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Intrathecal Therapy for Chronic Pain: A Review of ‘Pain Pumps’ and Ziconotide as Firstline Options

Jax Spine & Pain Centers Dr. Michael Hanes is a published author continually contributing to the study of medicine in an effort to make a difference. His most recent published contribution can be viewed by clicking here and an excerpt of his article/studies featured below with the aforementioned title the topic of discussion.

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By: Dr. Michael Hanes 
Objectives

To evaluate the evidence for ‘pain pumps’ and ziconotide as firstline intrathecal (IT) analgesia agents for patients with chronic pain.

Methods

Medline was searched (through July 2017) for “ziconotide” or “morphine” AND “intrathecal” AND “chronic pain,” with results limited to studies in human populations.

Results

The literature supports the use of ‘pain pumps’ (based primarily on noncontrolled, prospective, and retrospective studies) and ziconotide (based on randomized controlled trials and prospective observational studies) as first-choice IT therapies. The 2016 Polyanalgesic Consensus Conference (PACC) guidelines recommended both ‘pain pumps’ and ziconotide as firstline IT monotherapy for localized and diffuse chronic pain of cancer-related and non–cancer-related etiologies; however, one consensus point emphasized ziconotide use, unless contraindicated, as firstline IT therapy in patients with chronic non–cancer-related pain. Initial IT therapy choice should take into consideration individual patient characteristics (e.g., pain location, response to previous therapies, comorbid medical conditions, psychiatric history). Trialing is recommended to assess medication efficacy and tolerability. For both ‘pain pumps’ and ziconotide, the PACC guidelines recommend conservative initial dosing strategies. Due to its narrow therapeutic window, ziconotide requires careful dose titration. Ziconotide is contraindicated in patients with a history of psychosis. IT morphine administration may be associated with serious side effects (e.g., respiratory depression, catheter tip granuloma), require dose increases, and cause dependence over time.

CLICK HERE for a more in-depth look at Dr. Hanes’ and his colleagues findings.

Conclusion

Based on the available evidence, ‘pain pumps’ and ziconotide are recommended as firstline IT monotherapy for cancer-related and non–cancer-related pain. The choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication.After its 2016 meeting, the PACC published updated guidelines to enhance patient safety and decrease the risk of complications related to IT therapy for pain relief. These guidelines recommended ‘pain pumps’ and ziconotide as firstline monotherapy for cancer-related and non–cancer-related pain. Ziconotide was recommended ahead of morphine (barring a contraindication for ziconotide) in patients with non–cancer-related pain [9]. Ultimately, the choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication. Applying the PACC 2016 guidelines in clinical practice—particularly the use of ziconotide as firstline IT therapy for patients with noncancer pain—may improve the efficacy and safety of IT therapy for patients with chronic pain. The interim analysis data of the PRIZM registry suggest sustained effectiveness when ziconotide is used as the first agent in the pump [10]; however, increased patient numbers and additional analyses of these data will contribute to our knowledge of and comfort in using nonopioid IT analgesics. In addition, data is needed to further understand the benefits and risks associated with the choice of initial IT medication (i.e., ‘pain pumps’ or ziconotide) in diverse chronic pain populations.

Jax Spine & Pain Centers is now accepting new patients. Dr. Hanes and all of the Double Board Certified Physicians at our centers are with you every step of the way when it comes to making sure you get the relief you need. Call 904.257.0060 for more information or fill out the consultation request form on our homepage and one of our customer care representatives will be happy to assist you.

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