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Background: Intravenous (IV) sedation analgesia is often employed in patients with chronic spinal pain undergoing diagnostic spinal injection procedures. The drugs used for intravenous sedation analgesia produce varying degrees of sedation, amnesia, anxiolysis, muscle relaxation, and analgesia. The very nature of these pharmacologic effects in altering the patient's level of consciousness, awareness, or response to a particular diagnostic stimulus invokes a sense of uncertainty about the results or response obtained from the diagnostic procedure. There is an ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity, specificity, and accuracy. Moreover, there is no consensus with regards to the use of sedation analgesic measures prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis., Objective: To assess and update the clinically significant effects sedation analgesia procedures have on the diagnostic accuracy and validity of interventional spinal techniques., Methods: A comprehensive literature search using PubMed, EMBASE, and Cochrane Library review databases up to September 2012 was performed. The search included systematic and narrative review articles, prospective and retrospective studies, as well as cross-referencing of bibliographies from notable primary and review articles and abstracts from scientific meetings and peer-reviewed non-indexed journals. The search emphasized the effects of sedation analgesia on diagnostic spinal interventions., Conclusion: Based on a review of the available evidence, it appears that the administration of mild to moderate sedation does not confound the results or diagnostic validity of spinal injection procedures. Specifically, immediate pain relief after cervical and lumbar facet joint controlled nerve blocks is not enhanced by IV sedation with midazolam or fentanyl. This is especially true if stringent outcome criteria are employed, such as at least 75% pain relief combined with an increase in range of motion for pain limited movements.

Background: Chronic persistent pain as a result of terminal illness, either as a consequence of the disease or the necessary treatment, is common in patients with cancer. For these patients with moderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effective option for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathy and nociceptive pain in the cancer population. However, there is a scarcity of comprehensive guidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer., Objective: This article outlines consensus guidelines for the implementation of intrathecal therapy in patients with cancer-related pain and other end of life states causing pain. We highlight the multidisciplinary criteria that warrant careful consideration to ensure meaningful analgesia., Methods: Evidence was compiled, ranked, and strength considered by an invited panel of well-published and innovative clinician research leaders in pain medicine. Based on that analysis, an accumulation of evidence from observational and randomized prospective trials supports the use of intrathecal (IT) drug delivery to provide effective analgesia for patients with cancer-related pain, including individuals at the end of life. Although not all patients are candidates for this invasive treatment modality, clinicians can determine the appropriateness of proceeding with device implantation by carefully evaluating the individual's overall medical status, psychological stability, social support system, and prognosis of disease. Further, consumption of health care resources and cost-effective treatment is becoming more of a priority; not only is this therapy appropriate medically, but also economically. This multifaceted approach to patient selection assists in maximizing treatment effect and avoiding unintended consequences of therapy., Limitations: The limitations of these guidelines include that these are of expert panel guidelines. The literature describes appropriate preparation of guidelines based on evidence derived from randomized trials and systematic reviews. However, there is also value for consensus-based guidelines due to non-availability of evidence from either systematic reviews of randomized trials or randomized trials alone. In addition, the evidence is not available on many aspects of intrathecal infusion systems even with observational studies and case reports. Thus, the present approach with expert consensus guidelines is acceptable., Conclusions: These consensus guidelines are intended to assist clinicians in identifying the candidacy of patients with cancer-related pain and end of life diseases causing pain that may benefit from intrathecal drug delivery. With careful consideration of the patient's medical comorbidities and prior therapies, communication with the oncologist, proper psychological evaluation, and appropriate trialing technique, clinicians can effectively optimize the use of IT therapy for cancer pain. The panel advocates for a much wider application of IT therapy to provide meaningful analgesia for patients with cancer pain, including those at the end of life from a variety of causes.

Unlabelled: Medication errors involving analgesics, including mistakes in prescribing, are a major contributor to suboptimal therapeutic outcomes and preventable adverse patient events. A systematic evaluation of 2,044 prevented (near-miss) analgesic prescribing errors detected in a teaching hospital was performed to better understand these errors and contributing error-prone analgesic medication characteristics. The overall detected error rate was 2.87 errors per 1,000 analgesic orders, with the error rate more than twice as high in pediatric patients than in adults. Error rates varied widely between drugs, dosage forms, and routes of administration, but there was general consistency of error rates within drug groups with similar characteristics. Commonly prescribed medications were associated with the most errors, but less frequently prescribed agents had higher error rates. A number of factors were found to contribute to errors, and the following characteristics contributed to 40% of errors: availability in dose forms for multiple routes of administration; modified dosage forms; atypical dosage regimens; sound-alike drug names; and analgesics used on an ongoing scheduled basis., Perspective: Identifiable analgesic product characteristics and uses are associated with higher risk for errors. The findings of this study can guide patient and caregiver education, and can be incorporated into medication safety strategies to reduce patient risk from analgesic errors., (Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Intrathecal therapy offers an invasive alternative for the long-term management of select patients with intractable pain associated with various disease states, including those of noncancer origin. It is commonly accepted that proper patient selection is essential to optimizing treatment outcomes, yet the practice of candidate selection for device implantation varies widely. A multifaceted approach--with consideration of preexisting medical comorbidities; psychological status; associated social, technical, and economic issues; and response to intrathecal trialing--enables practitioners to fully evaluate the appropriateness of implanting a patient with an intrathecal drug delivery system. Yet, to date no standard set of guidelines have been developed to aid practitioners in navigating this evaluation process. Using experience- and knowledge-based expert opinion to systematically evaluate the available evidence, this article provides consensus guidelines aimed at optimizing the selection of patients with noncancer pain for intrathecal therapy. In conclusion, complete assessment of a patient's physical, psychological, and social characteristics, can guide practitioners in determining the appropriateness of initiating intrathecal therapy. These consensus guidelines are intended to assist with weighing this risk/benefit ratio of intrathecal therapy, thereby minimizing the potential for treatment failure, unacceptable adverse effects, and excess mortality.

Background: Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function., Study Design: A systematic review of intrathecal infusion devices for chronic non-cancer pain., Objective: To determine the efficacy, utilization, safety, and complications associated with the use of intrathecal infusion devices for long-term management of chronic non-cancer pain., Methods: Literature search was performed through EMBASE, Medline, Cochrane databases, and systematic reviews identified from 1966 to December 2008. Studies were then reviewed and assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF)., Outcome Measures: The primary outcome measure was pain relief (short-term relief < or = one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were also utilized., Results: The level of evidence for intrathecal infusion systems indicated either Level II-3 or Level III (limited) based on U.S. Preventive Services Task Force (USPSTF) criteria., Limitations: The limitations of this study include the paucity of literature, lack of quality evidence, and lack of randomized trials., Conclusion: This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain.

Intrathecal analgesia has emerged as a key therapeutic option for pain relief for patients who have failed other treatment avenues as well as patients with adequate analgesia on high dose enteral or parenteral therapy but with unacceptable side effects. Intrethecal infusions of analgesics have been increasingly utilized since the later 1980s for the treatment of persistent pain. The purpose of this review is to provide research based clinical insight regarding the safe and appropriate use of the intrathecal infusion modality. Long-term intrathecal infusion analgesia or long-term intrathecal or long-term intrathecal analgesic therapy has significantly progressed over the past 25 years. The evidence for implantable intrathecal infusion systems is strong for short-term improvement in pain of malignancy or neuropathic pain. The evidence is moderate for long-term management of persistent pain. Reasonably strong evidence exists for the use of ong-term intrathecal analgesic therapy in alleviation of cancer pain; however, the evidence supporting long-term efficacy in persistent noncancer pain is less convincing. Future studies are needed to better define the role of long-term intrathecal analgesic therapy in persistent pain, especially with respect to which pain conditions or subpopulations of patients are most responsive to long-term intrathecal analgesic therapy, and which agents or combination of agents are most appropriate for which pain conditions or subpopulations of patients. Novel combinations of intrathecal analgesics such as clonidine and gabapentin deserve future study. The current body of literature supports the use of intrathecal agents for the treatment of moderate or severe pain related to cancer and noncancer origins. Further clinical studies are needed to evaluate the efficacy and safety of new intrathecal drugs, the complications related to these devices, and the proper selection of patients to receive these treatments.