Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain

Background: Chronic persistent pain as a result of terminal illness, either as a consequence ofthe disease or the necessary treatment, is common in patients with cancer. For these patients withmoderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effectiveoption for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathyand nociceptive pain in the cancer population. However, there is a scarcity of comprehensiveguidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer.Objective: This article outlines consensus guidelines for the implementation of intrathecal therapyin patients with cancer-related pain and other end of life states causing pain. We highlight themultidisciplinary criteria that warrant careful consideration to ensure meaningful analgesia. Methods: Evidence was compiled, ranked, and strength considered by an invited panel of wellpublished and innovative clinician research leaders in pain medicine. Based on that analysis, anaccumulation of evidence from observational and randomized prospective trials supports the useof intrathecal (IT) drug delivery to provide effective analgesia for patients with cancer-related pain,including individuals at the end of life. Although not all patients are candidates for this invasivetreatment modality, clinicians can determine the appropriateness of proceeding with deviceimplantation by carefully evaluating the individual’s overall medical status, psychological stability,social support system, and prognosis of disease. Further, consumption of health care resources andcost-effective treatment is becoming more of a priority; not only is this therapy appropriate medically,but also economically. This multifaceted approach to patient selection assists in maximizing treatmenteffect and avoiding unintended consequences of therapy.Limitations: The limitations of these guidelines include that these are of expert panel guidelines.The literature describes appropriate preparation of guidelines based on evidence derived fromrandomized trials and systematic reviews. However, there is also value for consensus-based guidelinesdue to non-availability of evidence from either systematic reviews of randomized trials or randomizedtrials alone. In addition, the evidence is not available on many aspects of intrathecal infusion systemseven with observational studies and case reports. Thus, the present approach with expert consensusguidelines is acceptable.Conclusions: These consensus guidelines are intended to assist clinicians in identifying thecandidacy of patients with cancer-related pain and end of life diseases causing pain that may benefitfrom intrathecal drug delivery. With careful consideration of the patient’s medical comorbidities andprior therapies, communication with the oncologist, proper psychological evaluation, and appropriatetrialing technique, clinicians can effectively optimize the use of IT therapy for cancer pain. The paneladvocates for a much wider application of IT therapy to provide meaningful analgesia for patientswith cancer pain, including those at the end of life from a variety of causes. Key words: Intrathecal, cancer, palliative, pain, guidelines, opioids, consensus, selection, evidence