Long‐term intrathecal morphine and bupivacaine in “refractory” cancer pain. I. Results from the first series of 52 patients

Abstract

Neither epidural (EDA) or intrathecal (IT) morphine nor EDA opiate + bupivacaine provides acceptable relief of some types of cancer pain, e.g. pain originating from mucocutaneous ulcers, deafferentation pain, continuous and intermittent visceral and ischaemic pain, and that occurring with body movement as a result of a fracture. To improve pain relief in such conditions, we gave combinations of morphine and bupivacaine through open IT-catheters to 52 patients with "refractory", severe (VAS 7-10 out of 10), complex cancer pain (Edmonton Stage-3), for periods of 1-305 (median = 23) days. The efficacy of the treatment was estimated from: 1) daily dosage (intraspinal and total opiates, and intraspinal bupivacaine), and 2) scores of non-opiate analgesic and sedative consumption, gait and daily activities, and amount and pattern of sleep. Forty-four patients obtained continuous and acceptable pain relief (VAS 0-2), 26 of them with daily doses of IT-bupivacaine of less than or equal to 30 mg/day (less than or equal to 1.5 mg/h). Higher IT-bupivacaine doses (greater than 60-305 mg/day), not always giving acceptable pain relief, were necessary in 13 patients with deafferentation pain from the spinal cord or brachial or lumbosacral plexuses or pain from the coeliac plexus, or from large, ulcerated mucocutaneous tumours. By combining IT-bupivacaine with IT-morphine, it was possible to use relatively low IT-morphine doses (10-25 mg/day during the first 2 months of treatment) in more than half of the patients. The IT-treatment significantly decreased the total (all routes) opiate consumption and significantly improved sleep, gait and daily activities. For the whole period of observation (6 months), the IT-treatment was assessed as adequate in 3.8%, good in 23.1%, very good in 59.6% and excellent in 13.5% of the cases. Adverse effects of the IT-bupivacaine (paraesthesiae, paresis, gait impairment, urinary retention, anal sphincter disturbances and orthostatic hypotension) did not occur with doses of 2.5-3.0 mg/h (approx. 60-70 mg/day).

Neurological impairment during long-term intrathecal infusion of bupivacaine in cancer patients: a sign of spinal cord compression

“…Co-administration of bupi vacaine IT has been advocated to improve pain relief sub stantially in these situations and we used this technique in our patients (Sjoberg et al, 1991). Morphine IT does not give rise to motor or sensory impairment and IT bupiva caine below a dosage of 45 rng day"1, by continuous infu sion has been reported not to produce neurological sideeffects either (Sjoberg et al, 1994).…”

Controversies over spinal treatment in advanced cancer patients

“…Use of such a regiment meant that pain syndromes refractory to systemic or epidural treatments with a morphine-bupivacaine ratio of 1:1 could be well controlled [42,55,57]. Other advantages include a low total opioid daily consumption, thus preventing the potential side effects from high doses of morphine, additional antimicrobial activity of high concentration of bupivacaine, and smaller daily infusion volumes, permitting a rational utilization of home care resources (recharge of pumps, nurse visits and so on).…”

The Cerebrospinal Fluid in Severe Pain Conditions : Clinical, Pharmacological and Proteomic Aspects

“…In Sweden, the infusion of a combination of morphine and bupivacaine via an externalized catheter has been studied extensively by a group in Gothenburg, both for cancer pain [172,219,220] and non-cancer pain [62,171]. Bupivacaine can also be used as the sole agent for ITA [61,67,142].…”

“…Since 1981, there has been a plethora of uncontrolled studies assessing the efficacy of ITA for cancer pain [11,38,51,86,91,123,176,198,219,220]. In 2010, Meyers and co-workers performed a systematic review, finding 12 randomized controlled trials (RCT) about intraspinal analgesia for cancer pain [166].…”