Pain Pumps

“The pain went from my mid-back all the way to the toes of both my feet, he recalls. I was in agony. I couldn’t work. I couldn’t do anything. I was basically just inhabiting my bedroom.”

Oral and injectable pain medications worked for a while, but eventually the medicines only put him to sleep, and even that was only for a couple of hours before he’d wake up in pain.

Etess searched for answers. He was on a daily cocktail of morphine and Demerol, but it wasn’t doing the trick. He didn’t want to go through life in a drug-fueled fog, but every doctor he visited told him nothing could be done about his condition other than continuing, or maybe tweaking, his drug regimen.

“I was 30, he recalls, and I thought, at the rate I’m going, I’m going to be dead before long from an accidental overdose.”

But Etess’ life would miraculously return to normal in 1993, when a doctor told him about an implantable pain pump.

When oral pain medications aren’t effective—or when their side effects are unacceptable—there is often another option. For more than 20 years, implantable pain pumps have brought relief to patients living with chronic pain. Etess participated in an early clinical trial.

An implantable pump delivers medicine to the exact site where it’s needed. It may sound like science fiction, but the way it works is actually quite simple. Mark Wallace, MD, professor of clinical anesthesia and director of the Center for Pain and Palliative Medicine at the University of California at San Diego, explains, “For pain signals to reach the brain, they have to travel through the spinal cord. In other words, the spinal cord is the gateway to the brain. Pain medications work by reaching the spinal cord, where they modulate or dampen the pain signals, thus reducing pain.”

Oral and injectable pain medications are systemic, meaning they travel throughout the body and may cause unwanted side effects that Dr. Wallace says may include “sedation, fatigue, constipation, dizziness, cognitive impairment and nausea.”

According to Dr. Wallace, implantable pain pumps may virtually erase those unwanted side effects. “By delivering pain medications next to the spinal cord, we use a fraction of the dose, resulting in better pain relief and fewer side effects. In a sense, we are putting the medication ‘where the money is,’” he says.

How Pain Pumps Work

The system consists of two components: a pump, which is programmed to regulate the precise dose and timing of drug release, and a catheter, the tip of which is placed into the intrathecal space (that is, the space inside the “thecal” lining of the spinal cord). In this way, the catheter, which Dr. Wallace says is “about the size of a thin spaghetti noodle,” delivers the medication to what doctors call the “site of action.” There, it interrupts the pain signal as it travels through the spinal cord, stopping it before it can reach the brain.

Here’s how the implant procedure works. First, Dr. Wallace explains, “The catheter is placed into the spinal canal percutaneously through a needle.” This is usually done using local anesthesia. Once the catheter is in place, local anesthesia can be injected into the catheter to numb the spine.

“A small incision is then made in the back in order to anchor the catheter, and the pump is implanted in the subcutaneous tissue of the lower abdomen,” continues Dr. Wallace. “The catheter is then ‘tunneled’ under the skin and connected to the pump.”

The operation to implant an intrathecal device usually takes an hour or two and typically results in a hospital stay of less than 24 hours. “It is considered a minor procedure that can be done on an outpatient basis,” says Dr. Wallace. “However, the doctor may elect to admit the patient overnight for observation when starting the pump.”

The physician programs the pump with an “electronic prescription,” so the amount of drugs delivered to the system is precise and carefully calibrated to each patient’s body.

In some cases, patients may get a handheld device (a remote) that allows them to control delivery of an extra dose of medication, if needed.

Hank Etess has one that he uses only if he needs a boost over the 24/7 continual flow of meds the pump delivers. He describes the device as being as simple to use as a garage door opener. “There’s one button to turn it on and another to give myself the medicine,” he says. “It couldn’t be easier.”

Refilling implantable pain pumps are typically simple and quick procedures, as well. Depending on the dose and concentration of medication, they are refilled every 30-90 days in about 15 minutes in a doctor’s office.

Are You a Candidate for a Pain Pump?

Pain pumps are never a first option, says Dr. Wallace. They’re to be considered only when other less invasive methods haven’t worked or when oral pain meds aren’t helping as they should. “The cost and invasive nature [of a pain pump] necessitate a careful evaluation to determine whether each individual patient is likely to achieve benefit,” says Dr. Wallace.

Before considering a pain pump implant, Dr. Wallace advises starting with the least invasive therapies, such as exercise, relaxation techniques and over-the-counter analgesics. Next steps may include prescription pain meds, physical therapy, psychological therapies and oral opioids.

More invasive therapies include spinal injections, nerve blocks and spinal cord stimulation. “The top tier of this treatment pyramid is reserved for the most invasive therapies, including pain pumps,” says Dr. Wallace.

People who suffer from chronic pain from failed back surgery or complex regional pain syndrome (CRPS/RSD) are candidates for a pain pump. Patients with phantom limb pain, chronic pancreatitis, chronic vertebral compression fractures and severe spinal degeneration may also be candidates, says Dr. Wallace.

People in the late stages of cancer may also benefit from an implantable pump. The pump allows for personal control over the amount of pain medication. Linnea Burman, marketing director for Medtronic’s targeted direct delivery division, says the pump may allow a patient with advanced cancer to “be more present at the end of life.”

“That’s the goal with pain pumps,” Burman says. “You should be able to go about your life.”

If you and your doctor determine that a pain pump may be right for you, you’ll first undergo a trial infusion of drugs to see how you respond and if you experience any unacceptable side effects. Dr. Wallace explains that a temporary catheter is inserted into the spinal column through a needle and then connected to an external pump that delivers the medication. After a successful trial of usually three or four days, the catheter is removed and the patient is scheduled for the implant at a later date.

Approved Implantable Pump Medications

Doctors have three FDA-approved medication choices for implantable pain pumps. Morphine has been available for the longest time in the United States. Baclofen is indicated for severe muscle spasms, (spasticity), which can be painful. Ziconotide, known by the trade name Prialt, is a newer drug that shows strong results. It earned FDA approval for intrathecal administration about seven years ago.

Ziconotide is a calcium channel blocker and has the advantage that it is not an opioid. Dr. Wallace says ziconotide is “an attractive alternative to morphine in the treatment of neuropathic pain,” also noting that “with any drug, the goal is always the lowest possible dosage.”

Similar to oral meds, medications that are not indicated for pumps but still are found to be effective after extensive research are used even without FDA approval.

More to Think About

Any surgical procedure comes with risks, including bleeding, infection, drug reactions and nerve damage. A patient with an active infection prior to surgery must be treated before the implant is performed. Additional risks associated with spinal procedures include headache and spinal fluid leaks.

There can also be complications with the device itself. The catheter could break or get a kink in it—just as a garden hose might—which can result in a drug underdose. Programming errors can result in drug overdoses, and an inflammatory reaction is possible at the catheter tip, which can cause spinal compression, possibly leading to paresthesia or paralysis.

Some complications could require a second surgery to repair, for instance, to replace or reposition the catheter. Talk to your doctor about the risks involved with pump therapy, and let him or her help you weigh the benefits and risks.

Dr. Wallace explains that people with certain conditions may have heightened risks with an implanted pain pump. People with diabetes and chronic infections (which increase the risk of infection of the pump), people using blood thinners (which can increase the risk of bleeding), and people with pulmonary disease such as sleep apnea need to discuss these existing conditions with their doctors when considering an implanted device.

Here’s a side benefit to pain pumps that many people don’t consider. An implantable pump allows people to reduce the amount of medicine in their home. Diversion of drugs (that is, people taking drugs that were prescribed for someone else) has become a big societal issue that the health care industry is heavily focused on. Burman calls it an “epidemic,” and notes that the pain pump is one step in reducing the chance someone will take a drug that was not prescribed for them.

The Freedom of Pain Relief

For Hank Etess, it’s an understatement to say the device has been life-changing. The judge who could barely leave his bedroom now has virtually no limits. “The only thing I can’t do is SCUBA dive at over 30 feet,” he says.

Not only is his pain manageable, but he’s been clear-headed since having the device implanted. “I have no sensation of being medicated,” he reports. What’s more, his device is nearly impossible to detect. Etess has even undergone physicals in which the doctor didn’t realize it was there.

Etess has common-sense advice for anyone considering an implant. “Remember, this is a three-way relationship,” he says, referring to the patient, the doctor and the pump. “The pump does what it’s told to do. But you need to have clear communication with your doctor. If you’re experiencing pain, speak up. The doctor can adjust your dosage. “Pain disrupts your whole life,” he says. “The pain pump gave me my life back. {PP}