Download Treating Malignant Pain c IDDS

Malignant Pain
The Role of IDDS
Mark Schlesinger, MD
Schlesinger Pain Centers
www.schlespain.com
Malignant Pain
When I graduated from medical school over 30 years ago, I never promised
to cure anyone, but I did promise to relieve pain and allay suffering.
What is Malignant Pain?
What is Malignant Pain?
• Pain caused by the cancer itself
What is Malignant Pain?
• Pain caused by the cancer itself
• What will not be discussed?
What is Malignant Pain?
• Pain caused by the cancer itself
• What will not be discussed?
• Post-Surgical Pain
• Radiation Neuritis
• Post-Chemotherapy Pain
• Pain in Cancer Survivors
Pain Sub Types
• Nociceptive Pain
– Bone Metastases
• Neuropathic Pain
– Nerve Root Invasion
– Spinal Cord Invasion
– Brachial or Lumbar Plexus Invasion
• Visceral Pain
– Pancreatic Cancer Involving Celiac Plexus
What is IDDS?
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Intrathecal Drug Delivery Systems
Direct Administration of Drugs to Spinal Cord
Fully Implantable Therapies
Programmable vs. Non-Programmable
Why IDDS?
• Potency
– Multiple Spinal Receptors
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Opiate Receptors
Sodium Channels
Calcium Channels
Adrenergic Receptors
NMDA Receptors
Why IDDS?
• Side Effects
Systemic Opiates
Spinal Opiates/Drugs
Decreased LOC
Pruritis
Depression
Respiratory Depression
Decreased Gag Reflex
Pulmonary Aspiration
Decreased Appetite
Nausea & Vomiting
Constipation
Immune Suppression
Decreased Libido
Pedal Edema
Intrathecal Drugs
• Mostly Off-Label Uses
Approved
Morphine
Ziconitide
Baclofen
Not used:
Commonly Used
Hydromorphone
Fentanyl
Sufentanyl
Bupivacaine
Ropivacaine
Clonidine
Ketamine
Demerol due to side effects & drug interactions
Intrathecal Drug Mixtures
Double, double toil and trouble;
Fire burn and cauldron bubble.
Intrathecal Drug Mixtures
Non-Programmable Pumps
• Codman 3000
– Three Sizes
• 16 cc, 30 cc & 50 cc
– Fixed Flow Rates
• 16 cc size, 4 models delivering 0.3-1.3 cc per day
• 30 cc size, 4 models delivering 0.3-1.7 cc per day
• 50 cc size, 3 models delivering 0.5-3.4 cc per day
– Dose Controlled Changing Drug Concentration
Programmable Pumps
• Codman Medstream
Medtronic Synchromed II
Programmable Pumps
• Codman Medstream
– Pump Type: Gas Driven Piston Pump
– Service Life: 8 years
– Minimum Flow Rate: 0.10 cc per day
• Medtronic Synchromed II
– Pump Type: Gas Driven Roller Pump
– Service Life: 7 years
– Minimum Flow Rate: 0.05 cc per day
Programmable Pumps
• Codman Medstream Pump
– Diameter 76.0 mm
• 20 cc
• 40 cc
Thickness 21.6 mm Weight
Thickness 28.2 mm Weight
150 gm
155 gm
• Medtronic Synchromed II Pump
– Diameter 87.5 mm
• 20 cc
• 40 cc
Thickness 19.5 mm Weight
Thickness 26.0 mm Weight
165 gm
175 gm
Programmable Pumps
• Codman Medstream Pump
– MRI Compatibility
• Certified to 3 Tesla
• Effect of Magnetic Field ?
• Medtronic Synchromed II Pump
– MRI Compatibility
• Certified to 3 Tesla
• Effect of Magnetic Field
Rotor Lock-Up, Restarts
Programmable Pumps
• Medtronic Synchromed II Pump
– Programming Modes
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Simple Continuous – for baseline pain
Bolus Delivery – for sudden adjustments
Flex Mode – Multiple Programmable Steps
PTM – Intrathecal PCA, with all the bells & whistles
– Therapy modeled after intravenous & epidural PCA
– Advantages
» Better Pain Control
» Lower Total Dose of Medication
» Fewer Side Effects
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
Continuous Infusion – the normal rate of infusion of the drug. This determines the
steady state level of the drug and thereby the effectiveness of therapy.
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
Continuous Infusion – the normal rate of infusion of the drug. This determines the
steady state level of the drug and thereby the effectiveness of therapy.
PCA Dose – the patient controlled analgesia dose. This is the amount that the patient
can administer at any one time.
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
Continuous Infusion – the normal rate of infusion of the drug. This determines the
steady state level of the drug and thereby the effectiveness of therapy.
PCA Dose – the patient controlled analgesia dose. This is the amount that the patient
can administer at any one time.
Lockout Interval – the minimum time between allowable PCA doses. The larger the
lockout interval the lower the risk of overdose and the higher the risk of
underdose.
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
Continuous Infusion – the normal rate of infusion of the drug. This determines the
steady state level of the drug and thereby the effectiveness of therapy.
PCA Dose – the patient controlled analgesia dose. This is the amount that the patient
can administer at any one time.
Lockout Interval – the minimum time between allowable PCA doses. The larger the
lockout interval the lower the risk of overdose and the higher the risk of
underdose.
Maximum Daily PCA Dose – the maximum number of times that the patient can give
themselves a PCA dose. Again the lower the maximum dose, the lower the risk
of overdose, but the higher the risk of underdose.
PCA Basics
Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
Continuous Infusion – the normal rate of infusion of the drug. This determines the
steady state level of the drug and thereby the effectiveness of therapy.
PCA Dose – the patient controlled analgesia dose. This is the amount that the patient
can administer at any one time.
Lockout Interval – the minimum time between allowable PCA doses. The larger the
lockout interval the lower the risk of overdose and the higher the risk of
underdose.
Maximum Daily PCA Dose – the maximum number of times that the patient can give
themselves a PCA dose. Again the lower the maximum dose, the lower the risk
of overdose, but the higher the risk of underdose.
Maximum Periodic PCA Dose – this allows the physician to set the maximum number
of doses for a 2, 4, 8 or 12 hour period. This is most useful to allow a greater
number of daytime as opposed to nighttime injections.
Who Is A Candidate?
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Pain Syndromes at or below clavicle
Nociceptive, Neuropathic or Visceral Pain
Life Expectancy at least 3-6 months
Unrelieved Pain
Not the best practice.
Side Effects
Preferred reason!
– Usually at the level of Oxycontin 60mg per day
Epidural Trial
• Office Procedure
• Catheters placed within 24 hours
• Trials up to 2 weeks long
Final Implantation
Day Surgery Procedure
Lumbar Needle Entry
Catheter Tip: Cervical, Thoracic or Lumbar
Pump in R or L Buttock
Follow Up Care
• Initial Care
– Everyday for 2-3 days
– Twice a week for two weeks
– Every month or so thereafter
• Long Term
– Dozens of Patients
– Hundreds of Syringes
• Shifts in Pain Patterns
Case Study
• PB 48 YO W male presents in 2000
Case Study
Radical Prostatectomy
Radiation
Chemotherapy
Hormone Manipulation
Case Study
2006
Case Study
2007
Case Study
• 04/08/08 Initial Consultation
– Pain Primarily in Pelvis
• 04/10/08 Epidural Trial Placement
• 04/17/08 Permanent Implantation
– Morphine 0.7 mg per day c good relief of pain
Case Study
• Summer 2008
– Increased pain despite increased morphine dose
– Add Bupivacaine
Case Study
• Summer 2008
– Increased pain despite increased morphine dose
– Add Bupivacaine
• Fall 2008
– Increased pain despite increased combined dose
– Add Clonidine
Case Study
• Summer 2008
– Increased pain despite increased morphine dose
– Add Bupivacaine
• Fall 2008
– Increased pain despite increased combined dose
– Add Clonidine
• Christmas 2008
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Therapy Failing
Increased pain despite increased combined dose
Pain Shifting to legs
Add Ziconitide
Case Study
• 03/02/09
– Pump Increased
Hospitalized with abdominal pain
Case Study
• 03/02/09
Hospitalized with abdominal pain
– Pump Increased
• 03/03/09 AM
– Decreased Appetite
– Nausea and Vomiting
– Low Grade Fever
Symptoms worsen
Case Study
• 03/02/09
Hospitalized with abdominal pain
– Pump Increased
• 03/03/09 AM
Symptoms worsen
– Decreased Appetite
– Nausea and Vomiting
– Low Grade Fever
• 03/03/09 PM
– CAT Scan of Abdomen
– Surgical Consultation
– Sigmoid Colectomy
Dx: Intraabdominal Process
Case Study
• 03/02/09
Hospitalized with abdominal pain
– Pump Increased
• 03/03/09 AM
Symptoms worsen
– Decreased Appetite
– Nausea and Vomiting
– Low Grade Fever
• 03/03/09 PM
Dx: Intraabdominal Process
– CAT Scan of Abdomen
– Surgical Consultation
– Sigmoid Colectomy
• 03/08/09
Discharged in good condition