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Interventional Pain Management: How to choose, when to decide
In understanding the rationale for interventional pain management, it is important to remember why pain management is important to patient care.
Pain management enables a patient to communicate with family and medical providers, achieve comfort and satisfaction, participate in their care—tolerating chemo, etc. — and may be essential to their survival. A multidisciplinary approach to pain management – and one that doesn’t unfairly raise patients’ expectations -- is important, says Shane Brogan, MD, Huntsman Cancer Institute, University of Utah, speaking at the 6th Annual Chicago Supportive Oncology Conference.
Interventional cancer pain management compliments medical management and may reduce or eliminate the need for opioids. It offers a more rapid control of symptoms. One promising area is Intrathecal Therapy, Brogan says. This is the delivery of drugs directly where they need to go -- to the central nervous system, bypassing the GI tract and liver.
This is something you would consider for a patient who’s on a fair dose of opioids and doesn’t seem to be making progress with them, Brogan says, or for a patient who has had terrible side effects with the opioids. Advantages include improved pain control and rapid pain control. Patients are better able to tolerate aggressive chemotherapy.
There are several ways to deliver intrathecal drugs, Brogan notes:
Simple percutaneous: It’s easy, done at the bedside and inexpensive. But there is a higher infection and failure rate and is suitable only for short-term use (several days.)
Tunneled catheter: This method is more secure, has a lower infection risk and it’s easy to alter drugs and their rate of delivery. The drugs can also be bolused by a nurse. This may be more appropriate for aggressive end-of-life care.
Implanted: This is an electronic pump with a small drug reservoir. The patient has a remote control device and can give boluses for breakthrough pain. It can be refilled percutaneously. Infection and complication rates are lower and it’s more cost-effective over the long term. The implanted pump is the size of a hockey puck and the remote control is the size of a cell phone. It allows more patient freedom.
There are some contraindications, but most are easily managed, Brogan says. They can include anticoagulation, sepsis, skin infections over the back, neutropenia and major central canal spinal stenosis compromising CSF flow. Complications (less than 1-2% of cases) include infection, pump seroma, catheter or pump failure and catheter tip granuloma.
Intrathecal analgesia had positive results in a 2003 study in the Journal of Clinical Oncology when compared with non-interventional medical management. It was found to significantly improve pain-related outcomes, reduced drug toxicities and improved survival (53.9% vs. 37.2% at six months) compared with medical management in patients with refractory cancer pain.
Interventional pain options are numerous and should be considered early in the treatment continuum, Brogan says. Options should be considered in the context of the overall care plan.
“We have to work as a team,” Brogan says. “And consider all the symptoms. You don’t want to be the guy of last resort. You have to think of pain options early and send someone for consultation.”
