Intrathecal Pump Problems

[morepropofolplease]

Recently started at a new position and inherited a couple intrathecal pump patients. Both were placed a decade ago for piss poor reasons (back pain) somewhere else across the country. I am not sure where everyone stands on these but I personally don’t see a role for them outside of end of life pain cancer pain. One calls the clinic routinely complaining how no previous docs have ever increased his dose and how terribly he has been mismanaged blah blah blah. I have told him at the last refill I don’t agree with the indication that this was placed and have no intention to increase his dose. Period.

He still calls of course and I am pretty fed up with it. He only has about a year battery life left. I’m thinking about just telling him we are going to start weaning him off starting now or he can try to find someone else. I would have been happy to have just replaced the pump if he wasn’t causing so many problems but I don’t really want anything to do with this. He is already on a fairly high dose of dilaudid. I hate pumps with a passion at this point. Am I alone in this? Am I being unreasonable?

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[Baron Samedi]

Pumps for cancer pain are a huge headache but have the ability to drastically improve the quality of life for these patients.

Pumps for nonmalignant pain have all of the headache, none of the benefit, and no end point. Its not worth the hassle.

 

[callmeanesthesia]

Did a lot of pumps for cancer pain in fellowship and saw some truly life-changing outcomes. Also managed a couple ICU admissions from a local community-based doc who did a lot of pumps for non-cancer pain, with all sorts of weird cocktails in them. One where it was mis-programmed to a 100% increase instead of 10%, and another containing baclofen, clonidine, opioid, and ketamine that failed and stopped. Out in practice on my own now, I have no intention of starting, and have gladly declined to take over a couple. Even the one I explanted because she came to me as a new patient saying it wasn’t working and she wanted it out turned out to be a huge headache. I say wash your hands of them with extreme prejudice.

 

[lobelsteve]

I have had good pump patients and bad pump patients. Both cancer, non-cancer, as well as baclofen. Declined to take outside patients and implanted several. When you do something as a last resort for a marginal or poor candidate, you get expected outcomes.

 

[deleted875186]

I personally think they can help for low back pain in the right patient. Of course these high doses are doomed to fail. This patient sounds doomed to fail.

I think you did the right think being Frank with the patient, tell him you can’t increase the dose. I don’t think I would explant the pump.

 

[Ferrismonk]

I hate pumps. In my opinion they are a relic from when opiates were good medicine.

Only two types of patients are candidates, baclofen pumps for severe spasticity and opiates for palliative at end of life when oral/transdermal are intolerable.

My recommendation is to treat them as you would any other opiate patient. If you are okay with high-dose patients staying high dose without increases, then do the same for your pumps. If you aren't, you should wean.

If you don't agree with the established plan, make your own plan. Give the patient an opportunity to seek a second opinion elsewhere, then implement your plan after a month or two.

 

[Orin]

I'm a fan of the therapy but I've stopped and explanted more than most as well. There are bad patients with any therapy but it's not the device that's at fault.

For baclofen, it's a real win and changes the arc of a patient and caregivers life. For pain, it's a lot harder to see the wins, but in cancer it has level 1 evidence for improvement in symptom burden with equivalent if not superior analgesia.

 

[morepropofolplease]

Appreciate all the responses. Glad i am not the only one that has conflicting feelings about pumps. Will have the conversation with him at the next refill that we will start weaning down or he can head elsewhere. Should be fun... do not anticipate he will enjoy the news.

 

[NJPAIN]

I’m on board with dislike for pumps. Just cleaned out some old office files and couldn’t believe how many pump patients I had way back in the day. Every name made me cringe as each and every one was a hassle.

A few months ago on a Facebook forum one of the young KOLs for several device companies talked about how great microdosing works and how all of the bad rap for pumps came out of how us seniors mismanaged them by using high dose opioids. My recollection is that every patient went from “micro” dose to “mega” dose in short order. The admixtures and changing concentrations is enough to make you crazy. Despite all the hard work the patients are never satisfied.

 

[deleted472101]

I think pumps have their place.

Just like any therapy we do in pain, proper selection is key.

you can have a bad injection patient or SCS patient. Easy thing about those is that they will just leave.

Pumps stick around because you are their doctor.

 

[bedrock]

Agree that pump selection is key. However that selection should be limited to baclofen, or end of life for CA patient.

If you select any other patient for a pump then you are asking for trouble.

 

[deleted131481]

If inclined you could try Prialt. I'm transitioning two inherited pumps to Prialt. I'm not that optimistic but it's safer.

I echo @bedrock - pumps for ca pain and spasticity.

I have about 8 inherited pumps after 2 left. 4 are baclofen and seem to be doing ok (one mixed with morphine but coming off). Two are transitioning to Prialt as above. Not too optimistic but said I'd try. May offer them PO buprenorphine. The other 2 opioid pumps I said I won't increase, I don't recommend pumps, etc but am willing to continue same dose and no oral opioids.

 

[Baron Samedi]

I'm transitioning two inherited pumps to Prialt. I'm not that optimistic but it's safer.

I'm sure it is safer but I can't help but remember the one guy in fellowship I had who got admitted for psychosis and hallucinations telling him to kill himself because of Prialt.

 

[Ferrismonk]

The thing about pumps is that you're always playing with fire. Even if you assume you always have the perfect happy and compliant patients, you never get a pocket fill, a leaking catheter, a tube kink that needs to be explored, or pump failure leading to withdrawal, the patient can STILL have a loss or change in insurance leading to the medication or pump replacement no longer being affordable. Heck, even if the insurance they currently have simply changes it's policy the medication my no longer be affordable. Pumps are not worth the risk or the hassle.

 

[Laryngospasm]

Pumps are all about patients selection.. and no patient should be selected.

 

[BobBarker]

I have done two for cancer in the past few months and will probably do a couple more soon. Neither patient made it to refill but the pump was very helpful. I have two patients with pulmonary fibrosis that I am considering implanting. They probably have 3 years or so to live.