Palliative pain pump

[Dansk2011]

---

Members do not see this ad.

Anyone have any good resources for pain pumps? Did a lot of management in fellowship but it's been a while now. Currently manage baclofen pumps and have been asked to consider managing pumps for terminal patients with pain that is poorly controlled with oral meds and patches. Neurosurgeons willing to implant and also help manage issues. Specifically have a young guy that is inpatient with metastatic colon cancer to the spine who is on a Dilaudid pca (something like 2400 MME per day) whose pain cannot be controlled with oral meds. Probably has less than 6 months to live and obviously can't stay in the hospital forever. Just not sure where to start in regard to trial dose (single shot vs indwelling catheter). Don't really have option to send to academic center as nearest is maybe 5 hours away and no one in the area managing pain pumps. I'm not necessarily thrilled about it and certainly not willing to do anything but palliative/terminal pumps. However feel there could be a place for it in our system. Open to other suggestions recs as well for helping this guy out too.

 

[NVO]

With less than 6mo left to live, stuck in hospital on HM PCA, I would go directly to pump and skip the trial.
At 2400 MME I would use HM instead of morphine. Add bupi for sure and maybe Ziconitide if youre feeling frisky.
Daily basal would likely be around 5mg HM to start and PTM at 10% of that. See how he does and how many PTMs he uses and adjust settings accordingly afterwards. Ideally can DC him if pain is the only reason he is in the hospital. 40ml pump otherwise you'd be refilling it every 2-3 weeks

 

[painisfear]

I agree with skipping the trial and using bupivacaine as an adjunct. Sometimes neurosurgeons are not particular about catheter placement location (dorsal intrathecal space, tip just proximal to area of most pathology in the spine). The PCA dosage creates significant tolerance and in younger patients I find its more difficult to wean oral or IV opioids while titrating up a pain pump - you have to be more systematic about it as opposed to reactive in my experience.

 

[Dansk2011]

Thanks for the input. I've been speaking to the neurosurgeons about just implanting as opposed to trial but they seem set on a trial. I wouldn't do the implant so would be up to them although I'll continue to push for that. I thought about adding bupi but our stupid hospital admin won't allow use of compounded medications. So will have to use single agent. I figured seeing as he is already usinf HM would make sense to use that in the pump. Curious as to dose of bupi you'd consider if they happen to change their policy. Doubtful they will but good to know just in case. Very much appreciate the input.

 

[BoardingDoc]

Thanks for the input. I've been speaking to the neurosurgeons about just implanting as opposed to trial but they seem set on a trial. I wouldn't do the implant so would be up to them although I'll continue to push for that. I thought about adding bupi but our stupid hospital admin won't allow use of compounded medications. So will have to use single agent. I figured seeing as he is already usinf HM would make sense to use that in the pump. Curious as to dose of bupi you'd consider if they happen to change their policy. Doubtful they will but good to know just in case. Very much appreciate the input.

You can go with 5-10mg bup/day as a starting range. I'd err on the lower side and try to do the same with the HM dose, that way you have wiggle room to go up by simply increasing the pump dose without having to consider reformulation if the patient continues to get pain but also has somnolence from a mismatch opioid/local ratio.

 

[Ronin1]

Just do a single shot morphine trial 1 mg intrathecal. If tolerated go to implant and titrate as needed. He’s in the hospital so no big rush

 

[callmeanesthesia]

I haven’t done pumps since fellowship but isn’t 5 mg a little high of a starting basal? That would be 5 x100 (IT to IV) x 30/1.5 (hydrophone IV to OME) = 10,000 right?

 

[Baron S]

At that MME I am not sure a single shot will be all that accurate.

I'd have a conversation with the patient and tell them that for him to get a pump he needs to  say that the trial worked. Then I'd do a single shot (1mg like Ronin1 suggested) at a low dose to check the box.

 

[CB1Antagonist]

Used pumps for cancer pain as a fellow (MD Anderson) and infrequently implanted in practice (about 1 per year). From my biased and admittedly anecdotal experience, a cancer patient tolerating high dose (>200 MEDD) without pain relief is unlikely to get any relief from intrathecal infusion.
The ideal pump candidate is someone who can't tolerate systemic opioids due to side effects. In this instance, IT pump is a slam dunk.

 

[Dansk2011]

Used pumps for cancer pain as a fellow (MD Anderson) and infrequently implanted in practice (about 1 per year). From my biased and admittedly anecdotal experience, a cancer patient tolerating high dose (>200 MEDD) without pain relief is unlikely to get any relief from intrathecal infusion.
The ideal pump candidate is someone who can't tolerate systemic opioids due to side effects. In this instance, IT pump is a slam dunk.

I don't really know what alternative there is for this guy. Again open to suggestions and appreciate any input in regard to treatment. But he is inpatient on a Dilaudid pca averaging 2400 mme per day and his pain is not controlled. So at this rate, if nothing is done then he will sit in the hospital until something gives or his time comes. They've tried different oral meds prior to including methadone as well as a fentanyl patch and it wasn't touching his pain.

 

[Dansk2011]

I haven’t done pumps since fellowship but isn’t 5 mg a little high of a starting basal? That would be 5 x100 (IT to IV) x 30/1.5 (hydrophone IV to OME) = 10,000 right?

I did it backwards. 2400 mme/day would be 24 mg/day morphine IT using the 100:1 conversion oral to Intrathecal. Then IT morphine to hydromorphone is 5:1, so it would be 4.8 mg/day....?

 

[callmeanesthesia]

I did it backwards. 2400 mme/day would be 24 mg/day morphine IT using the 100:1 conversion oral to Intrathecal. Then IT morphine to hydromorphone is 5:1, so it would be 4.8 mg/day....?

Isn’t it 300:1 oral to intrathecal? (3:1 oral to IV then 100:1 IV to IT)

 

[Dansk2011]

Isn’t it 300:1 oral to intrathecal? (3:1 oral to IV then 100:1 IV to IT)

I've seen both. Very confusing. But there was a relatively recent article in neuromodulation journal using 100:1. Maybe split the difference...

 

[CB1Antagonist]

As a contrarian view, it is very difficult to tell apart pure nociceptive/neuropathic pain from suffering/existential angst.
In this situation, I think the palliative folks at MD Anderson have a better approach. Convert to oral methadone and titrate to effect. The usual considerations of slow titration go out the window given the circumstance. They also used neuroleptics (zyprexa/risperidone etc) as adjuvants to opioids in this situation with good results

 

[Ronin1]

You are just doing the single shot trial to make sure he is tolerant to intrathecal morphine. I did one once that had projectile vomiting for hours afterwards.

 

[Dansk2011]

As a contrarian view, it is very difficult to tell apart pure nociceptive/neuropathic pain from suffering/existential angst.
In this situation, I think the palliative folks at MD Anderson have a better approach. Convert to oral methadone and titrate to effect. The usual considerations of slow titration go out the window given the circumstance. They also used neuroleptics (zyprexa/risperidone etc) as adjuvants to opioids in this situation with good results

I completely understand. He however was already on methadone at very high doses and failed. Then weaned down/off during his hospitalization. Unfortunately our palliative folks, which is like 2 providers, don't really do anything pain wise. It's a bit annoying. They focus on goals of care. Appreciate the perspective.

 

[NVO]

I did it backwards. 2400 mme/day would be 24 mg/day morphine IT using the 100:1 conversion oral to Intrathecal. Then IT morphine to hydromorphone is 5:1, so it would be 4.8 mg/day....?

This is the exact conversion I did to get to 5mg/day. I use the same ratios (100:1 rather than 300:1).

Bupi you should be fine with a 1:1 ratio with the HM. Unlikely to get neuro sx such as weakness/bowel/bladder but if you do you could always reformulate to half the ratio. May be confounding with progression of dz esp with spine mets

 

[callmeanesthesia]

Survey of pain specialists regarding conversion of high-dose intravenous to neuraxial opioids - PMC

The conversion of high-dose intravenous (IV) opioids to an equianalgesic epidural (EP) or intrathecal (IT) dose is a common clinical dilemma for which there is little evidence to guide practice. Expert opinion varies, though a 100 IV:10:EP:1 IT ...

pmc.ncbi.nlm.nih.gov

Survey of IV to IT conversions used.

 

[Orin]

Anyone have any good resources for pain pumps? Did a lot of management in fellowship but it's been a while now. Currently manage baclofen pumps and have been asked to consider managing pumps for terminal patients with pain that is poorly controlled with oral meds and patches. Neurosurgeons willing to implant and also help manage issues. Specifically have a young guy that is inpatient with metastatic colon cancer to the spine who is on a Dilaudid pca (something like 2400 MME per day) whose pain cannot be controlled with oral meds. Probably has less than 6 months to live and obviously can't stay in the hospital forever. Just not sure where to start in regard to trial dose (single shot vs indwelling catheter). Don't really have option to send to academic center as nearest is maybe 5 hours away and no one in the area managing pain pumps. I'm not necessarily thrilled about it and certainly not willing to do anything but palliative/terminal pumps. However feel there could be a place for it in our system. Open to other suggestions recs as well for helping this guy out too.

Start with the PACC guidelines maybe? They just had a cancer update:

The Polyanalgesic Consensus Conference (PACC)®: Updates on Clinical Pharmacology and Comorbidity Management in Intrathecal Drug Delivery for Cancer Pain - PubMed

The PACC recommends best practices regarding the use of intrathecal drug delivery in cancer pain, with an emphasis on managing the unique disease and patient characteristics encountered in oncology. These evidence- and consensus-based expert opinion recommendations should be used as a guide to...

pubmed.ncbi.nlm.nih.gov

In this case, the question depends on where the pain is and what exactly the generators are.
- Spine mets' pain can be managed with radiation, tumor ablation/kyphoplasty, or pumps.
- If neurosurgery is on board, they can offer cordotomy, myelotomy, etc for non-axial or visceral pain.
- If rad onc is on board, bony mets can be offered hypophysectomy

Opioids intrathecally may help more in some cases, but generally if they are failing systemic opioids due to lack of analgesia, they aren't necessarily going to do better with intrathecal opioids.

Ask your Medtronic rep for the nearest cancer pain doctor that manages pumps. Most of us/them are happy to provide a curbside consult as it's a labor of love. Can private message me if you can't find one near you.

The conversion is a bit of a fairy dust number but 1:100 and 1:300 conversions are both reasonable for morphine, but you don't want to dose intrathecally identically to systemic numbers as the IV/PO conversions are also somewhat fabricated as well. The relative ratios are probably true, but it just doesn't seem to work the same with everyone.

Realistically trial doses change based on how you do it, single shot vs catheter. If the hospital won't let you compound, then you do a single agent and follow it with another. Sometimes that's easier for you as you aren't limited by concentrations but realize it's not at all the same as what the IT pump can do.

 

[Centurion38]

Real talk: this is futile. Neurosurgeons should be thinking about chordotomy or some other palliative technique, not IT therapy.

IT opioids aren't a magic elixir. Tolerance develops as predictably as with PO delivery route. 2400 MME per day? This is hyperalgesia.

This needs end stage Ketamine with "war crimes" dosing, maybe Methadone, and Hospice.

The neurosurgeons will implant, sure. It will get infected (probably). Then he'll be on 3200 MME per day and back in your clinic.

Or worse, he'll still be on 2400 MME per day, have an IT pump with 10 mg hydromorphone, 10 mg Bupivacaine and you'll be getting paged q2 that he has no bladder control, 3+ peripheral edema, and "lost" his fentanyl patches (again).

Run. You'll thank me later.

 

[callmeanesthesia]

Real talk: this is futile. Neurosurgeons should be thinking about chordotomy or some other palliative technique, not IT therapy.

IT opioids aren't a magic elixir. Tolerance develops as predictably as with PO delivery route. 2400 MME per day? This is hyperalgesia.

This needs end stage Ketamine with "war crimes" dosing, maybe Methadone, and Hospice.

The neurosurgeons will implant, sure. It will get infected (probably). Then he'll be on 3200 MME per day and back in your clinic.

Or worse, he'll still be on 2400 MME per day, have an IT pump with 10 mg hydromorphone, 10 mg Bupivacaine and you'll be getting paged q2 that he has no bladder control, 3+ peripheral edema, and "lost" his fentanyl patches (again).

Run. You'll thank me later.

I think with opioids alone in the pump you’re right. We implanted pumps with opioids and bupivacaine, and I think the local makes all the difference for focal pain. I had a similar patient, inpatient on dilaudid PCA, end stage pancreatic cancer, discharged a few days after implant.

 

[Ducttape]

we used to discuss opioid hyperalgesia.

he is on mega doses of opioids, with an end of life issue, that is associated the concurrent psychological aspects.

if not hyperalgesia, then consider that the disease is opioid resistant.


options?

methadone but this time with ketamine

consider hospice with IV PCA

if the pain is in the vertebral body, what about intracept

if it is radicular/neuropathic, chemical ablation of spinal nerve (it has been many years since i did one, but it was successful)

most radically, opioid cessation

 

[Dansk2011]

we used to discuss opioid hyperalgesia.

he is on mega doses of opioids, with an end of life issue, that is associated the concurrent psychological aspects.

if not hyperalgesia, then consider that the disease is opioid resistant.


options?

methadone but this time with ketamine

consider hospice with IV PCA

if the pain is in the vertebral body, what about intracept

if it is radicular/neuropathic, chemical ablation of spinal nerve (it has been many years since i did one, but it was successful)

most radically, opioid cessation

Was on methadone and ketamine combined and failed. I don't know of intracept for bony mets. I've know of osteocool but we don't offer it here so not an option. The Mets in vertebra are very anterior which is interesting so not sure about safety with location.

 

[lobelsteve]

Was on methadone and ketamine combined and failed. I don't know of intracept for bony mets. I've know of osteocool but we don't offer it here so not an option. The Mets in vertebra are very anterior which is interesting so not sure about safety with location.

Safety? Did you say safety? If the pills do not kill him before the cancer...

 

[Orin]

Was on methadone and ketamine combined and failed. I don't know of intracept for bony mets. I've know of osteocool but we don't offer it here so not an option. The Mets in vertebra are very anterior which is interesting so not sure about safety with location.

Anterior metastatic disease should be a little safer and easier to Osteocool, but Intracept could do the same thing that you're trying to do from an analgesia perspective. I've done the inverse, using tumor ablation hardware for off label BVNA, but in this case, if you're just trying to provide pain control, kyphoplasty at the level could suffice without requiring too much mental gymnastics.

I'm still not clear about the pain pattern here, but other things people have described for spinal pain if you're looking for non-pharmacologic voodoo, the MDA team and some other cancer providers talk about using PNS for spine mets.

Case report Case report: Use of peripheral nerve stimulation for treatment of pain from vertebral plana fracture - PMC
or
Case series Peripheral Nerve Stimulation for Back Pain in Patients With Multiple Myeloma as Bridge Therapy to Radiation Treatment: A Case Series - PubMed

 

[Dansk2011]

Safety? Did you say safety? If the pills do not kill him before the cancer...

Yeah I'm not prescribing him anything just trying to help with other options. I don't do osteocool or intracept nor do I do kyphoplasty so it would be the surgeons. I mentioned it as an option and they felt as if the tumors were too anterior in regard to the spine. Have asked around locally about intracept and no seems convinced it would help. Didn't feel it would be realistic and I can't force it. He has mets to L5 and sacrum as well as throughout liver and lungs. As well as some other retroperitoneal locations. Pain is primarily in his low back with some abdominal pain. Not really neuropathic. Seems primarily bony. Have recommended sending him to a cancer center but everyone is super reluctant and he doesn't want it. Went ahead with a single shot morphine trial although I'm not convinced it will help but I guess we will see. He doesn't want hospice with a pca as he still feels he has some spunk left in him and everyone seems to be tip toeing around prognosis. Extremely frustrating. I hear what your saying though.

 

[Dansk2011]

Anterior metastatic disease should be a little safer and easier to Osteocool, but Intracept could do the same thing that you're trying to do from an analgesia perspective. I've done the inverse, using tumor ablation hardware for off label BVNA, but in this case, if you're just trying to provide pain control, kyphoplasty at the level could suffice without requiring too much mental gymnastics.

I'm still not clear about the pain pattern here, but other things people have described for spinal pain if you're looking for non-pharmacologic voodoo, the MDA team and some other cancer providers talk about using PNS for spine mets.

Case report Case report: Use of peripheral nerve stimulation for treatment of pain from vertebral plana fracture - PMC
or
Case series Peripheral Nerve Stimulation for Back Pain in Patients With Multiple Myeloma as Bridge Therapy to Radiation Treatment: A Case Series - PubMed

Thanks I'll check these out. Appreciate the input.

 

[Ducttape]

i assume he is already been given palliative radiation and he is already on NSAID.

i had a lady with bone mets who was on 50 mcg fentanyl with oxy IR who found significant benefit on celebrex and went off all opioids. sometimes oncology bypasses the simple treatments...

 

[Dansk2011]

i assume he is already been given palliative radiation and he is already on NSAID.

i had a lady with bone mets who was on 50 mcg fentanyl with oxy IR who found significant benefit on celebrex and went off all opioids. sometimes oncology bypasses the simple treatments...

Yes to both. Ended up getting a 1 mg morphine trial single shot and he did very well.

 

[lobelsteve]

Yes to both. Ended up getting a 1 mg morphine trial single shot and he did very well.

They all do. If he is around 3-4 weeks after implant, let us know how many calls per day this generates.