Intraspinal opioids for nonmaligant pain

Krames, Elliot

doi:10.1007/bf02938168

Cited by 4 publications

(4 citation statements)

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“…The erection subsided I ntraspinal drug delivery pump therapy has been increasingly utilized in patients with intractable, nonmalignant pain (1)(2)(3)(4)(5). It is well accepted that a temporary trial of intraspinal analgesia be conducted to document efficacy prior to the implantation of a permanent intrathecal drug delivery pump (1). A patient-controlled continuous epidural opioid infusion trial, conducted on an outpatient basis, is one of the approaches chosen by many interventionists (6) including the authors.…”

Section: Case Reportmentioning

confidence: 99%

Priapism — A Rare Complication Following Continuous Epidural Morphine and Bupivacaine Infusion

Ruan

2007

Pain Phys

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Background: Intraspinal drug delivery (IDD) therapy has been increasingly used in patients with intractable, nonmalignant pain who fail to respond to conventional treatment or can not tolerate systemic opioid therapy due to side effects. By infusing a small amount of analgesics directly into the cerebrospinal fluid (CSF) in close proximity to the receptor sites in the spinal cord, one is able to achieve the spinally mediated analgesia, sparing side effects ffrom systemic opioids. Prior to permanent intraspinal pump implantation, an intraspinal opioid screening trial is required to document the efficacy of intraspinal opioid for analgesia. Although there are a few approaches in conducting such screening trials, a patient-controlled continuous epidural morphine infusion trial, performed in an outpatient setting, is widely accepted by many interventional pain specialists. The major advantage of conducting an outpatient functional opioid infusion trial versus an inpatient trial is that it more closely mimics what the patient does in his or her usual activities of daily living, therefore minimizing the false positive rate of the inpatient screening trial. Objective: To describe a rare complication, priapism, observed during an outpatient continuous epidural morphine and bupivacaine infusion trial. Case Report: A 49-year-old male with intractable, chronic low back pain due to diffuse lumbar degenerative disc disease, lumbar spondylosis referred to our clinic for consideration of IDD therapy, after failing to respond to multi-modality pain management including medications, physical therapy with modality, transcutaneous nerve stimulation (TENS), and various interventional procedures. Following a pre-implant psychological evaluation, he was scheduled for the outpatient epidural morphine and bupivacaine infusion trial. A tunneled lumbar epidural a catheter was placed at L3-L4 with the catheter tip advanced to L1 under fluoroscopic guidance. The proximal tip of the catheter was then tunneled, subcutaneously, and connected to a MicrojectTM PCEA pump (Codman, Raynham, MA, USA) and reservoir bag containing preservative-free morphine 0.4 mg/mL and bupivacaine 0.016%. The pump was programmed to deliver a basal rate of 0.5 mL/h. The bolus dose was 0.2 mL with a 60-minute lock out interval. The patient was instructed how to use the pump properly before discharging home. Two hours following the initiation of infusion trial, the patient started to experience penile erection. It was initially painless, but became progressively painful and intensified. The unremitting priapism lasted 8 hours, finally resolving 2 to 3 hours after discontinuing the infusion. The patient recovered fully without any sequelae. Conclusion: Priapism may occur as a rare complication following epidural morphine administration. This report represents the third case report thus far in the literature revealing priapism induced by epidural morphine administration, yet, it is the only report, to our knowledge, describing priapism occurring in a patient undergoing an outpatient epidural morphine and bupivacaine infusion trial. We believe that epidural morphine, rather than bupivacaine, is responsible for causing priapism in this patient, through a yet to be defined spinal mechanism. Key words: Epidural morphine and bupivacaine infusion trial, intraspinal drug delivery pump, priapism

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Section: Case Reportmentioning

confidence: 99%

Priapism — A Rare Complication Following Continuous Epidural Morphine and Bupivacaine Infusion

Ruan

2007

Pain Phys

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“…The issue of side effects must remain a serious consideration. Opioids may be delivered by a variety of mechanisms, including orally or by a drug administration system (DAS; Krames, 1997). The use of a medication contract has been recommended.…”

Section: Medication Managementmentioning

confidence: 99%

“…Attempts to control the experience of pain by disruption of nociception has progressed into implantable technology (Root, Weaver, & Hahn, 1998). Such systems include SCS (Shetter, 1997) and DAS (Krames, 1997;Stangl & Loeser, 1997). In the case of SCS an electrode of varying configurations is implanted epidurally and programmed to electrically disrupt nociceptive signals, presumably to alter the experience of pain.…”

Section: Invasive Therapiesmentioning

confidence: 99%

Chronic pain.

Doleys¹

2000

Handbook of Rehabilitation Psychology.

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The definition of pain has remained elusive (Feurestein, 1994). Because pain is often considered a subjective phenomenon, some consider it t o be whatever an individual says it is. Sarno (1991) believes pain to be a response to maladaptive, repressed, or unresolved negative emotions. Most accept pain as a multidimensional problem having both affectiveemotional and sensory-discriminative components as outlined by the International Association for the Study of Pain (IASP; Merskey & Bogduk, 1994). More recently, there has been greater attention to conceptualizing pain as a disease rather than a symptom (Cousins, 1999;Liebeskind, 1991). Clearly, the definition one chooses influences assessment, diagnostic, therapeutic, and outcome measurement strategies.Pain is frequently divided into two categories, acute and chronic. Acute pain is generally associated with some defined tissue damage or disease process and is short lived. Chronic pain has been thought of in several ways (Feurestein, 1994). On occasion it has been defined by the duration of pain; historically, 6 months has been the cut-off but in some instances 3 months has been applied. In other circumstances, the term chronicity has been used to refer to pain complaints and symptoms that were considered to be qualitatively or quantitatively disproportionate to the underlying physical pathology. Some definitions associate the term with the type and degree of comorbidities, and individuals are considered to have chronic pain if they develop concomitant depression, anxiety, disability, or drug abuse.Pain is further subdivided into cancer and noncancer. Cancer pain specifies the etiology as some type of cancer. The assessment and treatment of cancer pain has historically been related to amelioration of the cause or palliation. Although frequently undertreated, pain secondary to cancer has been more widely accepted and less controversial than pain of noncancer origin. Improvement in quality of life and pain control are related t o both types of pain. However, restoration of function and what one ordinarily thinks of under the rubric of rehabilitation is a more common concern with noncancer pain. This chapter focuses primarily on noncancer pain, although there are similarities in assessment, treatment, and psychosocial issues between cancer and noncancer pain (

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“…Today, more and more patients are turning to a growing number of minimally invasive interventional pain management procedures, including various pain blocks (27), spinal endoscopy (28), radiofrequency denervation (29,30), intradiscal electrothermal annuloplasty (31), and implantable technologies (32). The latter includes surgical procedures such as spinal cord stimulation (33)(34)(35) and drug administration systems (36)(37)(38). The application of these and other interventional procedures is best conceptualized and carried out within a multidisciplinary model, where comprehensive assessment of complex pain problems leads to appropriate multidimensional treatment plans and where patient selection for invasive procedures continues to be an issue of highest importance.…”

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confidence: 99%

Multidisciplinary Collaboration Between Pain Physicians and Psychologists: Ageless Wisdom for the New Millennium

Thompson¹

2003

Pain Phys

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Intraspinal opioids for nonmaligant pain

Cited by 4 publications

References 65 publications

Priapism — A Rare Complication Following Continuous Epidural Morphine and Bupivacaine Infusion

Priapism — A Rare Complication Following Continuous Epidural Morphine and Bupivacaine Infusion

Chronic pain.

Multidisciplinary Collaboration Between Pain Physicians and Psychologists: Ageless Wisdom for the New Millennium

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