Intrathecal Pharmacology

Abstract

Abstract Intrathecal therapy (IT) is a vital component in the treatment of moderate to severe refractory cancer or noncancer pain. Knowledge and clinical experience using targeted intrathecal drug delivery have continued to grow as evidenced in the writings of the Polyanalgesic Consensus Conference (PACC). The distinguished authors of the PACC guidelines point out that IT is not a salvage therapy for high-dose opioid failure and recommend earlier IT trials for appropriate patient populations. They emphasize that treatment should be based on disease indications with known mechanisms so that appropriate drug selection can take place. Currently, there are only two FDA-approved medications for IT: morphine and ziconotide. Use of other medications such as bupivacaine, clonidine, and baclofen to treat chronic pain states is off-label. This chapter focuses on the pharmacokinetics, pharmacodynamics, and evidence for use of these and other medications in the intrathecal space. Current research continues to explore both new medications and medication combinations with the aim of improving patient safety and sustainable outcomes.