receiving intrathecal morphine when compared with other routes of delivery.
The pharmacological management of dental pain
Published in Expert Opinion on Pharmacotherapy, 2020
Joseph V. Pergolizzi, Peter Magnusson, Jo Ann LeQuang, Christopher Gharibo, Giustino Varrassi
Dental pain may be secondary to other chronic painful conditions such as traumatic neuropathy, postherpetic neuralgia, and complex regional pain syndrome [77]. Moderate to severe chronic pain may resist localization in the body and migrate from one area to the next, including the dentition. In such cases, overall pain control is necessary to reduce the dental pain. These chronic pain conditions may be treated pharmacologically with opioids, either as oral or transdermal therapy or with an intrathecal pump. Some chronic pain patients derive benefit from device-related therapies such as neurostimulation. Pain with a neuropathic component may have to be addressed with an anticonvulsant. In case of persistent neurological pain, referral to a neurologist may be warranted.
Intrathecal drug delivery for pain management: recent advances and future developments
Published in Expert Opinion on Drug Delivery, 2019
Sameer Jain, Mark Malinowski, Pooja Chopra, Vishal Varshney, Timothy R. Deer
Intrathecal Pump Delivery Systems may be categorized into fixed-rate pumps and variable-rate pumps. The fixed-rate pumps were designed to provide a continuous flow of medication into the targeted area. These pumps operate mechanically and are powered by a gas pressure chamber surrounding a flexible inner reservoir, both made of titanium.
An overview of the pharmacotherapeutics for dystonia: advances over the past decade
Published in Expert Opinion on Pharmacotherapy, 2022
O. Abu-hadid, J. Jimenez-Shahed
Baclofen inhibits neuronal activity by acting as an agonist to GABAB receptors at the level of the brain and spinal cord. It is used for spasticity and dystonia, mainly in the context of cerebral palsy, and can be either orally or intrathecally administered. A case series suggested that intraventricular baclofen, into the third ventricle, may be a more targeted therapy for dystonia, as it is administered in close proximity to the cortex [107]. Interestingly, a case report of a 22-year old patient with dystonia due to cerebral palsy, shows that prepontine placement of the intrathecal catheter, through endoscopic third ventriculostomy, is a feasible option if lumbar intrathecal pump is contraindicated due to an active local infection [108]. Over the past decade, many studies have evaluated the intrathecal administration of baclofen in patients with dystonia in the context of cerebral palsy. A DB-RCT examined 36 patients with dyskinetic cerebral palsy, where 17 patients received intrathecal baclofen (ITB) and 16 patients received placebo [109]. The study shows that the primary outcome of the goal attainment score, which is the degree of achieving goals set by family members, was higher in patients who received ITB compared to those who received placebo [109]. In addition, the dystonia subscale of the dyskinesia impairment scale during activity (p = 0.045) and rest (p = 0.013) significantly improved in the ITB group [109]. Interestingly, there was no significant difference when using the Barry-Albright dystonia scale [109]. One of the explanations for this discrepancy is that the dyskinesia impairment scale can capture more of the variability rendering the Barry-Albright dystonia scale less sensitive [110,111]. A case series of three patients who developed an acute dystonic storm shows improvement after intraventricular baclofen administration [112]. A case report of a patient with DYT1 shows she had a good response to ITB prior to and during pregnancy with no perinatal complications [113]. The method of response measurement was not reported. An additional case report showed successful use of ITB in a patient with periodic focal dystonia in the left foot associated with complex regional pain syndrome [114]. A final case report also shows successful use of 5 mg of oral baclofen in the evening to treat Meige syndrome [115].