ITP for generalized cancer pain?

[PainBrain78]

Correct me if I’m wrong. I do not see how an ITP would likely cover generalized cancer pain. Im getting pressure from higher-ups (I’m employed) to utilize this modality. Does anyone have wild success with this for cancer pain? I’ve had a few cancer patients with ITPs and we’re still taking oral narcotic medications. Appreciate any advise or good literature sources.

TIA!

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[Baron Samedi]

Tell the higher ups that they can implant them and manage if they want to.

 

[Ducttape]

i consider ITP if patients have documented reasons for failing other methods of opioid therapy for cancer pain.

specifically severe intolerance such as vomiting or constipation.

you could use it for pain refractory to "standard" opioid doses, although the refractoriness suggests that opioid therapy may not the best treatment anyways...

 

[Espn123]

It’s an amazing therapy for terminal cancer pain, both nociceptive in the spine and visceral pain are great indications in those who can’t tolerate opioids

 

[MitchLevi]

I think a pump is a great option for terminal pts.

 

[au bon pain]

For cancer patients with likely TD but not so sick they’re unlikely to heal well, agree with others they can be a great option.

But to really serve these patients well (and safely), you have to be at a place that’s well-staffed and has redundancy. If you’re at a place with constant staff turnover, important messages not being delivered to you in a timely manner, no good relationship with a reliable compounding pharmacy, not enough capable people willing to refill, adjust and also troubleshoot them when things go wrong…not gonna be good for the patient or you.

 

[callmeanesthesia]

My opinion (haven’t done a pump since fellowship about 5 years ago, but in fellowship did a lot):
A pump is probably not great for truly generalized pain but can still help. Choosing a more hydrophilic opiate will help it spread farther and cover a broader area. If you’re talking generalized pain due to mets everywhere, you can hopefully cover the worst area. Have to ask how long they have and whether pump is justified though. Generalized pain because their oncologist has escalated them up and up and now they’re on a 500 OME a day and have OIH? Also surprisingly might help because you cut the dose down by about 100-fold especially if you can replace some opioid with local. I saw a couple patients with pancreatic cancer who were a real mess prior to the pump get a lot of QOL back.

Au bon pain is spot on though. It takes a lot to serve those patients well. You need a smooth pipeline from the cancer center to you, to the OR, to pump refills. These aren’t people who can wait a month to see you, another month for a trial (not sure if they do those for cancer pumps still - sometimes we were able to bypass a trial?) and then another month for the implant. Pumps were almost the only reason I had to go in on the weekend.

I wouldn’t want to have to set all that up.

 

[Orin]

Correct me if I’m wrong. I do not see how an ITP would likely cover generalized cancer pain. Im getting pressure from higher-ups (I’m employed) to utilize this modality. Does anyone have wild success with this for cancer pain? I’ve had a few cancer patients with ITPs and we’re still taking oral narcotic medications. Appreciate any advise or good literature sources.

TIA!

PACC guidelines say you can use it for diffuse pain. I wouldn't start with that population for it, but the guidelines suggest you can. The evidence and consensus is weaker there with III/C-D/Moderate for diffuse/global pain that is malignant or not.

The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines - PubMed

New algorithms and guidance have been established to improve care with the use of intrathecal drug delivery.

pubmed.ncbi.nlm.nih.gov

If you're doing it in cancer for diffuse pain, Ziconotide is line 1A followed by morphine. If bean counters are pushing you to use it, tell them you'll only do it with Ziconotide and their interest will fade quickly I suspect, but so might yours.


The cancer/hospital folks are likely looking at Stearns' data which suggest significant savings for the system and good outcomes for patients with pumps over conventional medical management.

If you're gonna do it, start with doing chronic non-malignant low dose monotherapy or simple baclofen pumps that won't cause you a headache. Once you're 10 - 20 pumps in with a good pipeline, then start thinking about cancer ones. They're not easier, but folks like to do them since they die sooner. If you're going to have a system though, it is a lot easier to develop/troubleshoot on a clear phenotype like spasticity or using the 'control workflow' where you do just low dose monotherapy without systemic opioids.

Then when the system is good, start with the patients that are dying soon, always infected, on high dose regimen, and poor protoplasm all around.

Or just don't do it.

 

[PainBrain78]

My opinion (haven’t done a pump since fellowship about 5 years ago, but in fellowship did a lot):
A pump is probably not great for truly generalized pain but can still help. Choosing a more hydrophilic opiate will help it spread farther and cover a broader area. If you’re talking generalized pain due to mets everywhere, you can hopefully cover the worst area. Have to ask how long they have and whether pump is justified though. Generalized pain because their oncologist has escalated them up and up and now they’re on a 500 OME a day and have OIH? Also surprisingly might help because you cut the dose down by about 100-fold especially if you can replace some opioid with local. I saw a couple patients with pancreatic cancer who were a real mess prior to the pump get a lot of QOL back.

Au bon pain is spot on though. It takes a lot to serve those patients well. You need a smooth pipeline from the cancer center to you, to the OR, to pump refills. These aren’t people who can wait a month to see you, another month for a trial (not sure if they do those for cancer pumps still - sometimes we were able to bypass a trial?) and then another month for the implant. Pumps were almost the only reason I had to go in on the weekend.

I wouldn’t want to have to set all that up.

This is my exact problem with the ideology of using ITP for generalized pain using a hydrophilic opioid ie fentanyl. What is truly the difference between transdermal fentanyl vs IT fentanyl. It seems IT fentanyl is lipophilic so it won’t stay in IT anyways and absorbed systemically.

 

[PainBrain78]

i consider ITP if patients have documented reasons for failing other methods of opioid therapy for cancer pain.

specifically severe intolerance such as vomiting or constipation.

you could use it for pain refractory to "standard" opioid doses, although the refractoriness suggests that opioid therapy may not the best treatment anyways...

I’m above standard doses at this point unfortunately. I’ve slowly climbed to 500 MMEs. I’ve encouraged to go to ER but she refuses due to cost. Still 9/10 pain, unable to sleep. Adjuvant medications unhelpful. Metastatic melanoma however she is responding to immunotherapy so no palliative care. A real doozy.

 

[Espn123]

I’m above standard doses at this point unfortunately. I’ve slowly climbed to 500 MMEs. I’ve encouraged to go to ER but she refuses due to cost. Still 9/10 pain, unable to sleep. Adjuvant medications unhelpful. Metastatic melanoma however she is responding to immunotherapy so no palliative care. A real doozy.

the pump is tough to titrate w mme like that

 

[Ducttape]

consider a switch to methadone or stopping opioids altogether.

at 500 MED, with increasing doses with no benefit, OIH is a significant concern.


i do know some docs that will put in the pump as the intrathecal dose used is significantly less in total mg amount than the oral dose, but i think that is an inadequate basis for starting a pump. the problem is probably the medication and not the disease process

 

[PainBrain78]

A few months ago I discussed switching to methadone and she was highly resistant but I think we’re to the point that this is basically her only option. She’s on fentanyl 150 mcg and dilaudid 32 mg per day.

Planning to stop fentanyl patch for 12 hour and initiating methadone 10 mg TID.

I don’t use methadone often but every time I do the conversion always shocks me.

 

[kstarm]

We had a guy on 90mg of methadone and 25mg of oral dilaudid Q2h last year. He was having terrible pain related to a neck cancer. He was on hospice and then hospice refused to take him back and provided no transition plan. In the hospital we ultimately converted him to Bupe and a much lower dose of oral dilaudid he had a huge improvement in his pain and function. You might want to consider bupe for some of these high dose cancer patients.

 

[PainBrain78]

Love that. I hadn’t considered it for this patient in particular although I prescribe a lot of buprenorphine. I’ll definitely keep that in mind. Thanks for the suggestion.

 

[au bon pain]

We had a guy on 90mg of methadone and 25mg of oral dilaudid Q2h last year. He was having terrible pain related to a neck cancer. He was on hospice and then hospice refused to take him back and provided no transition plan. In the hospital we ultimately converted him to Bupe and a much lower dose of oral dilaudid he had a huge improvement in his pain and function. You might want to consider bupe for some of these high dose cancer patients.

Agreed, also had positive results with bup for cancer pain. And sensitization/oih not really an issue. Somehow there’s this notion that bup isn’t “as good” as full agonists for pain...which is funny because there’s no real basis for that idea. Of course if we’re talking about non-cancer / non-palliative pain then there’s really no good evidence for opioids anyway.

 

[Baron Samedi]

A few months ago I discussed switching to methadone and she was highly resistant but I think we’re to the point that this is basically her only option. She’s on fentanyl 150 mcg and dilaudid 32 mg per day.

Planning to stop fentanyl patch for 12 hour and initiating methadone 10 mg TID.

I don’t use methadone often but every time I do the conversion always shocks me.

10 TID is too much to start due to nonlinear conversion. High risk of OD.

Med rec for other QT-prolonging meds. Obtain baseline EKG, take off patch. After 12 hours can take methadone 5 TID. Make sure caregivers have access to nalaxone. Adjust no more frequently than weekly by 2.5mg/dose increments in an outpatient. Obtain new EKG after 4-6 weeks.

 

[PainBrain78]

10 TID is too much to start due to nonlinear conversion. High risk of OD.

Med rec for other QT-prolonging meds. Obtain baseline EKG, take off patch. After 12 hours can take methadone 5 TID. Make sure caregivers have access to nalaxone. Adjust no more frequently than weekly by 2.5mg/dose increments in an outpatient. Obtain new EKG after 4-6 weeks.

Risk of withdrawal with 5 mg TID?

 

[Baron Samedi]

Risk of withdrawal with 5 mg TID?

She has the dilaudid which should help. The unfortunate answer is still yes due to how long it takes to get to steady state with methadone but it's better than an unintentional OD.

 

[PainBrain78]

Ok gotcha. So you would manage with discontinuing fentanyl, replacing with methadone and continuing dilaudid.

Originally I was planning on discontinuing fentanyl and dilaudid but perhaps this is too aggressive.

 

[Ducttape]

i would disagree.

i would replace all current opioids with methadone, not a half arsed replacement of just eliminating the fentanyl and keeping the dilaudid. neither are working. and yes, you do run risk of withdrawal, but the patient wont OD on 10 mg 3 times daily if he is off both agents.

if you want to add in a little of some other breakthrough opioid, thats fine, but importantly wait until he stabilizes on his new regimen, and that may take a week.

you have to let him know either way the first couple of days may be a little rough, and i would schedule to see him or to have contact with him the day after he changes over.

agree with checking EKG. agree with reviewing med list to make sure there are no other agents that can increase QTc.

at 30 mg a day of methadone, the risk of QTc interval increase is low unless it is mixed with some other agent, but rechecking EKG is reasonable precaution.

 

[Baron Samedi]

I should have added that my strategy would be to rapidly titrate down on the hydromorphone as well over the next week or two until methadone only.

I do think that even if you do stop both opioids cold turkey that you'll need some initial breakthrough med, like Ducttape said. I would personally just keep it as hydromorphone as the patient already has some and is used to taking it.

 

[mdo1738]

10 TID is too much to start due to nonlinear conversion. High risk of OD.

Med rec for other QT-prolonging meds. Obtain baseline EKG, take off patch. After 12 hours can take methadone 5 TID. Make sure caregivers have access to nalaxone. Adjust no more frequently than weekly by 2.5mg/dose increments in an outpatient. Obtain new EKG after 4-6 weeks.

Methadone only prolongs QTc at doses above 100 mg daily. I can appreciate doing it from a CYA perspective but not necessary at low doses.

 

[kstarm]

I was at a talk by addiction medicine within the last year and they recommend against checking EKGs for methadone. The data they presented was strong that methadone does increase QTc but not to anything clinically meaningful. In the neighborhood of 5-15ms at doses for addiction maintenance. The data apparently that QTc concerns was used initially I guess was pretty poor but the mantra has continued that we need to be vigilant. We have quit checking routinely at the hospital unless there are other risk factors besides methadone and if there is QTc concerns recommend other medications are adjusted first which are more likely to be problematic. I would encourage you to look into this more closely if you are routinely doing EKGs for people on methadone.

Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort

Methadone is associated with prolongation of the electrocardiographic QTc interval. QTc prolongation may be linked to cardiac dysrhythmia and sudden cardiac death. The rate of these events is unknown in methadone-maintained patients.This retrospective ...

www.ncbi.nlm.nih.gov