Safety and tolerability of high doses of intrathecal fentanyl for the treatment of chronic pain

Sulane Do Ouro, MD; Santiago Esteban, BS; Una Sibirceva, MD; Beverly Whittenberg, MD; Russell Portenoy, MD; Ricardo A. Cruciani, MD, PhD

doi:10.5055/jom.2006.0053

Authors

Sulane Do Ouro, MD
Santiago Esteban, BS
Una Sibirceva, MD
Beverly Whittenberg, MD
Russell Portenoy, MD
Ricardo A. Cruciani, MD, PhD

DOI:

https://doi.org/10.5055/jom.2006.0053

Keywords:

fentanyl, intrathecal, dose escalation, chronic pain

Abstract

Fentanyl is commonly used systemically or neuraxially for the management of chronic pain. It can be administered intrathecally via implanted pump, but it is generally considered only after trials of intrathecal (IT) morphine and hydromorphone have proven ineffective. Published experience with IT fentanyl is limited, and long-term therapy at relatively high doses has not been described previously. We describe four patients who were treated with IT fentanyl after other analgesic approaches had failed and who gradually underwent dose escalation to levels as high as 20 times those previously reported. Safety and tolerability were maintained during dose titration. Our experience highlights an expanding scope of practice in the use of IT opioids in general and fentanyl specifically and suggests that high-dose fentanyl can be used safely in highly selected patients.

Author Biographies

Sulane Do Ouro, MD

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York.

Santiago Esteban, BS

Universidad Austral, Facultad the Medicina, Buenos Aires, Argentina; Research Division, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York.

Una Sibirceva, MD

Department of Medicine, Beth Israel Medical Center, New York, New York.

Beverly Whittenberg, MD

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York.

Russell Portenoy, MD

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York; Departments of Neurology and Anesthesiology, Albert Einstein College of Medicine, Bronx, New York.

Ricardo A. Cruciani, MD, PhD

Research Division, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York; Departments of Neurology and An es thesiology, Albert Einstein College of Medicine, Bronx, New York.

References

Hassenbusch SJ, Portenoy RK, Cousins M, et al.: Polyanalgesic Consensus Conference 2003: An update on the management of pain by intraspinal drug delivery—report of an expert panel. J Pain Symptom Manage. 2004; 27(6): 540-563.

Hassenbusch SJ, Portenoy RK: Current practices in intraspinal therapy—a survey of clinical trends and decision making. J Pain Symptom Manage. 2000; 20(2): S4-S11.

Bennett G, Serafini M, Burchiel K, et al.: Evidence-based review of the literature on intrathecal delivery of pain medication. J Pain Symptom Manage. 2000; 20(2): S12-S36.

Baxter AD, Laganiere S, Samson B, et al.: A comparison of lumbar epidural and intravenous fentanyl infusions for postthoracotomy analgesia. Can J Anaesth. 1994; 41(3): 184-191.

Siddik-Sayyid SM, Aouad MT, Jalbout MI, et al.: Intrathecal versus intravenous fentanyl for supplementation of subarachnoid block during cesarean delivery. Anesth Analg. 2002; 95(1): 209-213.

Pick CG, Roques B, Gacel G, et al.: Supraspinal mu 2-opioid receptors mediate spinal/supraspinal morphine synergy. Eur J Pharmacol. 1992; 220(2-3): 275-277.

Sheu R, Goloff M, Esteban S, et al.: Panic attacks after spinal cord stimulator implantation. A case report. Anesth Analg. 2006 (in press).