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Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations

  • Bård Lundeland EMAIL logo , Lars Janerås and Gunnvald Kvarstein
Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

In this issue of the Scandinavian Journal of Pain, Kehua Zhou and co-workers present a case report on two patients treated for several years with intrathecal (IT) morphine due to chronic pain after multiple failed spinal operations [1]. Despite this treatment, the patients had insufficient pain relief and compromised function for activities of daily living. This was emphasized by the use of additional opioids (per oral, transdermal) and willingness to undergo further back surgery during the ongoing IT morphine treatment. Additionally, the patients experienced severe side effects, including respiratory complications that caused visits at hospital emergency departments. One of the patients was also transferred to a nursing home after developing dementia-like symptoms. The two patients were finally included in a pain programme based on education, physiotherapy and tapering of opioids via conversion to methadone. After discontinuation of opioids both interestingly described better pain-control and improved function, and the patient showing symptoms of dementia improved and could be discharged home.

1 Post-surgical chronic back and leg pain (CBLP)

The term post-surgical CBLP, formerly known as failed back surgery syndrome, describes a condition with persistent or recurring low back pain, with or without sciatica following one or more spine surgeries [2]. The condition is complex, involving biological, psychological and social factors, and the incidence of post-surgical CBLP is commonly described as occurring between 10 and 40% [2]. A broad rehabilitation approach seems to be important. In a Cochrane review from 2015 multidisciplinary rehabilitation programmes for chronic low back pain were found superior to usual care or physical treatments with respect to long-term pain and disability [3]. Spinal cord stimulation (SCS) is a treatment modality offered to patients with post-surgical CBLP, and RCTs including this patient population show better outcome for SCS compared with reoperation and with conventional management [4,5].

2 Intrathecal opioids in chronic pain

Many patients with post-surgical CBLP become chronic opioid users although the evidence for pain relief and function improvement is insufficient for this treatment [6]. In the USA, a more liberal prescription of opioids for chronic pain has caused an epidemic of abuse and overdose fatalities during the last decades [7,8]. The intention with IT drug delivery (ITDD) is to achieve adequate concentration of a drug by administration close to the site of action in the spinal cord, and then reduce the side effects compared with systemic administration [9]. The International Neuromodulation Society regularly organizes consensus conferences and publishes guidelines for ITDD, with the last update this year [10]. In the USA only morphine, ziconotide, and baclofen have been approved for intrathecal use by the Food and Drug Administration [11], but other drugs are used off-label, e.g. clonidine and several opioids [10]. In severe cancer pain IT opioids in combination with a local anaesthetic have been described as a safe and effective treatment [10,12,13]. For chronic pain, support for IT opioid administration is based on prospective and retrospective non-controlled trials [10], while ziconotide has tested positive in placebo controlled RCTs, although with short follow-up periods [14,15,16]. Severe complications of ITDD have been described, including deaths due to respiratory depression by opioids or other central nervous depressant drugs [9,17], and drug leakage in connection with the refilling process can be life-threatening [18,19]. Long-term IT opioid therapy has also profound effects on the neuroendocrine functions [20], and can lead to catheter-tip granuloma with spinal cord compression, particularly after high concentrations and high dosages [21]. In addition, severe infections (meningitis and epidural abscess) and neurological damage have been reported [9].

3 Opioid weaning

In Zhou and colleagues’ case report, IT morphine weaning was done with a conversion to methadone before tapering the opioid treatment. An advantage with methadone is the possibility to stabilize the analgesic effect, but the conversion ratios from morphine to methadone vary considerably [22]. It is also possible to taper IT morphine treatment directly by reducing the infusion rate regularly, for instance by 5% every week, but often there will be a need of systemic opioids for a period after the IT infusion has been stopped. When IT morphine fails, the pain can be considered to be opioid-resistant and it would be reasonable to taper and discontinue the systemic opioids as well.

4 Conclusions and implications

Chronic pain is difficult to treat, and when all other treatments fail, some patients receive IT morphine as a last resort, but the evidence for this treatment is limited, as it is for long-term systemic opioids for chronic pain [6]. A placebo-controlled RCT needs a double-dummy design, but would still be difficult to blind. Due to the limited evidence and the potential severe side effects, IT morphine for chronic (non-cancer) pain should be restricted to a few and highly selected patients, and importantly, continuation requires substantial function improvement, not only pain reduction [8]. Most of our chronic pain patients treated with IT morphine have reported disappointing effect, and in our experience IT morphine infusion should not be combined with systemic opioid administration. Zhou and co-workers’ case report underlines the importance of a tight follow-up of patients receiving IT morphine, and they emphasize the importance of stopping treatment if the effect is not significant or severe side effects occur.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.07.006.

Department of Pain Management and Research, Oslo University Hospital, PB 4956 Nydalen, 0424 Oslo, Norway

  1. Conflict of interest: None declared.

Reference

[1] Zhou K, Sheng S, Wang GG. Management of patients with pain and severe side effects while on intrathecal morphine therapy: a case study. Scand J Pain 2017;17:37–40.Search in Google Scholar

[2] Chan CW, Peng P. Failed backsurgerysyndrome. PainMed 2011;12:577–606.Search in Google Scholar

[3] Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015;350:h444.Search in Google Scholar

[4] North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery 2005;56:98–106, discussion 106-7.Search in Google Scholar

[5] Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O’Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson J, North RB. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain 2007;132:179–88.Search in Google Scholar

[6] Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Path ways to Prevention Workshop. Ann Intern Med 2015;162:276–86.Search in Google Scholar

[7] Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription opioid use, misuse, and use disorders in U. S. adults: 2015 national surveyon drug use and health. Ann Intern Med 2017, http://dx.doi.org/10.7326/M17-0865 [Epub ahead of print].Search in Google Scholar

[8] Ballantyne JC, Sullivan MD. Intensity of chronic pain - the wrong metric? N Engl J Med 2015;373:2098–9.Search in Google Scholar

[9] Duarte R, Raphael J, Eldabe S. Intrathecal drug delivery for the management of pain and spasticity in adults: an executive summary of the British Pain Society’s recommendations forbest clinical practice. Br J Pain 2016;10:67–9.Search in Google Scholar

[10] Deer TR, Pope JE, Hayek SM, Bux A, Buchser E, Eldabe S, DeAndres JA, Erdek M, Patin D, Grider JS, Doleys DM, Jacobs MS, Yaksh TL, Poree L, Wallace MS, Prager J, Rauck R, DeLeon O, Diwan S, Falowski SM, Gazelka HM, Kim P, Leong M, Levy RM, McDowell IIG, McRoberts P, Naidu R, Narouze S, Perruchoud C, Rosen SM, Rosenberg WS, Saulino M, Staats P, Stearns LJ, Willis D, Krames E, Huntoon M, Mekhail N. The polyanalgesic consensus conference (PACC): recommendations on intrathecal drug infusion systems best practices and guidelines. Neuromodulation 2017;20:96–132.Search in Google Scholar

[11] Bottros MM, Christo PJ. Current perspectives on intrathecal drug delivery. J Pain Res 2014;7:615–26.Search in Google Scholar

[12] Kiehela L, Hamunen K, Heiskanen T. Spinal analgesia for severe cancer pain: a retrospective analysis of 60 patients. Scand J Pain 2017;16:140–5.Search in Google Scholar

[13] Vissers KC, Besse K, Wagemans M, Zuurmond W, Giezeman MJ, Lataster A, Mekhail N, Burton AW, van Kleef M, Huygen F. 23. Pain in patients with cancer.Pain Pract 2011;11:453–75.Search in Google Scholar

[14] Staats PS, Yearwood T, Charapata SG, Presley RW, Wallace MS, Byas-Smith M, Fisher R, Bryce DA, Mangieri EA, Luther RR, Mayo M, McGuire D, Ellis D. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. JAMA 2004;291:63–70.Search in Google Scholar

[15] Wallace MS, Charapata SG, Fisher R, Byas-Smith M, Staats PS, Mayo M, McGuire D, Ellis D, Ziconotide Nonmalignant Pain Study 96-002 Group.Intrathecal ziconotide in the treatment of chronic nonmalignant pain: a randomized, double-blind, placebo-controlled clinical trial. Neuromodulation 2006;9:75–86.Search in Google Scholar

[16] Rauck RL, Wallace MS, Leong MS, Minehart M, Webster LR, Charapata SG, Abraham JE, Buffington DE, Ellis D, Kartzinel R, Ziconotide 301 Study Group.A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adultswith severe chronic pain. J Pain Symptom Manage 2006;31:393–406.Search in Google Scholar

[17] Coffey RJ, Owens ML, Broste SK, Dubois MY, Ferrante FM, Schultz DM, Stearns LJ, Turner MS. Mortality associated with implantation and management of intrathecal opioid drug infusion systems to treat noncancer pain. Anesthesiology 2009;111:881–91.Search in Google Scholar

[18] Johnson ML, Visser EJ, Goucke CR. Massive clonidine overdose during refill of an implanted drug delivery device for intrathecal analgesia: a review of inadvertent soft-tissue injection during implantable drug delivery device refills and its management. Pain Med 2011;12:1032–40.Search in Google Scholar

[19] Berger B, Vienenkoetter B, Korporal M, Rocco A, Meinck HM, Steiner T. Accidental intoxication with 60 mg intrathecal baclofen: survived. Neurocrit Care 2012;16:428–32.Search in Google Scholar

[20] Abs R, Verhelst J, Maeyaert J, Van Buyten JP, Opsomer F, Adriaensen H, Verlooy J, Van Havenbergh T, Smet M, Van Acker K. Endocrine consequences of long-term intrathecal administration of opioids. J Clin Endocrinol Metab 2000;85:2215–22.Search in Google Scholar

[21] Arnold PM, Harsh V, Oliphant SM. Spinal cord compression secondary to intrathecal catheter-induced granuloma: a report of four cases. Evid Based Spine CareJ 2011;2:57–62.Search in Google Scholar

[22] Peng P, Tumber P, Stafford M, Gourlay D, Wong P, Galonski M, Evans D, Gordon A. Experience of methadone therapy in 100 consecutive chronic pain patients in a multidisciplinary pain center. Pain Med 2008;9:786–94.Search in Google Scholar
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2017.09.003

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  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
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  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
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  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
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  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
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  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
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  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
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  35. Original experimental
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