Intrathecal Bolus Drug Delivery Safe for Breakthrough Pain

Intrathecal therapy
Intrathecal therapy
Drug delivery with an intrathecal bolus is safe for the treatment and management of unpredictable breakthrough pain.

Drug delivery with an intrathecal bolus is safe for the treatment and management of unpredictable breakthrough pain and may optimize care costs by reducing the requirement for oral analgesic therapies, according to findings from a retrospective review published in Pain Practice.1

Researchers examined medical records of 69 patients to determine the change in oral breakthrough opioid requirements with an intrathecal bolus vs basal infusion. Of 69 patients, 18 (78% men; mean age, 59.9) were included in the bolus group and 51 (57% men; mean age, 61.4) were in the nonbolus group. Baseline and follow-up data included medication consumption as well as Pain Disability Index measures.

The main indications for intrathecal therapy included neuropathic pain (6% bolus plus continuous infusion/24% continuous infusion alone) or spine pain with or without previous spine surgery (78% bolus plus continuous infusion /62% continuous infusion alone).

Only 2 patients (11%) in the bolus option group required continued oral opiates for the management of breakthrough pain compared with 29 patients in the nonbolus group (57%). Pain Disability Index scores were similar in both groups at baseline, and decreased at follow-up: from 53±14 to 42±13 in the bolus group (P =.067), and from 50±11 to 36±16 (P <.001) in the basal infusion group. Pain levels assessed with the numeric rating scale were also similar in both groups at baseline, and showed significant decreases from baseline to follow-up in the bolus group (from 7.7±1.7 to 6.3±2.3; P <.001), and in the continuous infusion group (from 7.5±1.7 to 5.6±2.4; P <.001).

In addition, patients with the bolus device had total daily intake of intrathecal opiates decreasing from 75% at baseline to 11% at follow-up, compared with a 76% to 57% decrease in the nonbolus option group. Intrathecal opioids were morphine (56% in the bolus group; 47% in the continuous infusion group), and hydromorphone (44%, 53%, respectively).

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Although these findings show promise for reducing opioid usage via the administration of an intrathecal bolus device, the investigators note that the retrospective design of this study and the small number of patients included in the analysis limit the findings. The researchers also comment that the cohort’s pain diagnoses were broad, and bolus and basal doses feature varying levels of opiate tolerance.

Despite the study’s inherent limitations, the investigators believe that targeted drug delivery with an intrathecal pump plays “an important role in the treatment of chronic pain, and therapeutic individualization will always be warranted.”

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  1. Bolash RB, Niazi T, Kumari M, Azer G, Mekhail N. Efficacy of a targeted drug delivery on-demand bolus option for chronic pain [published online May 18, 2017]. Pain Pract. doi:10.1111/papr.12602