This or That: Making Controversial Choices in Intrathecal Drug Delivery

Learning Outcomes

As a result of participating in this activity, learners will be better able to:

• evaluate patients who may benefit from an intrathecal pump
• select the right placement for the catheter
• determine correct dosing for intrathecal drug delivery

Outline

• History of Intrathecal Drug Delivery
• Areas of controversy
  • Catheter Tip Location
    • Spinal level
    • Dorsal vs Ventral
  • Trialing Prior to Implant
  • Conversion from Systemic to Intrathecal Opioids

Accreditation & Designation

Release date: This activity was released 8/19/2022.

Termination date: The content of this activity remains eligible for CME Credit until 8/18/2025, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation.

This activity includes discussions of unlabeled or investigational uses of commercial and/or developmental products.

This activity includes discussions and explorations of new and evolving topics. Such inclusion includes adequate justifications of statements based upon current science, evidence and clinical reasoning.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

California Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill
AB487 requires physicians licensed in California to complete a one-time CME activity for 12 hours of credits that addresses both pain management and the appropriate care and treatment of the terminally ill. This activity contributes to achievement of requirements with AB487.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Jill Sindt discloses the following financial relationships within the past 24 months: Consulting: Medtronic

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Schultz, D. M., Abd-Elsayed, A., Calodney, A., Stromberg, K., Weaver, T., & Spencer, R. J. (2021). Targeted drug delivery for chronic nonmalignant pain: longitudinal data from the product surveillance registry. Neuromodulation: Technology at the Neural Interface, 24(7), 1167-1175.
• Knight KH, Brand FM, Mchaourab AS, Veneziano G. Implantable intrathecal pumps for chronic pain: highlights and updates. Croat Med J. 2007 Feb;48(1):22-34. PMID: 17309136; PMCID: PMC2080496.
• Corning, J. L. (1888). A further contribution on local medication of the spinal cord, with cases. Medical Record (1866-1922), 33(11), 291.
• Tangen, K. M., Leval, R., Mehta, A. I., & Linninger, A. A. (2017). Computational and in vitro experimental investigation of intrathecal drug distribution: parametric study of the effect of injection volume, cerebrospinal fluid pulsatility, and drug uptake. Anesthesia & Analgesia, 124(5), 1686-1696.
• Deer, T. R., Hayek, S. M., Pope, J. E., Lamer, T. J., Hamza, M., Grider, J. S., ... & Mekhail, N. (2017). The Polyanalgesic Consensus Conference (PACC): recommendations for trialing of intrathecal drug delivery infusion therapy. Neuromodulation: Technology at the Neural Interface, 20(2), 133-154.
• Deer, T. R., Prager, J., Levy, R., Rathmell, J., Buchser, E., Burton, A., ... & Mekhail, N. (2012). Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation: Technology at the Neural Interface, 15(5), 436-466.
• Dominguez, E., Sahinler, B., Bassam, D., Day, M., Lou, L., Racz, G., & Raj, P. (2002). Predictive value of intrathecal narcotic trials for long‐term therapy with implantable drug administration systems in chronic non‐cancer pain patients. Pain Practice, 2(4), 315-325.
• Hamza, M., Doleys, D. M., Saleh, I. A., Medvedovsky, A., Verdolin, M. H., & Hamza, M. (2015). A prospective, randomized, single-blinded, head-to-head long-term outcome study, comparing intrathecal (IT) boluses with continuous infusion trialing techniques prior to implantation of drug delivery systems (DDS) for the treatment of severe intractable chronic nonmalignant pain. Neuromodulation: Technology at the Neural Interface, 18(7), 636-649.
• Ver Donck, A., Vranken, J. H., Puylaert, M., Hayek, S., Mekhail, N., & Van Zundert, J. (2014). Intrathecal drug administration in chronic pain syndromes. Pain Practice, 14(5), 461-476.
• Hatheway, J. A., Bansal, M., & Nichols-Ricker, C. I. (2020). Systemic opioid reduction and discontinuation following implantation of intrathecal drug-delivery systems for chronic pain: a retrospective cohort analysis. Neuromodulation: Technology at the Neural Interface, 23(7), 961-969.
• Krames, E. S., & Olson, K. (1997). Clinical realities and economic considerations: patient selection in intrathecal therapy. Journal of pain and symptom management, 14(3), S3-S13.
• Wallace, M., & Yaksh, T. L. (2000). Long-term spinal analgesic delivery: a review of the preclinical and clinical literature. Regional Anesthesia and Pain Medicine, 25(2), 117.
• Sindt, J. E., Odell, D. W., Tariq, R., Presson, A. P., Zhang, C., & Brogan, S. E. (2021). Initial intrathecal dose titration and predictors of early dose escalation in patients with cancer using a 100: 1 oral to intrathecal morphine conversion ratio. Neuromodulation: Technology at the Neural Interface, 24(7), 1157-1166.