Spinal analgesia in cancer pain management-MASCC general practice recommendations

Patients with cancer pain refractory to conventional medical management may benefit from spinal analgesia, although there are some critical points regarding some aspects which cannot be examined by an evidence-based approach. A group of experts was selected by MASSC to provide clinical practice advice on the use of spinal drug delivery in patients with cancer-related pain. Refractory cancer pain should be considered a condition in which a patient has failed to receive adequate analgesia or has developed uncontrolled side effects after comprehensive pain management. The intrathecal route (IT) with an implantable drug delivery system allows the administration of minimal doses of analgesics with significant clinical effects while avoiding major adverse effects and lower risks with prolonged use. Morphine and hydromorphone are the opioids of choice for IT treatment. Local anesthetics are an added value because of their additive-synergic effect on segmental areas. The efficacy of adding small amounts of local anesthetics to an ITDD relies on the positioning of the tip of the catheter close to the dermatome where the origin of the pain comes from. Their use, however, depends on the delivery system, because larger volumes are necessary. Ziconotide requires a slow dose titration, but it can be used in small volumes. In addition, once doses are stabilized, no tolerance occurs. A conversion ratio of 100:1 between oral and IT morphine is suggested for patients who receive high doses of systemic opioids. A higher ratio (300:1) should be used in patients prevalently switched to the IT route for uncontrollable adverse effects, receiving lower doses of systemic opioids. The use of boluses of hydrophilic opioids, like morphine, for treating breakthrough pain may be inadequate, as intrathecal opioids alone may be unable to adequately treat an episode of rapid pain onset and duration. The decision-making process for employing interventional therapies, like spinal analgesia, should be shared, taking into account the actual indications and needs, previous treatments, prognosis, timing, advantages and disadvantages, and complications, in any individual situation, managing all the aspects of care.