Skip to main content

Advertisement

SpringerLink
Log in

Intrathecal Therapy for Chronic Pain: Current Trends and Future Needs

  • Anesthetic Techniques in Pain Management (D Wang, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

The management of chronic pain continues to pose many challenges to healthcare providers. Intrathecal drug delivery systems (IDDS) provide an effective therapy for patients suffering from chronic pain intractable to medical management. However, the clinical growth of intrathecal therapy continues to face many challenges, and is likely underutilized secondary to its high-complexity and limited reimbursement. The clinical utility of IDDS remains limited by lack of prospective randomized, placebo-controlled studies. In addition, there remains a need to enhance physician knowledge on the pharmacodynamics and pharmacokinetics of intrathecal drug delivery and promote further research into this field and drug delivery modalities. The purpose of this article is to provide a comprehensive review of the determinants of successful intrathecal drug delivery with an emphasis on its use in noncancer pain.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bier A. Atempts over Cocainisirung of the Ruckenmarkers [in German]. Deutsche Zeitschrift für Chirurgie. 1899;51:9.

    Article  Google Scholar 

  2. Kitagawa O. On spinal anesthesia with cocaine. Jpn Soc Surg. 1901;3:185–91.

    Google Scholar 

  3. Knight KH, Brand FM, McHaourab AS, Veneziano G. Implantable intrathecal pumps for chronic pain: highlights and updates. Croat Med J. 2007;48:22–34.

    PubMed Central  PubMed  Google Scholar 

  4. Yaksh TL, Wilson PR, Kaiko RF, Inturrisi CE. Analgesia produced by a spinal action of morphine and effects upon parturition in the rat. Anesthesiology. 1979;51:386–92.

    Article  CAS  PubMed  Google Scholar 

  5. Goldstein A, Lowney LI, Pal BK. Stereospecific and nonspecific interactions of the morphine congener levorphanol in subcellular fractions of mouse brain. Proc Natl Acad Sci U S A. 1971;68:1742–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Pert CB, Snyder SH. Opiate receptor: demonstration in nervous tissue. Science. 1973;179:1011–4.

    Article  CAS  PubMed  Google Scholar 

  7. Wang JK, Nauss LA, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979;50:149–51.

    Article  CAS  PubMed  Google Scholar 

  8. Onofrio BM, Yaksh TL, Arnold PG. Continuous low-dose intrathecal morphine administration in the treatment of chronic pain of malignant origin. Mayo Clin Proc. 1981;56:516–20.

    CAS  PubMed  Google Scholar 

  9. Coombs DW, Saunders RL, Gaylor MS, Block AR, Colton T, Harbaugh R, et al. Relief of continuous chronic pain by intraspinal narcotics infusion via an implanted reservoir. JAMA. 1983;250:2336–9.

    Article  CAS  PubMed  Google Scholar 

  10. Auld AW, Maki-Jokela A, Murdoch DM. Intraspinal narcotic analgesia in the treatment of chronic pain. Spine. 1985;10:777–81.

    Article  CAS  PubMed  Google Scholar 

  11. Paice JA, Penn RD, Shott S. Intraspinal morphine for chronic pain: a retrospective, multicenter study. J Pain Symptom Manage. 1996;11:71–80.

    Article  CAS  PubMed  Google Scholar 

  12. Penn RD, Paice JA. Chronic intrathecal morphine for intractable pain. J Neurosurg. 1987;67:182–6. doi:10.3171/jns.1987.67.2.0182.

    Article  CAS  PubMed  Google Scholar 

  13. Henry-Feugeas MC, Idy-Peretti I, Baledent O, Poncelet-Didon A, Zannoli G, Bittoun J, et al. Origin of subarachnoid cerebrospinal fluid pulsations: a phase-contrast MR analysis. Magn Reson Imaging. 2000;18:387–95.

    Article  CAS  PubMed  Google Scholar 

  14. Friese S, Hamhaber U, Erb M, Kueker W, Klose U. The influence of pulse and respiration on spinal cerebrospinal fluid pulsation. Invest Radiol. 2004;39:120–30. doi:10.1097/01.rli.0000112089.66448.bd.

    Article  PubMed  Google Scholar 

  15. Alperin N, Vikingstad EM, Gomez-Anson B, Levin DN. Hemodynamically independent analysis of cerebrospinal fluid and brain motion observed with dynamic phase contrast MRI. Magn Reson Med. 1996;35:741–54.

    Article  CAS  PubMed  Google Scholar 

  16. Stockman HW. Effect of anatomical fine structure on the flow of cerebropsinal fluid in the spinal subarachnoid space. J Biochem Eng. 2006;128:106–14.

    Google Scholar 

  17. Degrell I, Nagy E. Concentration gradients for HVA, 5-HIAA, ascorbic acid, and uric acid in cerebrospinal fluid. Biol Psychiatry. 1990;27:891–6.

    Article  CAS  PubMed  Google Scholar 

  18. Bernards CM. Cerebrospinal fluid and spinal cord distribution of baclofen and bupivacaine during slow intrathecal infusion in pigs. Anesthesiology. 2006;105:169–78.

    Article  PubMed  Google Scholar 

  19. Hettiarachchi HD, Hsu Y, Harris Jr TJ, Penn R, Linninger AA, Hettiarachchi HD, et al. The effect of pulsatile flow on intrathecal drug delivery in the spinal canal. Ann Biomed Eng. 2011;39. A study that analyzed cerebrospinal fluid flow patterns using single photon emission computed tomography in a human spine model as a predictor for the deliveery patterns of intrathecal drugs.

  20. Bernards CM. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesthesiol. 2002;16:489–505.

    Article  CAS  PubMed  Google Scholar 

  21. Ummenhofer WC, Arends RH, Shen DD, Bernards CM. Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Anesthesiology. 2000;92:739–53.

    Article  CAS  PubMed  Google Scholar 

  22. McQuay HJ, Sullivan AF, Smallman K, Dickenson AH. Intrathecal opioids, potency and lipophilicity. Pain. 1989;36:111–5.

    Article  CAS  PubMed  Google Scholar 

  23. Hayek SM, Joseph PN, Mekhail NA. Pharmacology of intrathecally administered agents for treatment of spasticity and pain. Semin Pain Med. 2003;1:238–53. doi:10.1016/j.spmd.2004.02.002.

    Article  CAS  Google Scholar 

  24. Herz AT H. Activities and sites of antinociceptive action of morphine-like analgesics and kinetics of distribution following intravenous, intracerebral and intraventricular application. In: Simmonds, editor. Advances in Drug Research. London: Academic Press; 1971. p. p. 739–53.

    Google Scholar 

  25. Bernards CM. Recent insights into the pharmacokinetics of spinal opioids and the relevance to opioid selection. Curr Opin Anaesthesiol. 2004;17:441–7.

    Article  PubMed  Google Scholar 

  26. Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, et al. Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012;15:436–64. doi:10.1111/j.1525-1403.2012.00476.x. Recommendations on proper management of intrathecal drug delivery systems developed by an expert panel.

    Article  PubMed  Google Scholar 

  27. Coffey RJ, Owens ML, Broste SK, Dubois MY, Ferrante FM, Schultz DM, et al. Mortality associated with implantation and management of intrathecal opioid drug infusion systems to treat noncancer pain. Anesthesiology. 2009;111:881–91. doi:10.1097/ALN.0b013e3181b64ab8.

    Article  PubMed  Google Scholar 

  28. Coffey RJ, Owens ML, Broste SK, Dubois MY, Ferrante FM, Schultz DM, et al. Medical practice perspective: identification and mitigation of risk factors for mortality associated with intrathecal opioids for noncancer pain. Pain Med. 2010;11:1001–9. doi:10.1111/j.1526-4637.2010.00889.x.

    Article  PubMed  Google Scholar 

  29. Hayek SM, Veizi IE, Narouze SN, Mekhail N. Age-dependent intrathecal opioid escalation in chronic noncancer pain patients. Pain Med. 2011;12:1179–89. doi:10.1111/j.1526-4637.2011.01188.x.

    Article  PubMed  Google Scholar 

  30. Veizi IE, Hayek SM, Narouze S, Pope JE, Mekhail N. Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients. Pain Med. 2011;12:1481–9. doi:10.1111/j.1526-4637.2011.01232.x.

    Article  PubMed  Google Scholar 

  31. Dominguez E, Sahinler B, Bassam D, Day M, Lou L, Racz G, et al. Predictive value of intrathecal narcotic trials for long-term therapy with implantable drug administration systems in chronic noncancer pain patients. Pain Pract. 2002;2:315–25. doi:10.1046/j.1533-2500.2002.02040.x.

    Article  PubMed  Google Scholar 

  32. Grider JSH, Etscheidt MA. Patient selection and outcomes using a low-dose intrathecal opioid trialing method for chronic nonmalignant pain. Pain Physician. 2011;14:343–51.

    PubMed  Google Scholar 

  33. Hamza M, Doleys D, Wells M, Weisbein J, Hoff J, Martin M. A prospective study evaluating the efficacy of opioid cessation and the use of low-dose intrathecal opioid management of noncancer pain.

  34. Deer T, Krames ES, Hassenbusch S, Burton A, Caraway D, Dupen S, et al. Management of Intrathecal Catheter-Tip Inflammatory Masses: an updated 2007 consensus statement from an expert panel. Neuromodulation. 2008;11:77–91. doi:10.1111/j.1525-1403.2008.00147.x.

    Article  PubMed  Google Scholar 

  35. Allen JW, Horais KA, Tozier NA, Wegner K, Corbeil JA, Mattrey RF, et al. Time course and role of morphine dose and concentration in intrathecal granuloma formation in dogs: a combined magnetic resonance imaging and histopathology investigation. Anesthesiology. 2006;105:581–9.

    Article  CAS  PubMed  Google Scholar 

  36. Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, et al. Polyanalgesic Consensus Conference — 2012: consensus on diagnosis, detection, and treatment of catheter-tip granulomas (inflammatory masses). Neuromodulation. 2012;15:483–95. doi:10.1111/j.1525-1403.2012.00449.x. discussion 96.

    Article  PubMed  Google Scholar 

  37. Tomycz ND, Ortiz V, McFadden KA, Urgo L, Moossy JJ. Management of symptomatic intrathecal catheter-associated inflammatory masses. Clin Neurol Neurosurg. 2012;114:190–5.

    Google Scholar 

  38. Boswell MV, Iacono RP, Guthkelch AN. Sites of action of subarachnoid lidocaine and tetracaine: observations with evoked potential monitoring during spinal cord stimulator implantation. Reg Anesth. 1992;17:37–42.

    CAS  PubMed  Google Scholar 

  39. Tejwani GA, Rattan AK, McDonald JS. Role of spinal opioid receptors in the antinociceptive interactions between intrathecal morphine and bupivacaine. Anesth Analg. 1992;74:726–34.

    Article  CAS  PubMed  Google Scholar 

  40. Penning JP, Yaksh TL. Interaction of intrathecal morphine with bupivacaine and lidocaine in the rat. Anesthesiology. 1992;77:1186–2000.

    Article  CAS  PubMed  Google Scholar 

  41. Ortner CM, Posch M, Roessler B, Faybik P, Rutzler K, Grabovica J, et al. On the ropivacaine-reducing effect of low-dose sufentanil in intrathecal labor analgesia. Acta Anaesthesiol Scand. 2010;54:1000–6. doi:10.1111/j.1399-6576.2010.02254.x.

    Article  CAS  PubMed  Google Scholar 

  42. Parpaglioni R, Baldassini B, Barbati G, Celleno D. Adding sufentanil to levobupivacaine or ropivacaine intrathecal anaesthesia affects the minimum local anaesthetic dose required. Acta Anaesthesiol Scand. 2009;53:1214–20. doi:10.1111/j.1399-6576.2009.02033.x.

    Article  CAS  PubMed  Google Scholar 

  43. Levin A, Datta S, Camann WR. Intrathecal ropivacaine for labor analgesia: a comparison with bupivacaine. Anesth Analg. 1998;87:624–7.

    CAS  PubMed  Google Scholar 

  44. van Dongen RT, Crul BJ, van Egmond J. Intrathecal coadministration of bupivacaine diminishes morphine dose progression during long-term intrathecal infusion in cancer patients. Clin J Pain. 1999;15:166–72.

    Article  PubMed  Google Scholar 

  45. Mironer YE, Haasis JC, Chapple I, Brown C, Satterthwaite JR. Efficacy and safety of intrathecal opioids/bupivacaine mixture in chronic nonmalignant pain: a double blind, randomized, crossover, multicenter study by the National Forum of Independent Pain Clinicians (NFIPC). Neuromodulation. 2002;5:208–13.

    Article  PubMed  Google Scholar 

  46. Zhong Z, Qulian G, Yuan Z, Wangyuan Z, Zhihua S. Repeated intrathecal administration of ropivacaine causes neurotoxicity in rats. Anaesth Intensive Care. 2009;37:929–36.

    CAS  PubMed  Google Scholar 

  47. Malinovsky JM, Charles F, Baudrimont M, Pereon Y, Le Corre P, Pinaud M, et al. Intrathecal ropivacaine in rabbits: pharmacodynamic and neurotoxicologic study. Anesthesiology. 2002;97:429–35.

    Article  CAS  PubMed  Google Scholar 

  48. Yamashita A, Matsumoto M, Matsumoto S, Itoh M, Kawai K, Sakabe T. A comparison of the neurotoxic effects on the spinal cord of tetracaine, lidocaine, bupivacaine, and ropivacaine administered intrathecally in rabbits. Anesth Analg. 2003;97:512–9. table of contents.

    Article  CAS  PubMed  Google Scholar 

  49. Sjoberg M, Nitescu P, Appelgren L, Curelaru I. Long-term intrathecal morphine and bupivacaine in patients with refractory cancer pain. Results from a morphine:bupivacaine dose regimen of 0.5:4.75 mg/mL. Anesthesiology. 1994;80:284–97.

    Article  CAS  PubMed  Google Scholar 

  50. Nitescu P, Dahm P, Appelgren L, Curelaru I. Continuous infusion of opioid and bupivacaine by externalized intrathecal catheters in long-term treatment of "refractory" nonmalignant pain. Clin J Pain. 1998;14:17–28.

    Article  CAS  PubMed  Google Scholar 

  51. McGivern JG. Ziconotide: a review of its pharmacology and use in the treatment of pain. Neuropsychiatr Dis Treat. 2007;3:69–85.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  52. Wermeling D, Drass M, Ellis D, Mayo M, McGuire D, O'Connell D, et al. Pharmacokinetics and pharmacodynamics of intrathecal ziconotide in chronic pain patients. J Clin Pharmacol. 2003;43:624–36.

    CAS  PubMed  Google Scholar 

  53. Staats PS, Yearwood T, Charapata SG, Presley RW, Wallace MS, Byas-Smith M, et al. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. JAMA. 2004;291:63–70. doi:10.1001/jama.291.1.63.

    Article  CAS  PubMed  Google Scholar 

  54. Wallace MS, Charapata SG, Fisher R, Byas-Smith M, Staats PS, Mayo M, et al. Intrathecal ziconotide in the treatment of chronic nonmalignant pain: a randomized, double-blind, placebo-controlled clinical trial. Neuromodulation. 2006;9:75–86. doi:10.1111/j.1525-1403.2006.00055.x.

    Article  PubMed  Google Scholar 

  55. Rauck RL, Wallace MS, Leong MS, Minehart M, Webster LR, Charapata SG, et al. A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manage. 2006;31:393–406. doi:10.1016/j.jpainsymman.2005.10.003.

    Article  CAS  PubMed  Google Scholar 

  56. Wallace MS, Rauck R, Fisher R, Charapata SG, Ellis D, Dissanayake S. Intrathecal ziconotide for severe chronic pain: safety and tolerability results of an open-label, long-term trial. Anesth Analg. 2008;106:628–37. doi:10.1213/ane.0b013e3181606fad.

    Article  CAS  PubMed  Google Scholar 

  57. Maier C, Gockel HH, Gruhn K, Krumova EK, Edel MA. Increased risk of suicide under intrathecal ziconotide treatment? - a warning. Pain. 2011;152:235–7. doi:10.1016/j.pain.2010.10.007.

    Article  CAS  PubMed  Google Scholar 

  58. Feng X, Zhang F, Dong R, Li W, Liu J, Zhao X, et al. Intrathecal administration of clonidine attenuates spinal neuroimmune activation in a rat model of neuropathic pain with existing hyperalgesia. Eur J Pharmacol. 2009;614:38–43. doi:10.1016/j.ejphar.2009.04.044.

    Article  CAS  PubMed  Google Scholar 

  59. Yaksh TL, Rathbun M, Jage J, Mirzai T, Grafe M, Hiles RA. Pharacology and toxicology of chronically infused epidural clonidine.HCl in dogs. Fundam Appl Toxicol. 1994;23:319–35.

    Article  CAS  PubMed  Google Scholar 

  60. Yaksh TL, Horais KA, Tozier NA, Allen JW, Rathbun M, Rossi SS, et al. Chronically infused intrathecal morphine in dogs. Anesthesiology. 2003;99:174–87.

    Article  CAS  PubMed  Google Scholar 

  61. Bevacqua BK, Fattouh M, Backonja M. Depression, night terrors, and insomnia associated with long-term intrathecal clonidine therapy. Pain Pract. 2007;7:36–8. doi:10.1111/j.1533-2500.2007.00108.x.

    Article  PubMed  Google Scholar 

  62. Belverud S, Mogilner A, Schulder M. Intrathecal pumps. Neurotherapeutics. 2008;5:114–22. doi:10.1016/j.nurt.2007.10.070.

    Article  PubMed  Google Scholar 

  63. Gerber HR. Intrathecal morphine for chronic benign pain. Best Pract Res Clin Anaesthesiol. 2003;17:429–42.

    Article  CAS  PubMed  Google Scholar 

  64. Turner JA, Sears JM, Loeser JD. Programmable intrathecal opioid delivery systems for chronic noncancer pain: a systematic review of effectiveness and complications. Clin J Pain. 2007;23:180–95. doi:10.1097/01.ajp.0000210955.93878.44.

    Article  PubMed  Google Scholar 

  65. Brown J, Klapow J, Doleys D, Lowery D, Tutak U. Disease-specific and generic health outcomes: a model for the evaluation of long-term intrathecal opioid therapy in noncancer low back pain patients. Clin J Pain. 1999;15:122–31.

    Article  CAS  PubMed  Google Scholar 

  66. Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592–6. doi:10.1056/NEJM199403033300902.

    Article  CAS  PubMed  Google Scholar 

  67. Rauck RL, Cherry D, Boyer MF, Kosek P, Dunn J, Alo K. Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain. J Pain. 2003;4:441–7.

    Article  CAS  PubMed  Google Scholar 

  68. Smith TJ, Staats PS, Deer T, Stearns LJ, Rauck RL, Boortz-Marx RL, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain, drug related toxicitiy, and survival. J Clin Oncol. 2002;20:4040–9.

    Article  CAS  PubMed  Google Scholar 

  69. Smith TJ, Coyne PJ, Staats PS, Deer T, Stearns LJ, Rauck RL, et al. An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug-related toxicity, and possibly better survival compared with comprehensive medical management (CMM). Ann Oncol. 2005;16:825–33. doi:10.1093/annonc/mdi156.

    Article  CAS  PubMed  Google Scholar 

  70. Burton AW, Rajagopal A, Shah HN, Mendoza T, Cleeland C, Hassenbusch SJ, et al. Epidural and intrathecal analgesia is effective in treating refractory cancer pain. Pain Med. 2004;5:239–47. doi:10.1111/J.1526-4637.2004.04037.X.

    Article  PubMed  Google Scholar 

  71. Ahmed SU, Martin NM, Chang Y. Patient selection and trial methods for intraspinal drug delivery for chronic pain: a national survey. Neuromodulation. 2005;8:112–20. doi:10.1111/j.1525-1403.2005.00227.x.

    Article  PubMed  Google Scholar 

  72. Anderson VC, Burchiel KJ, Cooke B. A Prospective, randomized trial of intrathecal injection vs. epidural infusion in the selection of patients for continuous intrathecal opioid therapy. Neuromodulation. 2003;6:142–52.

    Article  PubMed  Google Scholar 

  73. Kim D, Saidov A, Mandhare V, Shuster A. Role of pretrial systemic opioid requirements, intrathecal trial dose, and nonpsychological factors as predictors of outcome for intrathecal pump therapy: one clinician's experience with lumbar postlaminectomy pain. Neuromodulation. 2011;14:165–75.

    Google Scholar 

  74. Kamran S, Wright BD. Complications of intrathecal drug delivery systems. Neuromodulation. 2001;4:111–5. doi:10.1046/j.1525-1403.2001.00111.x.

    Article  CAS  PubMed  Google Scholar 

  75. Follett KA, Naumann CP. A prospective study of catheter-related complications of intrathecal drug delivery systems. J Pain Symptom Manage. 2000;19:209–15.

    Article  CAS  PubMed  Google Scholar 

  76. Follett KA, Burchiel K, Deer T, Dupen S, Prager J, Turner MS, et al. Prevention of intrathecal drug delivery catheter-related complications. Neuromodulation. 2003;6:32–41. doi:10.1046/j.1525-1403.2003.03005.x.

    Article  PubMed  Google Scholar 

  77. Deer TR, Prager J, Levy R, Burton A, Buchser E, Caraway D, et al. Polyanalgesic Consensus Conference–2012: recommendations on trialing for intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012;15:420–35. doi:10.1111/j.1525-1403.2012.00450.x. discussion 35.

    Article  PubMed  Google Scholar 

  78. Peerdeman SM, de Groot V, Feller RE. In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece. J Neurosurg. 2010;112:1308–10. doi:10.3171/2009.8.JNS081692.

    Article  PubMed  Google Scholar 

  79. Diefenbeck M, Muckley T, Hofmann GO. Prophylaxis and treatment of implant-related infections by local application of antibiotics. Injury. 2006;37 Suppl 2:S95–104. doi:10.1016/j.injury.2006.04.015.

    Article  PubMed  Google Scholar 

  80. Ilias W, le Polain B, Buchser E, Demartini L; oPTIMa study group. Patient-controlled analgesia in chronic pain patients: experience with a new device designed to be used with implanted programmable pumps. Pain Pract. 2008;8:164–70.

    Google Scholar 

  81. Maeyaert J, Buchser E, Van Buyten JP, Rainov NG, Becker R. Patient-controlled analgesia in intrathecal therapy for chronic pain: safety and effective operation of the Model 8831 Personal Therapy Manager with a Pre-implanted SynchroMed Infusion System. Neuromodulation. 2003;6:133–41. doi:10.1046/j.1525-1403.2003.03021.x.

    Article  PubMed  Google Scholar 

  82. Hayek SM. Intrathecal "microdosing": reality or artifact? Pain Med. 2012;13:1664–5. doi:10.1111/j.1526-4637.2012.01507.

    Article  PubMed  Google Scholar 

  83. Brodner RA, Taub A. Chronic pain exacerbated by long-term narcotic use in patients with nonmalignant disease: clinical syndrome and treatment. Mt Sinai J Med. 1978;45:233–7.

    CAS  PubMed  Google Scholar 

  84. Taylor CB, Zlutnick SI, Corley MJ, Flora J. The effects of detoxification, relaxation, and brief supportive therapy on chronic pain. Pain. 1980;8:319–29.

    Article  CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Salim M. Hayek served as a board member for Flowonix and a consultant for Medtronic. Michael C. Hanes declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Case Western Reserve University, Cleveland, OH, 44106, USA

    Salim M. Hayek & Michael C. Hanes

  2. Division of Pain Medicine, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA

    Salim M. Hayek & Michael C. Hanes

Authors
  1. Salim M. Hayek
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael C. Hanes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Salim M. Hayek.

Additional information

This article is part of the Topical Collection on Anesthetic Techniques in Pain Management

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hayek, S.M., Hanes, M.C. Intrathecal Therapy for Chronic Pain: Current Trends and Future Needs. Curr Pain Headache Rep 18, 388 (2014). https://doi.org/10.1007/s11916-013-0388-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-013-0388-x

Keywords

Search

Navigation