Constant infusion of morphine for intractable cancer pain using an implanted pump

Restricted access

✓ In the past, pain control for chronic pain syndromes using narcotic infusion has been carried out primarily via the intrathecal (subarachnoid) route. This report presents one of the first large series of terminally ill cancer patients with intractable pain treated with continuous epidural morphine infusions by means of implanted pumps and epidural spinal catheters. The purpose of the study was to demonstrate that the epidural route is effective with minimal complications, and that screening with temporary epidural catheter infusions results in a high rate of subsequent pain relief. A multidisciplinary team (neurosurgeon, anesthesiologists, psychiatrists, oncologists, and nurse clinicians) evaluated and treated all of the patients studied. Percutaneous placement of temporary epidural catheters for a trial assessment was performed by the anesthesiologists. Pain evaluations were conducted independently by psychiatrists using both verbal and visual analog scales. From 1982 to 1988, 41 (59.4%) of 69 patients evaluated for eligibility experienced good pain control during trial assessment and were subsequently implanted with Infusaid infusion pumps. Preinfusion pain analog values were 8.6 ± 0.3 and postimplantation values at 1 month were 3.8 ± 0.4 (p < 0.001). Over this same 1-month period, requirements of systemic morphine equivalents decreased by 79.3% with epidural infusions as compared to preinfusion requirements (p < 0.001 ). There were no instances of epidural scarring, respiratory depression, epidural infections, meningitis, or catheter blockage. One patient developed apparent drug tolerance and three patients required further catheter manipulations. This series strongly suggests that significant reductions in cancer pain can be obtained with few complications and a low morphine tolerance rate using chronic epidural morphine infusion. Anesthesiology and psychiatry input, along with temporary catheter infusion screening and quantitative pain evaluations using analog scales, are essential.

Article Information

Address reprint requests to: Samuel J. Hassenbusch, M.D., Ph.D., Department of Neurosurgery, S80-803, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195-5226.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Comparison of mean systemic narcotic doses (broken line) and mean epidural morphine doses (solid line), both using the left axis, with mean pain scale ratings (dotted line, using right axis) at evaluation periods before pump placement (0 months) and 1,3,6, and 9 months after pump implantation.

References

  • 1.

    Auld AWMaki-Jokela AMurdoch DM: Intraspinal narcotic analgesia in the treatment of chronic pain. Spine 10:7777811985Auld AW Maki-Jokela A Murdoch DM: Intraspinal narcotic analgesia in the treatment of chronic pain. Spine 10:777–781 1985

    • Search Google Scholar
    • Export Citation
  • 2.

    Brazenor GA: Long term intrathecal administration of morphine: a comparison of bolus injection via reservoir with continuous infusion by implanted pump. Neurosurgery 21:4844911987Brazenor GA: Long term intrathecal administration of morphine: a comparison of bolus injection via reservoir with continuous infusion by implanted pump. Neurosurgery 21:484–491 1987

    • Search Google Scholar
    • Export Citation
  • 3.

    Caballero GAAusman RKHimes J: Epidural morphine by continuous infusion with an external pump for pain management in oncology patients. Am Surg 52:4024051986Caballero GA Ausman RK Himes J: Epidural morphine by continuous infusion with an external pump for pain management in oncology patients. Am Surg 52:402–405 1986

    • Search Google Scholar
    • Export Citation
  • 4.

    Caputi CABusca GFogliardi Aet al: Epidural and intraventricular morphine therapy in the treatment of cancer pain. Minerva Anesthesiol 52:3513551986Caputi CA Busca G Fogliardi A et al: Epidural and intraventricular morphine therapy in the treatment of cancer pain. Minerva Anesthesiol 52:351–355 1986

    • Search Google Scholar
    • Export Citation
  • 5.

    Carl PCrawford MERavlo Oet al: Longterm treatment with epidural opioids. Anesthesia 41:32381986Carl P Crawford ME Ravlo O et al: Longterm treatment with epidural opioids. Anesthesia 41:32–38 1986

    • Search Google Scholar
    • Export Citation
  • 6.

    Coombs DW: Intraspinal analgesic infusion by implanted pump. Ann NY Acad Sci 531:1081221988Coombs DW: Intraspinal analgesic infusion by implanted pump. Ann NY Acad Sci 531:108–122 1988

    • Search Google Scholar
    • Export Citation
  • 7.

    Coombs DWPageau MGSaunders RLet al: Intraspinal narcotic tolerance. Preliminary experience with continuous bupivacaine HCl infusion via implanted infusion device. Int J Artif Organs 5:3793821982Coombs DW Pageau MG Saunders RL et al: Intraspinal narcotic tolerance. Preliminary experience with continuous bupivacaine HCl infusion via implanted infusion device. Int J Artif Organs 5:379–382 1982

    • Search Google Scholar
    • Export Citation
  • 8.

    Coombs DWSaunders RLFratkin JDet al: Continuous intra-thecal hydromorphone and clonidine for intractable cancer pain. J Neurosurg 64:8908941986Coombs DW Saunders RL Fratkin JD et al: Continuous intra-thecal hydromorphone and clonidine for intractable cancer pain. J Neurosurg 64:890–894 1986

    • Search Google Scholar
    • Export Citation
  • 9.

    Coombs DWSaunders RLGaylor MSet al: Relief of continuous chronic pain by intraspinal narcotics infusion via an implanted reservoir. JAMA 250:233623391983Coombs DW Saunders RL Gaylor MS et al: Relief of continuous chronic pain by intraspinal narcotics infusion via an implanted reservoir. JAMA 250:2336–2339 1983

    • Search Google Scholar
    • Export Citation
  • 10.

    Coombs DWSaunders RLLachance Det al: Intrathecal morphine tolerance: use of intrathecal clonidine, DA-DLE, and intraventricular morphine. Anesthesiology 62:3583631985Coombs DW Saunders RL Lachance D et al: Intrathecal morphine tolerance: use of intrathecal clonidine DA-DLE and intraventricular morphine. Anesthesiology 62:358–363 1985

    • Search Google Scholar
    • Export Citation
  • 11.

    Dagi TFChilton JCaputy Aet al: Long-term, intermittent percutaneous administration of epidural and intrathecal morphine for pain of malignant origin. Am Surg 52:1551581986Dagi TF Chilton J Caputy A et al: Long-term intermittent percutaneous administration of epidural and intrathecal morphine for pain of malignant origin. Am Surg 52:155–158 1986

    • Search Google Scholar
    • Export Citation
  • 12.

    Glynn CDawson DSaunders R: A double-blind comparison between epidural morphine and epidural clonidine in patients with chronic non-cancer pain. Pain 34:1231281988Glynn C Dawson D Saunders R: A double-blind comparison between epidural morphine and epidural clonidine in patients with chronic non-cancer pain. Pain 34:123–128 1988

    • Search Google Scholar
    • Export Citation
  • 13.

    Glynn CJJamous ADawson Det al: The role of epidural clonidine in the treatment of patients with intractable pain. Pain Suppl 4:451987 (Abstract)Glynn CJ Jamous A Dawson D et al: The role of epidural clonidine in the treatment of patients with intractable pain. Pain Suppl 4:45 1987 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 14.

    Harbaugh RESaunders RLReeder RF: Use of implantable pumps for central nervous system drug infusions to treat neurologic disease. Neurosurgery 23:6936981988Harbaugh RE Saunders RL Reeder RF: Use of implantable pumps for central nervous system drug infusions to treat neurologic disease. Neurosurgery 23:693–698 1988

    • Search Google Scholar
    • Export Citation
  • 15.

    Ingemar FAhlgren HAhlgren BE: Epidural administration of opiates by a new device. Pain 31:3533571987Ingemar F Ahlgren H Ahlgren BE: Epidural administration of opiates by a new device. Pain 31:353–357 1987

    • Search Google Scholar
    • Export Citation
  • 16.

    Müller HLuben VZierski Jet al: Long term spinal opiate treatment. Acta Anaesthesiol Belg 39 (Suppl 2): 83861988Müller H Luben V Zierski J et al: Long term spinal opiate treatment. Acta Anaesthesiol Belg 39 (Suppl 2):83–86 1988

    • Search Google Scholar
    • Export Citation
  • 17.

    Murphy TMHinds SCherry D: Intraspinal narcotics: nonmalignant pain. Acta Anaesthesiol Scand Suppl 85:75761987Murphy TM Hinds S Cherry D: Intraspinal narcotics: nonmalignant pain. Acta Anaesthesiol Scand Suppl 85:75–76 1987

    • Search Google Scholar
    • Export Citation
  • 18.

    Onofrio BMYaksh TL: Intrathecal delta-receptor ligand produces analgesia in man. Lancet 1:138613871983 (Letter)Onofrio BM Yaksh TL: Intrathecal delta-receptor ligand produces analgesia in man. Lancet 1:1386–1387 1983 (Letter)

    • Search Google Scholar
    • Export Citation
  • 19.

    Oyama TMurakawa TBaba Set al: Continuous vs. bolus epidural morphine. Acta Anaesthesiol Scand Suppl 85:77791987Oyama T Murakawa T Baba S et al: Continuous vs. bolus epidural morphine. Acta Anaesthesiol Scand Suppl 85:77–79 1987

    • Search Google Scholar
    • Export Citation
  • 20.

    Paice JA: New delivery systems in pain management. Nurs Clin North Am 22:7157261987Paice JA: New delivery systems in pain management. Nurs Clin North Am 22:715–726 1987

    • Search Google Scholar
    • Export Citation
  • 21.

    Penn RD: Drug pumps for treatment of neurologic diseases and pain. Neurol Clin 3:4394511985Penn RD: Drug pumps for treatment of neurologic diseases and pain. Neurol Clin 3:439–451 1985

    • Search Google Scholar
    • Export Citation
  • 22.

    Penn RDPaice JA: Chronic intrathecal morphine for intractable pain. J Neurosurg 67:1821861987Penn RD Paice JA: Chronic intrathecal morphine for intractable pain. J Neurosurg 67:182–186 1987

    • Search Google Scholar
    • Export Citation
  • 23.

    Penn RDPaice JAGottschalk Wet al: Cancer pain relief using chronic morphine infusion. Early experience with a programmable implanted drug pump. J Neurosurg 61:3023061984Penn RD Paice JA Gottschalk W et al: Cancer pain relief using chronic morphine infusion. Early experience with a programmable implanted drug pump. J Neurosurg 61:302–306 1984

    • Search Google Scholar
    • Export Citation
  • 24.

    Petros AJBowen RM: Epidural and oral clonidine in domiciliary control of deafferentation pain. Lancet 1:10341987 (Letter)Petros AJ Bowen RM: Epidural and oral clonidine in domiciliary control of deafferentation pain. Lancet 1:1034 1987 (Letter)

    • Search Google Scholar
    • Export Citation
  • 25.

    Shetter AGHadley MNWilkinson E: Administration of intraspinal morphine sulfate for the treatment of intractable cancer pain. Neurosurgery 18:7407471986Shetter AG Hadley MN Wilkinson E: Administration of intraspinal morphine sulfate for the treatment of intractable cancer pain. Neurosurgery 18:740–747 1986

    • Search Google Scholar
    • Export Citation
  • 26.

    Vainio ATigerstedt I: Opioid treatment for radiating cancer pain. Oral administration vs. epidural techniques. Acta Anaesthesiol Scand 32:1791851988Vainio A Tigerstedt I: Opioid treatment for radiating cancer pain. Oral administration vs. epidural techniques. Acta Anaesthesiol Scand 32:179–185 1988

    • Search Google Scholar
    • Export Citation
  • 27.

    Ventafridda VSpoldi ECaraceni Aet al: Intraspinal morphine for cancer pain. Acta Anaesthesiol Scand Suppl 85:47531987Ventafridda V Spoldi E Caraceni A et al: Intraspinal morphine for cancer pain. Acta Anaesthesiol Scand Suppl 85:47–53 1987

    • Search Google Scholar
    • Export Citation
  • 28.

    Wermeling DPFoster TSRecord KEet al: Drug delivery for intractable cancer pain. Cancer 60:8758781987Wermeling DP Foster TS Record KE et al: Drug delivery for intractable cancer pain. Cancer 60:875–878 1987

    • Search Google Scholar
    • Export Citation
  • 29.

    Yaksh TLOnofrio BM: Retrospective consideration of the doses of morphine given intrathecally by chronic infusion in 163 patients by 19 physicians. Pain 31:2112231987Yaksh TL Onofrio BM: Retrospective consideration of the doses of morphine given intrathecally by chronic infusion in 163 patients by 19 physicians. Pain 31:211–223 1987

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 472 472 22
Full Text Views 211 166 1
PDF Downloads 110 96 1
EPUB Downloads 0 0 0

PubMed

Google Scholar