Brogan, S.E., Winter, N.B., & Okifuji, A. (2015). Prospective observational study of patient-controlled intrathecal analgesia: Impact on cancer-associated symptoms, breakthrough pain control, and patient satisfaction. Regional Anesthesia and Pain Medicine, 40, 369–375. 

To assess efficacy of patient-controlled intrathecal analgesia for management of cancer-related pain, emphasizing impact on breakthrough pain control and other symptoms

After patients had placement of an intrathecal pump, patient-controlled analgesia was begun immediately. Usually, the starting PCIA dose was 10% of the daily opioid dose, administered every 2–4 hours as needed. Patients used PCIA in addition to previous breakthrough medications as needed. After hospital discharge, patients were instructed to use PCAI and NSAIDs for any residual incisional pain. Patients completed symptom inventory assessment and were asked to respond to questions about breakthrough pain.

• N = 58   
• MEAN AGE = 56.8 years (SD = 14.6 years)
• MALES: 68.9%, FEMALES: 22.1%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Various tumor types. Prostate and colorectal were most prevalent.
• OTHER KEY SAMPLE CHARACTERISTICS: All patients had planned implantation of an intrathecal pump due to either poorly controlled pain or intolerance of opioids from sedation, nausea, or constipation. Of the patients, 40% had opioid monotherapy via the intrathecal pump, and 42% received opioid and bupivacaine.

• SITE: Single site   
• SETTING TYPE: Multiple settings    
• LOCATION: Utah

• Prospective observational

• MD Anderson Symptoms Inventory
• Breakthrough pain survey

The follow-up period ranged from 12–82 days. On average, worst pain scores were 8.32 prior to the intervention and 4.98 postintervention (p < 0.001). Of the patients, 8% reported worse pain and 12% reported no change. Of the remaining patients, 56% reported at least a 30% reduction in pain, and 44% reported a 50% reduction. The percentage of patients reporting breakthrough pain after the intervention was reduced by 20% (p < 0.013), and efficacy of PCIA was reported to be better than the efficacy of prior breakthrough medications (p < 0.0001). Sixty-five percent had discontinued all nonintrathecal opioid medications at follow-up. Of a total of 98 pumps inserted, there was infection in one case requiring pump removal and antibiotics, and three patients developed postdural puncture headache that resolved in two to three weeks with use of an epidural blood patch.

Patient-controlled intrathecal analgesia was effective for improved chronic and breakthrough pain control.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Key sample group differences that could influence results 
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Various patients were receiving multiple different adjunct medications for pain. Measurement of breakthrough pain was not well described. High variability existed in the follow-up time frame for measurement.

Findings of this study showed that intrathecal patient-controlled analgesia was associated with improved pain control in patients with refractory and breakthrough cancer-related pain, and this intervention was associated with few complications. These findings are limited by the study design. These results are promising, and further well-designed research to establish the appropriate role of patient-controlled intrathecal analgesia in cancer-related pain control is warranted.