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Ziconotide: A rapid detoxification protocol for the conversion from intrathecal morphine–The Raffaeli Detoxification Model

William Raffaeli, MD, Donatella Righetti, MD, Donatella Sarti, PhD, Marco Balestri, MD, Isabella Ferioli, MD, Maria Cristina Monterubbianesi, MD, Alessandro Caminiti, MD


Objectives: To assess the efficacy and the safety of our rapid detoxification protocol in preventing signs and symptoms of withdrawal and pain severity.
Design: Prospective, open-label case series study.
Settings: Public primary care at the Pain and Palliative Care Unit of the Infermi Hospital of Rimini, Italy.
Patients: The authors studied 10 consecutive patients suffering from chronic noncancer pain who were refractory to intrathecal (IT) morphine, and hence indicated for ziconotide therapy.
Interventions: IT pump was refilled with saline solution, and each patient received endovenous morphine, oral clonidine, ketoprofen, and lorazepam for the first 3 days, and slow-release tramadol, oral clonidine, and ketoprofen for 10 days. Ziconotide therapy was started at the end of the 2-week detoxification treatment.
Main outcome measures: The observer-rated opioid withdrawal scale (OOWS) was used for the assessment of withdrawal signs, visual analogue scale was used for pain intensity assessment, and also adverse events were recorded.
Results: Withdrawal symptoms were experienced by 3 patients (30 percent). Their average OOWS decreased significantly (p < 0.05) from 4.3 ± 2.5 to 1.7 ± 0.6 at days 3 and 14 of protocol, respectively, with no increment of pain intensity. Withdrawal symptoms were resolved in 4 days on average without the need of adjuvant medications. One patient with high morphine dosage (20 mg/d), interestingly, did not show any withdrawal symptoms.
Conclusions: The detoxification protocol was effective in preventing withdrawal signs without increasing pain severity, allowing to rapidly convert IT morphine to ziconotide monotherapy in patients who are refractory to morphine.


opioid, detoxification, ziconotide, intrathecal therapy, abstinence symptoms

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