Background & Aims
Cancer is a leading cause of death globally and pain is experienced by two-thirds of patients with advanced, metastatic, or terminal disease. Pain relief can be achieved in 70-90% of patients following WHO guidelines for pain management. However, some patients have severe pain refractory to medication, for whom intrathecal pain treatment could be an option. Current evidence for intrathecal therapy in cancer pain is considered low quality due to the lack of large RCTs, resulting in a weak recommendation. Yet, intrathecal therapy is already used with good results in clinical practice, and randomization to a potentially less effective comparator treatment is not seen as ethically acceptable. To assess the role for intrathecal therapy, increased knowledge of treatment effect on pain as well as treatment related adverse events are warranted. This retrospective study aimed to assess complications and side effects related to intrathecal pain treatment in patients with terminal cancer.
Methods
This was a retrospective study on all patients who received intrathecal treatment with morphine and bupivacaine through externalized catheters for severe cancer-related pain refractory to conventional pain management, from 2015 to 2019 at the Pain Centre, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. Patients were identified and included post-mortem through the hospital´s local surgical registry. Data was collected through patient medical records. Technical complications (i.e., dysfunction of catheter or external pump) and biological complications (i.e., adverse effects on the patient) were defined as unexpected adverse events. Unwanted, but generally predictable effects from intrathecal treatment and the implantation procedure were classified as side effects. Data regarding systemic opioid use, converted to oral morphine milligram equivalents (MME), were collected at baseline and for the first 3 weeks of intrathecal therapy.
Results
Data were collected for 53 patients (26 men, 27 women; median age 57 years). Treatment-related complications were observed in 24 patients. Technical complications occurred in 13 patients, and most were resolved with minor adjustments bedside. There were 16 patients with biological complications of which 5 were serious, i.e., meningitis or neurological impairment, and 4 of these were reversible. Side effects related to intrathecal morphine and bupivacaine or the implantation procedure were observed in 35 patients. Numbness and/or weakness occurred in 30 patients, most commonly in the lower limbs (n=28), which precipitated falls in 5 patients. Systemic opioid doses decreased substantially during the first 3 weeks of intrathecal treatment, from a median daily dose of 681 MME (n=41, range 30-4470) before initiation of intrathecal treatment to 319 MME (n=26, range 0-1662). The median treatment duration time was 62 days (range 5-376).
Conclusions
Technical and biological complications related to intrathecal treatment with morphine and bupivacaine through externalized catheters are common, but mostly minor and reversible. Side effects are predominantly related to unwanted pharmacological effects from intrathecal drugs. Numbness and/or weakness in the lower extremities can potentially lead to falls. Intrathecal treatment enables the reduction of systemic opioid doses, which indicates a good treatment effect of pain relief. Hence, intrathecal therapy can be considered a pain-relieving treatment in patients with severe refractory cancer-related pain. Future research should focus on the experiences of patients in terms of acceptability and satisfaction of intrathecal pain treatment. Systematic prospective follow-up studies of patient-reported outcomes and qualitative patient interviews about treatment experiences are warranted to further assess the role and effectiveness of intrathecal pain therapy in terminal cancer.
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Presenting Author
Linda Bengtsson
Poster Authors
Linda Bengtsson
MD
Sahlgrenska University Hospital, Östra, Anaesthesiology and Intensive Care/Pain Center
Lead Author
Paulin Andréll
Institution of Clinical Sciences, University of Gothenburg
Lead Author
Sven-Egron Thörn
PhD
Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
Lead Author
Lars-Erik Dyrehag
PhD
Region Halland, Department of Rehabilitation/Pain Unit, Varberg, Sweden
Lead Author
Topics
- Specific Pain Conditions/Pain in Specific Populations: Cancer Pain & Palliative Care