Chronic nonmalignant
pain, persisting more than 6 months, affects 15%-30% of the United States population. The majority of
chronic pain patients respond to a combination of physical modalities and
non-opioid analgesics. However, approximately 20% do not derive sufficient
pain relief from traditional measures (back
surgery, oral drugs, etc.). An additional percentage of patients do not achieve a favorable balance between
analgesia and side effects with systemic
opioid therapy. For these patients, intraspinal delivery of
opioids may improve
pain relief, reduce suffering, and enhance quality of life and functional ability. Patient selection is a significant determinant of the success of this approach. Because
pain is a biopsychosocial phenomenon, psychological and social assessment are essential along with adequate trials of
opioid responsiveness. There are several valid approaches to conducting trials of intraspinal
pain therapy including epidural and intrathecal trials. Other important issues concern trial length, the utility of placebo trials, and
drug selection in cases where
morphine alone provides insufficient
analgesia.