Douglas P. Beall - Intrathecal Pump Drug Delivery

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Douglas P. Beall, MD, FIPP, FSIR, DAAPM

Director Interventional Spine Care, Comprehensive Specialty Care,

Chief of Radiology Services and Director of Fellowship Programs,

Oklahoma City, OK, USA

Intrathecal drug delivery (IDD) has been one of my very favorite treatments since I saw my first case performed in fellowship in the early 2000s and saw the incredibly good and immediate results. After transitioning from academia and into private practice I found myself inheriting 67 intrathecal baclofen patients from two physicians who were transitioning from managing this patient population to being employed hospitalists. As an Interventional Radiologist, my staff was unfamiliar and somewhat hesitant to accept this service line but did so anyway without hesitation and this patient population quickly became their favorite group.

Intrathecal medication delivery has since become an essential part of our medical and interventional practice. In patients who have certain conditions this therapy is absolutely essential including patients who have severe spasticity, multi-site pain, severe degenerative conditions without a surgical solution, patients with chronic pain on high-dose systemic narcotics, and metastatic cancer pain especially from a pancreatic source or those with bony metastases. I have found that IDD is often the only solution for some of the most complex patients and without it they simply do not receive optimal care.

As useful and essential as this therapy is it is, in my opinion, tremendously underutilized. I think there are two primary reasons for this. The first is that IDD has had its reputation tarnished in the early days of therapy where it was commonplace to provide oral opioid medication along with intrathecal opioids. As we now know, providing oral or systemic medication is a self-defeating strategy as it causes an upregulation of the cytochrome P-450 system to the point that there is no amount of intrathecal opioid that can be provided that can overcome the patients upregulated metabolic activity that eliminates the opioid very quickly and results in a very high tolerance to these medications. During the peak of the opioid epidemic, we were seeing patients with chronic pain that were on 5001000 MME of morphine or more for IDD trials. One of these patients was on an incredible 1200 MME of morphine daily and refused to taper his medication dose before the trial. We typically use a 1:100 ratio of intrathecal to oral MME of opioids for a bolus trial and keep the patients overnight with continuous monitoring of the pulse oximetry and cardiac activity and multiple vital signs measurements. In this patient, however I was very reluctant to give that amount of intrathecal morphine and settled on 8 mg of morphine injected as a bolus into the lumbar spine cerebrospinal fluid. We were prepared for treatment of an overdose of intrathecal medication but what happened was exactly the opposite with the patient receiving 23 h of excellent pain relief followed by a return of his pain to the point where he was unhappy, wanted to take his oral medication and checked out of the hospital against medical advice. This scenario permanently etched in my mind the absolute requirement not to use a combination of systemic and intrathecal medication as there is no amount of opioid that can be given intrathecally to overcome the hypermetabolism that results from systemic opioid administration.