Intrathecal Narcotic Infusion Pumps (ITNP) for Intractable Chronic Pancreatitis Pain: A Pilot Series

Abstract

Pain management remains the largest clinical problem for many chronic pancreatitis (CP) patients. Escalating narcotic requirements often make the clinician seek alternatives such as pancreas rest via jejunal feedings, surgical pancreatic denervation or pancreatectomy. Intrathecal narcotics are an alternative which offers the advantages of 1) reversibility; 2) lower total narcotic dose; 3) pancreas remains intact. Aim We herein report our experience with 9 such patients followed up to 6 years. Methods: 9 CP patients (etiology idiopathic 6, cystic fibrosis 2, lupus/HIV 1) with intractable upper abdominal pain, daily narcotic use, frequent hospitalizations, and failed pain relief with jejunal feedings and ERCP sphincter therapy were offered ITNP after a successful temporary intrathecal block. An intrathecal catheter was placed at L2-L3 interspace and subcutaneous pump placed in lower abdomen. Infusion rates were titrated to patient need with morphine equivalent doses of 2-10 mg per day. Results: Mean duration of ITNP in situ was 38 months (range 3-72 months). Mean oral narcotic dose before ITNP: 360 morphine equivalent mg per day; after: 45 mg per day. Mean hospital days before ITNP: >30 per year; after <2 per year. Four of 9 patients resumed at least partial work schedules. All patients stated that ITNP was at least moderately helpful for pain control. Major complications were: Catheter displacement (1); repositioned via surgery. Pedal lymphedema (1). No patient developed diabetes or worse steatorrhea. Summary In this pilot series, ITNP use in CP patients with high narcotic requirement and intractable pain resulted in improved pain control, much less daily narcotic use, and much fewer hospital days in all patients. The minority of patients resumed work. Complications were infrequent. Conclusions: ITNPs are an acceptable alternative for CP patients with high narcotic requirements and intractable pain.