Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Pain Pract. 2013 Apr;13(4):297-309. doi: 10.1111/j.1533-2500.2012.00584.x. Epub 2012 Aug 28.
Intrathecal (IT) drug delivery systems for patients with chronic non-malignant pain are intended to improve pain and quality of life and reduce side effects of systemic use. A subset of patients may have escalating pain, functional decline, and/or intolerable side effects even as IT opioid doses are increased. Discontinuation of IT medications may represent a viable treatment option but strategies to accomplish this are needed.
Three patients with intrathecal drug delivery systems (IDDS), inadequate pain control, and declining functionality underwent abrupt IT opioid cessation. This was accomplished through a standardized protocol with symptom-triggered administration of clonidine and buprenorphine, monitored using the clinical opiate withdrawal scale.
Symptoms of IT withdrawal were similar in all patients and included diuresis, agitation, hyperalgesia, mild diarrhea, yawning, and taste and smell aversion. Hypertension and tachycardia were effectively controlled by clonidine administration. Classic symptoms of withdrawal, such as piloerection, chills, severe diarrhea, nausea, vomiting, diaphoresis, myoclonus, and mydriasis, were not noted. At 2 to 3 months follow-up, patients reported decreased, but ongoing pain, with improvements in functional capacity and quality of life.
This preliminary work demonstrates the safety of abrupt IT opioid cessation utilizing standardized inpatient withdrawal protocols. To our knowledge, these are among the first reported cases of intentional, controlled IT opioid cessation without initiation of an opioid bridge: self-reported pain scores, functional capacity, and quality of life improved. The IT opioid withdrawal syndrome is characterized based upon our observations and a review of the literature.
为慢性非恶性疼痛患者提供鞘内（IT）药物输送系统旨在改善疼痛和生活质量，减少全身使用的副作用。即使增加 IT 阿片类药物剂量，一部分患者的疼痛仍可能加剧、功能下降和/或出现无法耐受的副作用。停止使用 IT 药物可能是一种可行的治疗选择，但需要制定相关策略。
三名 IT 药物输送系统（IDDS）患者出现疼痛控制不足和功能下降，进行了突然停止 IT 阿片类药物的治疗。这是通过一项标准化方案实现的，该方案在出现症状时触发给予可乐定和丁丙诺啡，并用临床阿片类戒断量表进行监测。
所有患者的 IT 戒断症状相似，包括利尿、激越、痛觉过敏、轻度腹泻、打哈欠以及味觉和嗅觉减退。通过给予可乐定可有效控制高血压和心动过速。未观察到经典的戒断症状，如竖毛、寒战、严重腹泻、恶心、呕吐、出汗、肌阵挛和瞳孔散大。在 2 至 3 个月的随访中，患者报告疼痛减轻，但仍持续存在，功能能力和生活质量有所改善。
这项初步工作证明了使用标准化住院戒断方案突然停止 IT 阿片类药物的安全性。据我们所知，这些是首次报告的有意、受控的 IT 阿片类药物停止使用而无需开始阿片类药物桥接的案例之一：自我报告的疼痛评分、功能能力和生活质量得到改善。根据我们的观察和文献回顾，描述了 IT 阿片类戒断综合征的特征。
