Intrathecal Drug Therapy for Spasticity and Pain: Practical Patient Management

217 Pages·1996·6.914 MB·English

by  Janet M. Gianino MS, RN, Judith A. Paice PhD, RN, Michelle M. York RN (auth.)

Intrathecal Drug Therapy
for Spasticity and Pain
Springer
New York
Berlin
Heidelberg
Barcelona
Budapest
Hong Kong
London
Milan
Paris
Santa Clara
Singapore
Tokyo
Intrathecal Drug Therapy
for Spasticity and Pain
Practical Patient Management
Janet M. Gianino
Michelle M. York
Judith A. Paice
Rush-Presbyterian-St. Luke's Medical Center,
Neuroscience Institute, Neurosurgery Division,
Chicago, Illinois
Foreword by Richard D. Penn
With 88 Illustrations
Springer·
Janet M. Gianino, MS, RN Michelle M. York. RN
Rush -Presbyterian· St. Luke's Rush - Presbyterian -51. Luke's
Medical Center Medical Center
Neurosurgery Division Neurosurgery Division
I72S West Harrison Street I72S West Harrison Street
Chicago, lL 60612 Chicago, IL 60612
USA USA
Judith A. Paice. PhD, RN
Rush -Presbyterian -St. Luke's
Medical Center
Neurosurgery Division
172S West Harrison Street
Chicago, IL 60612
USA
Library of Congress Cataloging.in·Publil;lltion Data
Gianino. Janet M.
Intratheca.l drug therapy for spasticity and pain ; practical
patient managflllent I by Janet M. Gianino, Michelle M. York. Judith
A. Paice.
p. em.
Includes biblioaraphical refereJJCe$.
ISBN-13: 97S-O-387-94552-1 (he : a1k. paper)
I. Antispasmodics. 2. Morphine. 3. Injection •• Spinal.
I. Title.
[DNLM: I. Mu$Cle Spastictty- drugtherapy. 2. Injections, Spinal.
3. Pain_druj tllerapy. 4. Baclofen-thera~tic use. S. Morphine
therap(utic use. WE Ss(! G<t13i 19I1S]
RM321.OS2 1995
6IS'.184-dc20
Printed on acid-fret: paper.
01996 SpriJlier-Verlll New York, Inc.
Reprinl of the original edition 1996
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Foreword
The amazing thing about treating spasticity and pain by intrathecal drug
infusion is how a minute amount of fluid containing a small amount of
drug can have such a significant clinical effect. A typical intrathecal dose
of medication is one hundred times less than the oral dose, yet produces
a marked reduction in pain or the elimination of rigidity and spasms. To
visualize how little fluid is infused, consider the average volume of 1/3
mL given per day by drug pump. A milliliter contains about 20 drops of
fluid; therefore a single drop of fluid is infused every 3 to 4 hours. At this
slow rate an observer would be unable to see the flow; it is so small that
the fluid if in the air would evaporate before accumulating at the tip of
the catheter. Infusing the medicine directly to the right area in the
nervous system clearly makes a huge difference in how much is needed.
The tool for achieving this is equally amazing. The accuracy of the
programmable implanted pump is higher than any other drug delivery
system used in clinical medicine; it is better than ±50/0, and it can go
from a range of a small fraction of 1 mL to 2 mL per hour. Furthermore,
the pump is reliable, giving what it is instructed to give and working in a
continuous fashion for 3 to 5 years. As would be expected, the pump
took many years to engineer and test, but it has been equal to the
demands placed on it.
Properly using this new technology requires many skills. Though it is
simple in concept, it is not necessarily so in application. Knowledge of the
mechanics of the pump and the pharmacology of drug delivery, accuracy
in the assessment of the patient's pain or spasticity, and correct diagnosis
of complications are just a few of the requirements. The nurse practitio
ners who wrote this book have developed the necessary skills and,
fortunately, taken the time from their busy schedules to write a guide to
the successful management of this sometimes difficult but very rewarding
new field of medicine. Beyond their technical skills and knowledge they
have manifested kindness, concern, meticulousness, and dedication in
y
vi Foreword
working with our patients. Their willingness to share their expertise and
experience to teach others the practical management skills they have
developed is another example of their energy and generosity. They are
models of what medical practitioners should strive to be in the chal
lenging world of medicine.
RICHARD D. PENN. M.D.
Rush -Presbyterian -St. Luke's
Medical Center
Chicago,IL
Contents
Foreword by Richard D. Penn, MD ............................. v
Introduction ............................................................ .
2 Spinal Cord Anatomy....................... ...... ................... 3
3 Implantable Delivery Systems ...................................... 15
4 The Operative Course............. ................ ................... 33
5 Pharmacology of Baclofen and Morphine.................. .... 55
6 Intrathecal Baclofen for Spasticity................................ 67
Spasticity........ .............. .. ........... ....... ................. 67
Current methods 0/ treatment................ ................ 76
Benefits 0/ reduced spasticity................................. 80
Patient selection....................... ........................... 86
Screening procedures........................................... 93
Patient management ....................................... ..... 96
Tolerance .......................................................... 118
7 Intraspinal Morphine for Pain............... ...................... 127
Physiology 0/ pain ........ .................... .................. 128
Intrathecal drug dosing ........................................ 138
Supplemental opioids........................................... 143
Adverse intraspinal drug effects................ ............. 146
Patient education ................................................ 149
Case study ......................................................... 149
8 Mechanical System Complications................................ 155
9 Starting Up a Program............................................... 173
10 Current Controversies and Future Applications ............... 187
vII
vIII Contents
References ............................................................ 189
Appendixes
Baclofen Patient Teaching Booklet............................... 201
2 Intrathecal Baclofen and Morphine: Policy and Procedure
(Rush-Presbyterian-St. Luke's Medical Center,
Chicago, IL) ............................................................ 207
3 Resources for Spasticity.............................................. 211
3.1 Patient Resources: Spasticity....................................... 211
3.2 Professional Resources: Spasticity................................ 212
3.3 Patient Resources: Travel Assistance
for the Disabled........................................................ 212
4 Resources for Pain .................................................... 213
4.1 Patient Resources: Pain.............................................. 213
4.2 Professional Resources: Pain .... ..................... .............. 214
5 Research Organizations .............................................. 215
6 Electronic Support Groups.......................................... 217
1
Introduction
Centuries ago, natural products, such as plants, animals, or minerals,
were ingested or applied to the skin to treat various disorders. For
example, juices from the pods of the plant Papaver somni/erum, a
member of the poppy family, were used to relieve pain. It is only since the
1800s that chemically active compounds were synthesized from plants
and other products into tablets, liquids, or topical solutions. Morphine,
an essential agent used today in the treatment of pain, was first isolated
in 1804 by Friedrich Wilhelm Sertiirner. Since that time, pharmacologic
advancements have led to the synthesis of many new agents to treat a
variety of diseases and symptoms.
Methods of drug delivery have also advanced. Injectable compounds
have been introduced, expanding the available methods of delivery, and
the use of intravenous delivery has become popular in the past 50 years.
Although oral, topical, and parenteral routes are useful, these delivery
systems have significant limitations. Most of these routes deliver the drug
widely throughout the body, leading to the desired effect, as well as
possible side effects. As we learn more about the pharmacokinetics and
pharmacodynamics of various agents, the specific site or sites of action
are being identified. Thus, delivery to the site of action produces a more
pronounced desired effect with fewer adverse effects.
Local delivery into the spinal cord is especially attractive in the
treatment of spasticity and pain. Antispasmodic agents, such as baclofen,
may produce significant central effects when given orally. The site of
action of baclofen is within the spinal cord; thus delivery into this site
would reduce spasticity at much lower doses when compared to oral
administration, producing fewer central effects. Most patients in pain
can tolerate oral opioids, yet a small percentage develop severe adverse
effects to morphine. These patients might also benefit by delivery of drug
into the spinal cord, a key anatomical site in pain processing, with fewer
side effects.
1
2 1. Introduction
The local delivery of drugs into the spinal cord began in 1901 in Japan
with the intrathecal bolus injection of morphine by a physician named
Kitagawa. The technology to chronically deliver intraspinal drugs pro
gressed slowly until the 1960s. Indwelling reservoirs, such as the Ommaya
reservoir, were introduced at that time to overcome barriers in chemo
therapy administration to the brain. I External catheters, often attached
to external pumps, were developed to improve intraspinal delivery.
Technology has only recently allowed totally implanted systems to deliver
drugs continuously into intraspinal spaces, minimizing complications
such as infections.2
Although minimizing the risk associated with intraspinal delivery, the
use of these more complex systems requires extensive training of health
professionals caring for patients receiving this therapy. Knowledge is
necessary of the mechanics of these systems, the pharmacokinetics of
drugs intended for intraspinal delivery, and the specific needs of patients
with neurologic disorders, cancer, and chronic nonmalignant pain who
receive this therapy. The purpose of this book is to provide clinicians with
the information necessary to provide safe and effective care to patients
being treated with intraspinal agents for spasticity and pain. Where
controversies exist in management, we have tried to present alternative
views. Additionally, although every effort has been made to be thorough,
no text can be completely comprehensive. Therefore, we have included
other resources to assist in the care of these patients.
The use of intraspinal drug delivery has rapidly expanded with the
advent of implantable systems. This expansion is likely to continue with
the investigation of new compounds with larger structures, such as
peptides and growth factors, for the treatment of spasticity, pain, other
neuromuscular disorders, and even neurodegenerative diseases. Knowl
edgeable clinicians can make informed judgments while providing care
for these patients as well as form collaborative relationships with basic
investigators to advance the underlying science of this technique.