Intrathecal Opioid Pumps: Few Pros, Many Cons

Christina Lasich, MD Health Pro August 08, 2011
  • An intrathecal opioid pump is really not something that you would wish for your BFF or your worst enemy. That special someone would have to be in a pretty dire situation in order to receive a pump. Once the pump is in place, that person is still probably in miserable pain just at a slightly lesser degree. However, now that person is dealing with the numerous problems associated with intrathecal pumps. Nope, these devices which inject chemicals directly into the spinal canal from a surgically implanted pump are fraught with enough complications that even a minor amount of benefit may not be worthwhile for anyone, friend or foe.

     

    Becoming a candidate for an intrathecal opioid pump is not a race that anyone really wants to win. Only the very worst cases of extremely severe pain are considered. Prior to declaring pump candidacy, the individual considering this treatment option must have been through an entire gamete of oral opioid medication options and have failed miserably. Usually this individual has pain from a malignancy, but occasionally people with non-malignant pain are considered. Before the surgeon can implant a pump, each candidate must be fully informed about the numerous problems that could arise from the moment that pump is implanted underneath the skin all the way until the moment he/she is pushing up daisies or the device is permanently removed or deactivated.

     

    Looking at the surgical complications is enough to give any candidate cold feet. Because the catheter from the pump enters the spinal canal, there is a risk of spinal fluid leaks, infections, and bleeding. The pump site, usually in the abdomen, can become very swollen, infected or painful.  And this is when the potential for complications is just beginning.

     

    Next, each candidate will face a life-long laundry list of potential mechanical complications. The catheter can kink, obstruct, dislodge, and disconnect. The pump can fail from battery depletion, pump inversion, pump erosion or technical difficulties. These mechanical failures are not something that any old hospital doctor can take care of as if he/she is the local one-stop pump mechanic. No, these failures are potentially life-threatening problems causing acute opioid withdrawal symptoms that require specialty care not found at a majority of health care centers.

     

    One would think that since this technology has been around for years that these pumps would be bomb proof by now. Nope, think again. These pumps are manufactured by one company alone. Without any competition in this market, there has been no motivation to improve this technology. The unreliability of these pumps is notorious with any doctor who has ever had to deal with one at 3 a.m. which is usually the time when the proverbial s*** hits the pump.

     

    Finally, each potential candidate who is trying to decide whether or not to try the intrathecal opioid pumps needs a very sobering discussion about the potential for death. Yes, friends or foes that have a pump delivering pain medications into the spinal canal have a 1 in 20 chance of death from overdose. The 4 percent chance of death is higher than what anyone who has routine anesthesia for surgery will face. Those who have a pump may feel like they are dying when the catheter becomes obstructed by a tumor. That's right, as if the risk of death, infection, and pump failure are not enough. Each lucky candidate should be aware that a granulomatous catheter tip tumor is likely to form on the tip of the catheter in the spinal canal, not a good place for a tumor. Not only do these tumors block the flow of medication causing withdrawals, these tumors can also compress the spinal cord or even grow into the spinal cord. At this point, any smiles from what little pain relief is accomplished are quickly replaced by frowns. Speaking of frowning, every four to five years the pump will need to be surgically replaced which only keeps a smile on the surgeon's face.

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    Oh, did I mention any benefits? No? That's right there are not many benefits to be gained from the intrathecal opioid pump. Those who have extreme pain and opt for the pump are usually still miserable because the pain is still severe. The pain score might reduce slightly, but remains very high. Is that enough to for someone to have a reasonable quality of life for years to come? Maybe, maybe not. The only people who really can benefit the most are individuals with malignant pain. What little life is left will be prolonged because the pain will be kept manageable enough for the person to remain functional and get his/her affairs in order. The shortened life expectancy from the malignancy negates any potential for pump failures and needs for replacements in the future. In other words, a person with cancer will not be around long enough for a majority of pump problems to become a problem. Yes, the reality about intrathecal opioid pumps is bleak because only in rare cases do the benefits outweigh the risks. Overall, a pump is not something that you should wish for anyone friend or enemy, but on rare occasion it may be absolutely necessary.