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The use of neuraxial analgesia for the goal of functional analgesia
is the next step beyond the optimum use of oral and transcutaneous
analgesia. The goal of pain relief with functional restitution should
be the guiding light of all approaches of analgesia. Once a patient
with acute, chronic, or cancer-related pain has been prescribed
a trial of opioids and adjuvant drugs, side effects having been
either treated or avoided with opioid sequential trials, then consideration
should be given to alternative delivery sources. Neuraxial analgesia,
with either single agent or a combination of drugs, may allow the
patient to achieve relief of intractable pain when opioid analgesia
alone has its limits.
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The discovery of the analgesic effects of neuraxial opioids,
alkaloids, and peptides has led to the expanded use of regional
anesthesia in long-term analgesic delivery systems. Today the choices of
analgesic agents include opioids, α2-agonists,
SNX-111, local anesthetic agents, and there are sure to be additional
agents added in the future. The clinician will always be faced with
a decision of when, what, and how. Patient selection, device selection,
and route of delivery are and will likely continue to be the key
questions.
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In this chapter we approach the patient in pain with options
for neuraxial analgesia. This includes discussions of drug choices
and pharmacology, patient selection, and optimization of conservative
therapy. Issues of delivery routes and device selection are explored,
and lastly, we give the reader insights into identification and
treatment of side effects and complications.
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Spinal opioids have been used in clinical practice routinely
since the late 70s. Epidural analgesia for postsurgical, obstetric,
and intractable cancer-related pain is considered standard medical
care. Intrathecal opioid therapy for chronic noncancer pain has
become an increasingly routine therapeutic approach over the last
10 years, although reimbursement issues continue to be problematic in
some states with some payers.
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Perhaps the most exciting new developments are in the area of
alternative agents that are being, or may soon be, used in spinal
drug delivery systems. The escalation of basic science research exploring
new spinally active agents has been brisk in the last decade, and
with newly committed funding for pain research at the National Institutes
of Health, the next decade will surely bring an explosion of research
and discovery in neuroaxial pharmacology.
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There continue to be major advances in systemic opioid management,
particularly the advent of long-acting oxycodone, transdermal and
transmucosal fentanyl, and the soon to be released long-acting hydromorphone.
These advances, and the controversy surrounding the potential link between
M3G and neurotoxicity,1 have left expert clinicians
debating if morphine is still the standard drug of choice or just
one of many choices for systemic therapy. There is not much debate,
however, over morphine’s superiority when administered
spinally, particularly for chronic cancer and noncancer administration.
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It seems clear that the potency of spinally administered ...