The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy

Timothy R. Deer, Salim M. Hayek, Jason E. Pope, Tim J. Lamer, Maged Hamza, Jay S. Grider, Steven M. Rosen, Samir Narouze, Christophe Perruchoud, Simon Thomson, Marc Russo, Eric Grigsby, Daniel M. Doleys, Marilyn S. Jacobs, Michael Saulino, Paul Christo, Philip Kim, Elliot Marc Huntoon, Elliot Krames, Nagy Mekhail

Research output: Contribution to journalReview article

Abstract

Introduction: Intrathecal (IT) drug infusion is an appropriate and necessary tool in the algorithm to treat refractory cancer and noncancer pain. The decision-making steps/methodology for selecting appropriate patients for implanted targeted drug delivery systems is controversial and complicated. Therefore, a consensus on best practices for determining appropriate use of IT drug infusion may involve testing/trialing this therapy before implantation. Methods: This current Polyanalgesic Consensus Conference (PACC) update was designed to address the deficiencies and emerging innovations since the previous PACC convened in 2012. A literature search identified publications available since the previous PACC publications in 2014, and relevant sources were contributed by the PACC members. After reviewing the literature, the panel determined the evidence levels and degrees of recommendations. The developed consensus was ranked as strong (>80%), moderate (50–79%), or weak (<49%). Results: The trialing for IT drug delivery systems (IDDS) remains an area of continued controversy. The PACC recommendations for trialing are presented in 34 consensus points and cover trialing for morphine, ziconotide, and medication admixtures; starting doses and titration practices; measurements of success; trial settings and monitoring; management of systemic opioids during trialing; and the role of psychological evaluation. Finally, the PACC describes clinical scenarios in which IT trialing is required or not required. Conclusion: The PACC provides consensus guidance on best practices of trialing for IDDS implants. In addition, the PACC recommends that no trial may be required in certain patient populations.

Original languageEnglish (US)
Pages (from-to)133-154
Number of pages22
JournalNeuromodulation
Volume20
Issue number2
DOIs
StatePublished - Feb 1 2017

Keywords

  • Cancer
  • guidelines
  • intrathecal drug infusion
  • noncancer
  • pain
  • review
  • trialing

ASJC Scopus subject areas

  • Neurology
  • Clinical Neurology
  • Anesthesiology and Pain Medicine

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  • Cite this

    Deer, T. R., Hayek, S. M., Pope, J. E., Lamer, T. J., Hamza, M., Grider, J. S., Rosen, S. M., Narouze, S., Perruchoud, C., Thomson, S., Russo, M., Grigsby, E., Doleys, D. M., Jacobs, M. S., Saulino, M., Christo, P., Kim, P., Huntoon, E. M., Krames, E., & Mekhail, N. (2017). The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy. Neuromodulation, 20(2), 133-154. https://doi.org/10.1111/ner.12543