Can a phone call be more effective than an intrathecal implanted pump?

Abstract

Pain is one of the most prevalent, burdensome, and feared symptoms among cancer patients. Even when the basic principles for the use of analgesic drugs are adhered to, some patients experience insufficient pain relief or considerable adverse effects from systemic opioids. Opioid switching or even change of the route of opioid administration may improve the opioid response in most cases, and only a small proportion of patients with cancer pain should be candidates for spinal treatment. A spinal treatment is indicated if systemic treatment has failed, either because of inadequate analgesia or because of intolerable side effects [10]. Although the proportion of cancer patients who may benefit from invasive therapies is small, it is still extremely important, given the level of suffering of patients unresponsive to multiple trials of opioids, possibly receiving high doses of opioids unsuccessfully and having consistent adverse effects. However, the real need for spinal analgesia remains unknown, as the size of the group from which patients are selected for spinal analgesia is rarely reported, and spinal opioids are often started before systemic opioid administration is optimized [11]. According to the prevalent and more accepted opinion in the field of cancer pain, indications for the use of spinal opioids should include patients treated by systemic opioids with effective pain relief but with unacceptable side effects, or unsuccessful treatment with sequential strong opioid drug trials despite escalating doses [11]. There is a scarcity of comprehensive guidelines in implanting intrathecal drug delivery systems in the treatment of pain caused by cancer, particularly in the selection of patients. In most studies of spinal therapy in cancer pain management, the selection of patients is often based on general considerations such as “failure of traditional cancer pain management approaches,” so that some patients may possibly receive spinal treatments regardless of a previous aggressive systemic approach including opioid and route switching [11]. We report a case of a patient who had been implanted spinally, unsuccessfully, but could be easily managed with simple measures in a traditional hospice with lowlevel facilities, just providing an expert advice by phone.