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

INTRODUCTIONIntrathecal (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.METHODSThis 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%).RESULTSThe 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.CONCLUSIONThe 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.

01 Feb 2017·Neuromodulation: Technology at the Neural InterfaceQ2 · MEDICINE

The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines

Q2 · MEDICINE

Review

Author: Huntoon, Marc ; Bux, Anjum ; Perruchoud, Christophe ; Rosenberg, William S ; Prager, Joshua ; Kim, Philip ; Pope, Jason E ; Diwan, Sudhir ; Narouze, Samir ; Wallace, Mark S ; Jacobs, Marilyn S ; Eldabe, Sam ; Leong, Michael ; Buchser, Eric ; Willis, Dean ; Saulino, Michael ; Rauck, Richard ; Poree, Lawrence ; Rosen, Steven M ; McRoberts, Porter ; Staats, Peter ; Falowski, Steven M ; Deer, Timothy R ; Doleys, Daniel M ; Krames, Elliot ; Gazelka, Helena M ; Levy, Robert M ; McDowell, Gladstone ; Yaksh, Tony L ; Naidu, Ramana ; Mekhail, Nagy ; Stearns, Lisa J ; Hayek, Salim M ; DeLeon, Oscar ; Grider, Jay S ; Patin, Dennis ; De Andrés, Jose A ; Erdek, Michael

INTRODUCTIONPain treatment is best performed when a patient-centric, safety-based philosophy is used to determine an algorithmic process to guide care. Since 2007, the International Neuromodulation Society has organized a group of experts to evaluate evidence and create a Polyanalgesic Consensus Conference (PACC) to guide practice.METHODSThe current PACC update was designed to address the deficiencies and innovations emerging since the previous PACC publication of 2012. An extensive literature search identified publications between January 15, 2007 and November 22, 2015 and authors contributed additional relevant sources. After reviewing the literature, the panel convened to determine evidence levels and degrees of recommendations for intrathecal therapy. This meeting served as the basis for consensus development, which was ranked as strong, moderate or weak. Algorithms were developed for intrathecal medication choices to treat nociceptive and neuropathic pain for patients with cancer, terminal illness, and noncancer pain, with either localized or diffuse pain.RESULTSThe PACC has developed an algorithmic process for several aspects of intrathecal drug delivery to promote safe and efficacious evidence-based care. Consensus opinion, based on expertise, was used to fill gaps in evidence. Thirty-one consensus points emerged from the panel considerations.CONCLUSIONNew algorithms and guidance have been established to improve care with the use of intrathecal drug delivery.

28 Oct 2013·NeuroRehabilitation: An International, Interdisciplinary JournalQ4 · MEDICINE

Neuropsychological and neuroanatomical sequelae of chronic non-malignant pain and opioid analgesia

Q4 · MEDICINE

Review

Author: Block, Cady ; Cianfrini, Leanne

Background: The pervasive disease of chronic pain is a common challenge for the clinical rehabilitation professional. Concurrent with physical and emotional symptoms, pain-related cognitive impairment has been reported. Although opioid analgesics are frequently prescribed, concern exists that opioids possess adverse cognitive effects of their own. Objectives: To review the neuropsychological and neuroanatomical sequelae of chronic non-malignant pain and opioid therapy, to clarify roles and benefits of neuropsychological assessment in a chronic pain population, and to provide recommendations for clinical practice and future research. Methods: This non-systematic review sought to provide a comprehensive synthesis of relevant neurobiology, neuroimaging, neuropsychological, and rehabilitation research literatures. We included citations from seminal and current texts as well as relevant original and review articles from 1980–2012 in PubMed and PubMedCentral online research databases. Discussion and summary/conclusions: To date, evidence from opioid studies suggests only mild deficits in specific cognitive domains (e.g., memory, attention/concentration) and only under specific conditions (e.g., dose escalations). Additionally, neuroimaging and neuropsychological evidence suggests that pain itself results in cognitive sequelae. Methodological improvements in future research will allow for better delineation of the contributing effects of pain and opioids, with an overall goal of improving evidence-based clinical treatment recommendations.

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