title: The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy.
abstract: BACKGROUND
  Intrathecal (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.
  
  
  METHODS
  This 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%).
  
  
  RESULTS
  The 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.
  
  
  CONCLUSIONS
  The 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.
authors.affiliation: Center for Pain Relief, Charleston, WV, USA.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Deer
authors.affiliation: Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Salim M
authors.initials: SM
authors.lastname: Hayek
authors.affiliation: Summit Pain Alliance, Santa Rosa, CA, USA.
authors.forename: Jason E
authors.initials: JE
authors.lastname: Pope
authors.affiliation: Mayo Clinic, Rochester, MN, USA.
authors.forename: Tim J
authors.initials: TJ
authors.lastname: Lamer
authors.affiliation: Virginia Commonwealth University Spine Center, Richmond, VA, USA.
authors.forename: Maged
authors.initials: M
authors.lastname: Hamza
authors.affiliation: UK HealthCare Pain Services, University of Kentucky College of Medicine, Lexington, KY, USA.
authors.forename: Jay S
authors.initials: JS
authors.lastname: Grider
authors.affiliation: Delaware Valley Pain & Spine Institute, Chalfront, PA, USA.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Rosen
authors.affiliation: Western Reserve Hospital, Cuyahoga Falls, OH, USA.
authors.forename: Samir
authors.initials: S
authors.lastname: Narouze
authors.affiliation: Hôpital de Zone Morges, Morges, Switzerland.
authors.forename: Christophe
authors.initials: C
authors.lastname: Perruchoud
authors.affiliation: Basildon and Thurrock University Hospitals FHT, Essex, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Thomson
authors.affiliation: Hunter Pain Clinic, Newcastle, NSW, Australia.
authors.forename: Marc
authors.initials: M
authors.lastname: Russo
authors.affiliation: Neurovations Clinical Research, Napa, CA, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Grigsby
authors.affiliation: Doleys Clinic, Birmingham, AL, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Doleys
authors.affiliation: California Pain Medicine Center, Los Angeles, CA, USA.
authors.forename: Marilyn S
authors.initials: MS
authors.lastname: Jacobs
authors.affiliation: MossRehab, Elkins Park, PA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Saulino
authors.affiliation: The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Christo
authors.affiliation: Bryn Mawr Hospital, Bryn Mawr, PA, USA.|Christiana Hospital, Newark, DE, USA.
authors.forename: Philip
authors.initials: P
authors.lastname: Kim
authors.affiliation: Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: Elliot Marc
authors.initials: EM
authors.lastname: Huntoon
authors.affiliation: Pacific Pain Treatment Center (ret.), San Francisco, CA, USA.
authors.forename: Elliot
authors.initials: E
authors.lastname: Krames
authors.affiliation: Cleveland Clinic, Evidence-Based Pain Management Research, Cleveland, OH, USA.
authors.forename: Nagy
authors.initials: N
authors.lastname: Mekhail
mesh_terms: D000700:Analgesics / Q000008:administration & dosage*; D016503:Drug Delivery Systems / Q000592:standards*; D006801:Humans; D007278:Injections, Spinal / Q000379:methods / Q000592:standards*; D010146:Pain / Q000188:drug therapy*
chemical_list: D000700:Analgesics
keywords: Cancer; guidelines; intrathecal drug infusion; noncancer; pain; review; trialing