Accessible Requires Authentication Published by De Gruyter October 1, 2017

Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study

Kehua Zhou, Sen Sheng and Gary G. Wang

Abstract

Background and aims

The use of intrathecal morphine therapy has been increasing. Intrathecal morphine therapy is deemed the last resort for patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions. However, effective treatments for patients with CNCP who “failed” this last resort because of severe side effects and lack of optimal pain control remain unclear.

Methods and results

Here we report two successfully managed patients (Ms. S and Mr. T) who had intractable pain and significant complications years after the start of intrathecal morphine therapy. The two patients had intrathecal morphine pump implantation due to chronic consistent pain and multiple failed surgical operations in the spine. Years after morphine pump implantation, both patients had significant chronic pain and compromised function for activities of daily living. Additionally, Ms. S also had four episodes of small bowel obstruction while Mr. T was diagnosed with end stage severe “dementia”. The successful management of these two patients included the simultaneous multidisciplinary approach for pain management, opioids tapering and discontinuation.

Conclusion

The case study indicates that for patients who fail to respond to intrathecal morphine pump therapy due to side effects and lack of optimal pain control, the simultaneous multidisciplinary pain management approach and opioids tapering seem appropriate.


2121 Main Street, Suite 210, Buffalo, NY 14214, United States

  1. Conflict of interest: No actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Acknowledgement

The authors would like to thank Professor Yuan Bo Peng MD, PhD for his valuable input during the manuscript drafting and revision process.

References

[1] Bier A. Attempts over Cocainisirung of the Ruckenmarkers. Langenbecks Arch Klin ChirVer Dtsch Z Chir 1899;51:361–9 [German]. Search in Google Scholar

[2] Alper MH. Intrathecal morphine: a new method of obstetric analgesia? Anesthesiology 1979;51:378–9. Search in Google Scholar

[3] Onofrio BM, Yaksh TL, Arnold PG. Continuous low-dose intrathecal morphine administration in the treatment of chronic pain of malignant origin. Mayo Clin Proc 1981;56:516–20. Search in Google Scholar

[4] Wallace M, Yaksh TL. Long-term spinal analgesic delivery: a review of the preclinical and clinical literature. Reg Anesth Pain Med 2000;25:117–57. Search in Google Scholar

[5] Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, Caraway D, Cousins M, De Andres J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell 2nd GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic consensus conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation 2012;15:436–64. Search in Google Scholar

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

[7] Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Phys 2008;11:105–20. Search in Google Scholar

[8] Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006;125:172–9. Search in Google Scholar

[9] Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med 2015;49:493–501. Search in Google Scholar

[10] Schuckit MA. Treatment of opioid-use disorders. N Engl J Med 2016;375:357–68. Search in Google Scholar

[11] Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315:1624–45. Search in Google Scholar

[12] Roditi D, Robinson ME. The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Manag 2011;4:41–9. Search in Google Scholar

[13] Bodnar RJ. Endogenous opiates and behavior: 2014. Peptides 2016;75:18–70. Search in Google Scholar

[14] Vuong C, Van Uum SH, O’Dell LE, Lutfy K, Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev 2010;31:98–132. Search in Google Scholar

[15] Van Bockstaele EJ, Peoples J, Menko AS, McHugh K, Drolet G. Decreases in endogenous opioid peptides in the rat medullo-coerulear pathway after chronic morphinetreatment. J Neurosci 2000;20:8659–66. Search in Google Scholar

[16] Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014;69:119–30. Search in Google Scholar

[17] Berna C, Kulich RJRJ. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90:828–42. Search in Google Scholar

[18] Argoff CE, Silvershein DI. A comparison of long- and short-acting opioids forthe treatment of chronic noncancer pain: tailoring therapy to meet patient needs. Mayo Clin Proc 2009;84:602–12. Search in Google Scholar

[19] Hyman SM, Fox H, Hong KI, Doebrick C, Sinha R. Stress and drug-cue-induced craving in opioid-dependent individuals in naltrexone treatment. Exp Clin Psychopharmacol 2007;15:134–43. Search in Google Scholar

[20] Svendsen KB, Andersen S, Arnason S, Arner S, Breivik H, Heiskanen T, Kalso E, Kongsgaard UE, Sjogren P, Strang P, Bach FW, Jensen TS. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain 2005;9:195–206. Search in Google Scholar

[21] National Highway Traffic Safety Administrations.Drugs and human performance face sheets: methadone.https://one.nhtsa.gov/people/injury/research/job185drugs/methadone.htm [accessed 24.06.17]. Search in Google Scholar

[22] Molokhia M, Majeed A. Current and future perspectives on the management of polypharmacy. BMC Fam Pract 2017;18:70. Search in Google Scholar

Received: 2017-04-25
Revised: 2017-06-26
Accepted: 2017-07-05
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain