Deer, T.R., Smith, H.S., Burton, A.W., Pope, J.E., Doleys, D.M., Levy, R.M., … Center For Pain Relief, Inc. (2011). Comprehensive consensus based guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain. Pain Physician, 14(3), E283–E312.

To identify guidelines for implementing intrathecal therapy (IT) and provide considerations for effective analgesia for chronic pain in patients with cancer or others at the end of life

• Authors state that the guidelines are based on available evidence from observational and randomized, prospective trials.
• Databases searched were not reported.
• Search keywords were intrathecal, cancer, palliative, pain, guidelines, opioids, consensus, selection, and evidence.
• Studies were included in the review if they involved patients with cancer-related pain or other end-of-life states causing pain.
• Exclusion criteria were not included.
• No conflicts of interest were identified.

This resource provides a summary of evidence and relevant recommendations regarding patient selection for IT therapy, implications of prior therapy and its results, use of IT pain therapy with concurrent chemotherapy or radiation, implications with epidural metastases, infection, comorbid conditions, social issues, and healthcare coverage.

• Several trials have demonstrated that IT therapy can reduce neuropathic-nociceptive pain while reducing drug-related toxicities and the need for supplementary systemic opioids.
• Despite a lack of robust evidence, clinical experience suggests that patients with poor pain relief or intolerance with systemic opioids can be effectively managed with IT.
• Potential clinical side effects include hyperalgesia, hypotension, sedation, and respiratory depression. Proper monitoring is essential, particularly in the first 24 hours after drug initiation.
• Patient selection should be based on the type of pain, although limited evidence exists in this area. IT may be appropriate for patients with soft tissue cancers with visceral nociceptive pain and pain attributed to bone metastases.
• No confirmed association has been found between patient response to oral opioids and response to IT therapy.
• Systemic infection was identified as a contraindication to device implantation. The authors reviewed evidence from the Centers for Disease Control regarding prophylaxis for surgical site infection. IT has been found to be useful for patients who are immunocompromised.
• Battery drain or electric failure of the implanted device can occur if the pump is directly in the radiation field and shielding. Minimizing radiation exposure or relocating the pump should be considered if the pump is directly in the radiation field.
• IT requires appropriate social support for follow-up and ongoing care. Lack of insurance coverage or social support is a contraindication to device implantation.

Recommendations provided are limited by reliance on consensus and the limited evidence available from clinical trials regarding the application of IT.

Consideration for comorbidities, support systems, compliance with recommended treatment plan, current or prior therapies, incorporation of the oncologist into the treatment plan, psychological monitoring, and appropriate trialing technique are key in the use of IT therapy. The authors advocate for wider application of IT therapy to effectively manage patients experiencing cancer and end-of-life pain.