Problems of long-term spinal opioid treatment in advanced cancer patients

Epidural and intrathecal techniques are well established techniques in canc er pain. However, several questions remain unresolved. The several problems of long-term spinal opioid treatment in advance cancer patients were revie wed. Indications for the use of spinal opioids include patients treated by systemic opioids with effective pain relief but with unacceptable side effe cts, or unsuccessful treatment with sequential strong opioid drug trials de spite escalating doses. Therefore, the previous aggressive treatment with s ystemic opioids would leave as failures patients with difficult pain syndro mes unresponsive to opioids. The choice of external or totally implanted de livery systems is based on different clinical considerations. The use of ex ternalized tunneled intrathecal catheters has not been associated with high er rates of complications and is easier to place and use at home in debilit ated patients late in the course of their disease. The intrathecal administ ration has a lower incidence of catheter occlusion, lower malfunctioning ra te, lower dose requirement, and more effective pain control. Due to the low er daily doses and volumes, intrathecal treatment proved to be more suitabl e for treatment at home by a continuous infusion than the epidural treatmen t. Advantages of infusion techniques are more evident when using local anes thetics, since intermittent administration of bupivacaine often results in motor paralysis and hemodynamic instability. Morphine is the opioid of choi ce. An epidural dose of 10% of the systemic dose is often used. However, in trathecal administration of opioids and bupivacaine may substantially impro ve pain relief in patients unresponsive to high epidural doses of these dru gs, Bupivacaine-induced adverse effects, including sensory deficits, motor complaints, signs of autonomic dysfunction or neurotoxicity have been repor ted to not occur with bupivacaine doses less than 30-60 mg/day, Adjuvant dr ugs may further improve analgesia. Different ranges of technical complicati on rates have been reported in the literature, most of them being associate d with epidural catheters. Subcutaneous tunneling and fixation of the cathe ter, bacterial filters, minimum changes of tubings, careful exit site care weekly, site protection and monitoring of any sign of infection to prevent infection, and training for family under supervision, are recommended. Area s for additional research include the use of spinal adjuvants, the ideal sp inal morphine-bupivacaine ratio, methods to improve spinal opioid responsiv eness and long-term catheter management with appropriate home care programs . (C) 1999 International Association for the Study of Pain. Published by El sevier Science B.V.