Jason Hale, Elizabeth Casserly and Jianguo Cheng
Chronic, non-malignant pain can be particularly challenging to treat. Patients who are resistant to medications, nerve blocks, and spinal cord stimulators may eventually receive intrathecal therapy. Opioids are often first line medications for intrathecal therapy, but they frequently cause unacceptable side effects or become ineffective due to tolerance. This is particularly problematic in non-cancer pain, as these patients often require ongoing pain management for decades. Fortunately, combining opioids with other intrathecal medications, such as bupivacaine, clonidine, or ziconotide is very common and often produces improved analgesia. Some patients, however, have persistent pain despite first line or combination therapy, and these patients can be particularly difficult to manage. Bupivacaine is well documented as an excellent adjunct medication in intrathecal therapy, but there is little evidence supporting its use as monotherapy. We reviewed four non-cancer chronic pain patients who failed opioid or ziconotide intrathecal therapy and ultimately were placed on intrathecal bupivacaine as monotherapy. Their clinical courses and pain control are presented based on thorough review of their medical records. Three of our four patients have, at present, achieved effective analgesia with intrathecal bupivacaine monotherapy. This report is limited by the small number of patients as well as the known limitations of retrospective study. However, these data suggest that that pain physicians may consider intrathecal bupivacaine as monotherapy in patients who have failed to respond to other treatment regimens.
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