title: Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients.
abstract: OBJECTIVE
  The purpose of this study was to examine the effect of intrathecal (IT) coadministration of bupivacaine with opioids during the initial phase of opioid titration and up to 1 year after implantation of an IT drug delivery system (IDDS).
  
  
  METHODS
  The study was designed as a retrospective study. OUTCOMES ANALYZED: The outcomes analyzed for this study were pain relief, oral opioid consumption, IT opioid, and bupivacaine dosage. METHODS AND PATIENT POPULATION: The patient population for this study were consecutively implanted patients over a period of 6 years in a tertiary single center with multiple practitioners. In this retrospective study, 126 consecutive noncancer intractable pain patients were implanted with IDDS and initiated with an IT opioid (O) as a single medication or an IT opioid and bupivacaine (O + B). Pain intensity, amount of oral opioids, dose, rate, and concentration of IT opioids and bupivacaine, and number and type of IT medication used were recorded at preimplant, implant, and at 3, 6, and 12 months postimplant.
  
  
  METHODS
  The intervention used for the study was the IT delivery device implant.
  
  
  RESULTS
  Significant reduction in pain intensity was observed in both groups at 12 months postimplant (O group: baseline 7.42 ± 2.1 to 5.85 ± 2.8 [n = 72, P < 0.001]; O + B group 7.35 ± 2 to 5.03 ± 2.4 (n = 54; P < 0.001]). The combination of opioids with bupivacaine from the start of IT infusion treatment resulted in a reduced progression of opioid dose escalation in comparison to patients started with opioids (O group). The rate of increase of IT opioids in the O group at 12 months was 535 ± 180%, whereas in the O + B, the dose increase was significantly lower at 185 ± 85% (P < 0.004). In both groups, there was a statistically significant decrease in oral opioid consumption compared with preimplant doses.
  
  
  CONCLUSIONS
  Concomitant initial coadministration of IT bupivacaine with opioids blunts the rate of IT opioid dose escalation during the first year after implant of an IDDS. More studies are necessary to thoroughly examine IT opioid dose escalation and the effects of addition of bupivacaine to IT opioids. Blunting IT opioid dose escalation may be a beneficial long-term effect of IT bupivacaine.
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio 44106, USA.
authors.forename: I Elias
authors.initials: IE
authors.lastname: Veizi
authors.forename: Salim M
authors.initials: SM
authors.lastname: Hayek
authors.forename: Samer
authors.initials: S
authors.lastname: Narouze
authors.forename: Jason E
authors.initials: JE
authors.lastname: Pope
authors.forename: Nagy
authors.initials: N
authors.lastname: Mekhail
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000627:therapeutic use*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000627:therapeutic use*; D002045:Bupivacaine / Q000008:administration & dosage / Q000627:therapeutic use*; D059350:Chronic Pain / Q000188:drug therapy*; D002986:Clinical Trials as Topic; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D002045:Bupivacaine