Role of primary care physicians in intrathecal pain management: a narrative review of the literature

ABSTRACT

Objectives: The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan.

Methods: The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors’ clinical and research expertise.

Results: IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a µ-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist.

Conclusions: Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.

KEYWORDS:

• Chronic disease
• pain
• patient education
• pharmacology/drug reactions
• primary care

Acknowledgments

The authors thank Agnella Matic, PhD, and Nancy Holland, PhD, of Synchrony Medical Communications, LLC for providing medical writing support and Synchrony Medical Communications for editorial assistance in formatting, proofreading, copy editing, and fact checking, which was funded by Jazz Pharmaceuticals in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3). Jazz Pharmaceuticals also reviewed the manuscript. Although Jazz Pharmaceuticals was involved in the review of the manuscript, the authors independently controlled the content of this manuscript, the ultimate interpretation, and the decision to submit it for publication in Postgraduate Medicine.

Declarations of interest

G McDowell reports receiving research grants from Flowonix Medical Inc., Jazz Pharmaceuticals, Mallinckrodt, and Medtronic, Inc.; serving as a consultant for Flowonix Medical Inc., Jazz Pharmaceuticals, Medtronic, Inc., and Insys Therapeutics, Inc.; serving on the speakers’ bureaus for Jazz Pharmaceuticals, Medtronic, Inc., and Insys Therapeutics, Inc; and serving on the Polyanalgesic Consensus Conference. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

Jazz Pharmaceuticals provided funding to Synchrony Medical Communications, LLC, for support in writing and editing this manuscript.