Patient Selection

Intrathecal medication therapy for pain management should be considered for patients for whom treatment with oral opioids failed owing to lack of efficacy or intolerable side effects if, in addition, they have a life expectancy of greater than 3 months and good cerebrospinal fluid (CSF) circulation. In general this intervention should be reserved for patients whose pain syndrome is considered to be chronic. Drug administration systems are not indicated for acute pain. Chronicity may be defined in terms of pain lasting longer than 3 or 4 months and inadequately relieved by standard medical management19 or as pain present more than a month beyond a normal expected healing time for the diagnosis.

In cases of malignant disease, pain expected to last longer than 3 months may be considered to be chronic. The indication for the use of a drug administration system then includes the treatment of chronic pain of nonmalignant origin and chronic cancer-related pain.

Patient selection is further refined by pain type. There are three specific pain types with characteristic symptoms. Table 15.1 lists the symptoms of the visceral nociceptive pain, somatic nociceptive pain, and neuropathic pain types. Nociceptive pain is pain mediated by receptors widely distributed in cutaneous tissue, bone, muscle, connective tissue, blood vessels, and viscera. These are classified as thermal, chemical, and mechanical according to the stimulus that activates them. Neuropathic pain is elicited by damage to the peripheral, central, or

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