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Timothy R Deer,
Joshua Prager,
Robert Levy,
James Rathmell,
Eric Buchser,
Allen Burton,
David Caraway,
Michael Cousins,
José De Andrés,
Sudhir Diwan, [......], Michael Saulino,
B Todd Sitzman,
Peter Staats,
Michael Stanton-Hicks,
Lisa Stearns,
Mark Wallace,
K Dean Willis,
William Witt,
Tony Yaksh,
Nagy Mekhail
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[hide abstract]
ABSTRACT: Introduction: The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences. Methods: The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain. Results: After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain. Conclusions: The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.
Neuromodulation 09/2012; 15(5):436-466. · 1.19 Impact Factor
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Timothy R Deer,
Robert Levy,
Joshua Prager,
Eric Buchser,
Allen Burton,
David Caraway,
Michael Cousins,
José De Andrés,
Sudhir Diwan,
Michael Erdek, [......], Michael Saulino,
B Todd Sitzman,
Peter Staats,
Michael Stanton-Hicks,
Lisa Stearns,
Mark Wallace,
K Dean Willis,
William Witt,
Tony Yaksh,
Nagy Mekhail
[show abstract]
[hide abstract]
ABSTRACT: Introduction: Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality. Methods: The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems. Results: Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy. Conclusions: Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.
Neuromodulation 07/2012; 15(5):467-482. · 1.19 Impact Factor
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ABSTRACT: Chronic pain-especially that which is refractory to conventional treatment-presents particular challenges to physicians and patients. Examination of the molecular and cellular mechanisms involved in this pathophysiology suggests that spinal instillation of therapeutic agents may offer an effective treatment option through the modification of the processing and sensation of chronic pain. Intrathecal therapy, used alone or in combination with other analgesic agents, may reduce chronic pain by attenuating both pre- and postsynaptic activities. This article reviews chronic pain pathophysiology and the mechanisms whereby spinally administered analgesics may modify chronic pain. Available treatment options are also considered, including recommendations from the 2007 Polyanalgesic Consensus Conference (PACC) guidelines on the use of intrathecal agents for nociceptive, neuropathic, and mixed pain.
Pain Practice 05/2012; · 2.21 Impact Factor
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Timothy R Deer,
Joshua Prager,
Robert Levy,
James Rathmell,
Eric Buchser,
Allen Burton,
David Caraway,
Michael Cousins,
José De Andrés,
Sudhir Diwan, [......], Michael Saulino,
B Todd Sitzman,
Peter Staats,
Michael Stanton-Hicks,
Lisa Stearns,
Mark Wallace,
K Dean Willis,
William Witt,
Tony Yaksh,
Nagy Mekhail
[show abstract]
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ABSTRACT: Introduction: Continuous intrathecal infusion of drugs to treat chronic pain and spasticity has become a standard part of the algorithm of care. The use of opioids has been associated with noninfectious inflammatory masses at the tip of the intrathecal catheter, which can result in neurologic complications. Methods: The Polyanalgesic Consensus Conference is a meeting of a group of well-published and experienced practitioners; the purpose of the meeting is to update the standard of care for intrathecal therapies to reflect current knowledge gleaned from literature and clinical experience. An exhaustive literature search was performed, and information from this search was provided to panel members. Analysis of the published literature was coupled with the clinical experience of panel participants to form recommendations regarding intrathecal inflammatory masses or granulomas. Results: The panel has made recommendations for the prevention, diagnosis, and management of intrathecal granulomas. Conclusion: The use of chronic infusions of intrathecal opioids is associated with the formation of inflammatory masses at the intrathecal catheter tip in a small minority of treated patients. Nonetheless, the appearance of these space-occupying lesions can lead to devastating neurologic sequelae. The prevention, early detection, and successful treatment of intraspinal granulomas are important considerations when offering intrathecal drug therapy to patients with chronic intractable pain.
Neuromodulation 04/2012; 15(5):483-496. · 1.19 Impact Factor
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Timothy R Deer,
Joshua Prager,
Robert Levy,
Allen Burton,
Eric Buchser,
David Caraway,
Michael Cousins,
José De Andrés,
Sudhir Diwan,
Michael Erdek, [......], Michael Saulino,
Peter Staats,
Michael Stanton-Hicks,
Lisa Stearns,
B Todd Sitzman,
Mark Wallace,
K Dean Willis,
William Witt,
Tony Yaksh,
Nagy Mekhail
[show abstract]
[hide abstract]
ABSTRACT: Introduction: Trialing for intrathecal pump placement is an essential part of the decision-making process in placing a permanent device. In both the United States and the international community, the proper method for trialing is ill defined. Methods: The Polyanalgesic Consensus Conference (PACC) is a group of well-published experienced practitioners who meet to update the state of care for intrathecal therapies on the basis of current knowledge in the literature and clinical experience. Anexhaustive search is performed to create a base of information that the panel considers when making recommendations for best clinical practices. This literature, coupled with clinical experience, is the basis for recommendations and for identification of gaps in the base of knowledge regarding trialing for intrathecal pump placement. Results: The panel has made recommendations for the proper methods of trialing for long-term intrathecal drug delivery. Conclusion: The use of intrathecal drug delivery is an important part of the treatment algorithm for moderate to severe chronic pain. It has become common practice to perform a temporary neuroaxial infusion before permanent device implantation. On the basis of current knowledge, the PACC has developed recommendations to improve care. The need to update these recommendations will be very important as new literature is published.
Neuromodulation 04/2012; 15(5):420-435. · 1.19 Impact Factor
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Timothy Deer,
Elliot S Krames,
Samuel Hassenbusch,
Allen Burton,
David Caraway,
Stuart Dupen,
James Eisenach,
Michael Erdek,
Eric Grigsby,
Phillip Kim, [......],
K Dean Willis,
William Witt,
Kenneth Follett,
Mark Huntoon,
Leong Liem,
James Rathmell,
Mark Wallace,
Eric Buchser,
Michael Cousins,
Ann Ver Donck
[show abstract]
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ABSTRACT: Background. Expert panel of physicians and nonphysicians, all expert in intrathecal (IT) therapies, convened in the years 2000 and 2003 to make recommendations for the rational use of IT analgesics based on the preclinical and clinical literature known up to those times, presentations of the expert panel, discussions on current practice and standards, and the result of surveys of physicians using IT agents. An expert panel of physicians and convened in 2007 to review previous recommendations and to form recommendations for the rational use of IT agents as they pertain to new scientific and clinical information regarding the etiology, prevention and treatment for IT granuloma. Method. A review of preclinical and clinical literature from 2000 to 2006 was undertaken and disseminated to an expert panel of physicians. Focused discussions concerning the rational use of IT agents and its relationship to the etiology of, prevention of, and treatment of IT granuloma were held. Results. This report presents here new knowledge of the etiology of catheter tip granuloma and guidelines for its prevention and treatment.
Neuromodulation 04/2008; 11(2):77-91. · 1.19 Impact Factor
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Timothy Deer,
Elliot S Krames,
Samuel Hassenbusch,
Allen Burton,
David Caraway,
Stuart Dupen,
James Eisenach,
Michael Erdek,
Eric Grigsby,
Phillip Kim, [......],
K Dean Willis,
William Witt,
Kenneth Follett,
Mark Huntoon,
Leong Liem,
James Rathmell,
Mark Wallace,
Eric Buchser,
Michael Cousins,
Ann Ver Donck
[show abstract]
[hide abstract]
ABSTRACT: Background. Expert panels of physicians and nonphysicians, all expert in intrathecal (IT) therapies, convened in the years 2000 and 2003 to make recommendations for the rational use of IT analgesics, based on the preclinical and clinical literature known up to those times, presentations of the expert panels, discussions on current practice and standards, and the result of surveys of physicians using IT agents. An expert panel of physicians and nonphysicians has convened in 2007 to update information known regarding IT therapies and to update information on new and novel opioid and nonopioid analgesic compounds that might show promise for IT use. Methods. A review of preclinical and clinical published relevant studies from 2000 to 2006 was undertaken and disseminated to a convened expert panel of physicians and nonphysicians to discuss new and novel analgesic agents for IT use. Results. The panelists identified several agents that were worthy of future studies for the clinical and rational use of IT agents that are presented in this article. Conclusions. A list of nonopioid IT analgesics, including gabapentin, adenosine, octreotide, the χ-conopeptide, Xen2174, the conopeptide, neurotensis 1 agonist, CGX-1160, the ω-conotoxin, AM-336, and physostigmine, were identified as worthy of future research by the panelists.
Neuromodulation 04/2008; 11(2):92-97. · 1.19 Impact Factor
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Timothy Deer,
Elliot S Krames,
Samuel J Hassenbusch,
Allen Burton,
David Caraway,
Stuart Dupen,
James Eisenach,
Michael Erdek,
Eric Grigsby,
Phillip Kim, [......],
K Dean Willis,
William Witt,
Kenneth Follett,
Marc Huntoon,
Leong Liem,
James Rathmell,
Mark Wallace,
Eric Buchser,
Michael Cousins,
Anne Ver Donck
[show abstract]
[hide abstract]
ABSTRACT: Background. Expert panels of physicians and nonphysicians in the field of intrathecal therapies convened in 2000 and 2003 to make recommendations for the rational use of intrathecal analgesics based on the preclinical and clinical literature known up to those times. An expert panel of physicians convened in 2007 to update previous recommendations and to form guidelines for the rational use of intrathecal opioid and nonopioid agents. Methods. A review of preclinical and clinical published relevant studies from 2000 to 2006 was undertaken and disseminated to a convened expert panel of physicians and nonphysicians. Focused discussions were held on the rational use of intrathecal agents and a survey asking questions regarding intrathecal therapies management was given to the panelists. Results. The panelists, after review of the literature from 2000 to 2006 and discussion, created an updated algorithm for the rational use of intrathecal opioid and nonopioid agents in patients with nonmalignant and end-of-life pain. Of note is that the panelists felt that ziconotide, based on new and relevant literature and experience, should be updated to a line one intrathecal drug.
Neuromodulation 10/2007; 10(4):300-28. · 1.19 Impact Factor
