Does Intrathecal Morphine in the Treatment of Cancer Pain Induce the Development of Tolerance?

Sallerin-Caute, B.; Lazorthes, Y; Deguine, Olivier; Francés, Bernard; Verdié, J. C.; Charlet, Jean-Paul; Bastide, Rémi

doi:10.1097/00006123-199801000-00009

Cited by 35 publications

(19 citation statements)

References 28 publications

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“…4 Typically, in adults, IT opioids can be carried on for months at a time with adequate analgesia but a low risk of tolerance. 5 We hypothesize that the difference seen with neuropathic pediatric pain may be an element of plasticity in pain fibers or the central nervous system that quickly adapts to medication antagonism. The exact mechanism still remains unclear.…”

Section: Discussionmentioning

confidence: 99%

The Use of an Intrathecal Pump to Manage Intractable Cancer Pain in a Pediatric Patient

Bengali

Huang

Gulur

2014

Journal of Pediatric Hematology/Oncology

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A 15-year-old girl with combined immune deficiency syndrome, diagnosed with metastatic squamous cell cancer of the anus, had significant pain secondary to vulvar-perianal condyloma. Conventional treatment with oral and intravenous analgesics was limited by significant side effects of mental status changes and urinary retention leading to clinical deterioration that precluded attempts at chemotherapy. An intrathecal pump was implanted in the challenging setting of neutropenia. There was a drastic improvement in her quality of life and the ability to tolerate further chemotherapy. The option of an intrathecal pump for pain control extended our patient's ability to enjoy important quality time with family by several months.

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Section: Discussionmentioning

confidence: 99%

The Use of an Intrathecal Pump to Manage Intractable Cancer Pain in a Pediatric Patient

Bengali

Huang

Gulur

2014

Journal of Pediatric Hematology/Oncology

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“…Un des intérêts majeurs des techniques d'analgésie périmédullaire est de prendre en compte par une seule technique plusieurs types de douleur c'est-à-dire par exemple une douleur nociceptive associée à une douleur neuropathique. Par ailleurs, il est largement démontré dans la littérature l'intérêt de l'analgésie multimodale c'est-à-dire le fait que deux ou plus produits à action synergique permettent de diminuer notablement la dose administrée de chacun d'entre eux pour obtenir un résultat nettement plus favorable que la simple addition de leur efficacité [20,24]. Il est alors nécessaire de « mélanger » les produits au sein du même réservoir d'administration ce qui implique un respect des concentrations propres à chaque produit, d'une titration [9] et d'un respect des études de stabilité de l'ensemble des produits soit seuls soit utilisés concomitamment.…”

Section: Un Produit Ou Plusieurs Médicamentsunclassified

“…La voie épidurale, mais surtout la voie intrathécale exposent moins que d'autres à ce phénomène de tolérance qui se traduit par une majoration des effets secondaires et une diminution des effets analgésiques [18,20]. Cette particularité s'explique peut-être par les très faibles doses, la faible imprégnation périphérique, par le fait que le patient ne peut en règle générale moduler l'administration.…”

Section: Toléranceunclassified

Spinal and epidural analgesia in the management of chronic pain

Meignier¹,

Verleysen-Robin²

2007

Douleur analg.

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La place des techniques d'analgésie périmédullaire dépend grandement de l'expérience des équipes, mais cette méthode analgésique reste globalement insuffisamment pratiquée en France au regard de l'expérience étrangère ; pourtant un choix, voire une sélection rigoureuse des patients, une sélection des produits et des techniques permettent une prise en compte adéquate de nombreuses situations extrêmes tant en douleur cancéreuse que bénigne ; les risques sont connus, identifiés et en large partie prévisibles ; le problème reste toujours celui de l'expérience humaine, de la lourdeur de l'investissement par l'équipe de prise en charge et de difficultés administratives certaines.Abstract: The importance of invasive methods in the treatment of chronic and recurrent debilitating pain remains controversial. Epidural and inthrathecal techniques are offering viable options by providing patients with relief, particularly in the case of pain with multiple manifestations and causal mechanisms, whether resulting from cancers or non-malignant tumours. However, these techniques also require experience and expertise to be safe. They are associated with some risk, which must be assessed and might have economic ramifications. Therefore, it is clear that the decision to use these methods must be based on a rigorous protocol for selecting patients and deciding appropriate analgesics; this requires a truly multidisciplinary medical team. For this reason, these techniques are part of a vast therapeutic reserve we rely on conservatively. They do not offer the best solution, but they can and should contribute to relieving pain in many of these patients.

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“…Intrathecal morphine is precluded in patients with cerebral metastasis who have increased intracranial pressure and spinal cord compression. The usual intrathecal doses of morphine are 0.2-20 mg per day, with average starting doses ranging between 0.53 and 3 mg. After 3 months doses are between 7 and 8 mg per day (range 1-80 mg) [14,239]. Drug-related hyperalgesia is a risk at greater than 20 mg of morphine per day, and alternative drugs are required when the pain fails to respond at this dose.…”

Section: Intrathecalmentioning

confidence: 99%

Morphine in cancer pain management: a practical guide

Donnelly

Davis

Walsh

et al. 2002

Support Care Cancer

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Morphine is the most practical and versatile analgesic for the relief of severe pain associated with advanced cancer. Information is available in the literature about its use in routine clinical practice. Morphine induces analgesia by reducing neurotransmitter release presynaptically and hyperpolarizing dorsal horn neurons at the postsynaptic level, thus preventing rostral transmission of nociception. Morphine has a unique metabolism via glucuronidation (UGT2B7), which results in an active metabolite (morphine-6-glucuronide). The pharmacokinetics of morphine relate to its hydrophilic characteristic, volume of distribution, route of administration and clearance. Renal failure alters its pharmacokinetics more than cirrhosis. The age of the patient and multiple medications will alter morphine pharmacokinetics. Morphine can be given by several different routes: oral, rectal, subcutaneous (s.c.), intravenous (i.v.), epidural and intrathecal. Recent experience confirms benefits of topical morphine for cutaneous pain associated with benign or malignant ulcers. Guidelines for morphine administration are reviewed, and in particular those of the Harry R. Horvitz Center for Palliative Medicine are outlined.

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Does Intrathecal Morphine in the Treatment of Cancer Pain Induce the Development of Tolerance?

Abstract: The requirement for a moderate increase in intrathecal opioid doses reflects the development of tolerance but did not limit the patients' ability to obtain adequate analgesia during the course of their painful disease.

Cited by 35 publications

References 28 publications

The Use of an Intrathecal Pump to Manage Intractable Cancer Pain in a Pediatric Patient

The Use of an Intrathecal Pump to Manage Intractable Cancer Pain in a Pediatric Patient

Spinal and epidural analgesia in the management of chronic pain

Morphine in cancer pain management: a practical guide

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