Devices or Care for Cancer Pain Management?

To the Editor The analysis of a prospective, multicenter product surveillance registry of intrathecal drug delivery systems (IDDSs)1 raises concerns about the underlying assumptions of need and the interpretation of data. The fact that cancer pain remains undertreated due to lack of adherence to guidelines does not imply such guidelines do not work; rather it is necessary to spread the knowledge regarding the use of opioids. The 3-step approach, improved by optimal use of opioids and tailored treatment, resolves most cancer pain issues, even in difficult cases. Thus, the bad examples should be not used to promote something other. The increased scrutiny of long-term systemic opioids used triggered by the opioid epidemic in the United States does not support the use of implantable techniques. Appropriate use by skilled professionals is a warranty for minimizing this risk. Is the statistically significant reduction in pain intensity from 6.6 to 5.5 clinically relevant? To most clinicians and patients, this would be considered a failure corresponding to evitable and prolonged suffering. The minimal clinically important difference should be of at least 2 points or <33%.2 Regarding data on quality of life on 41 available patients in a population with a median survival of 3 months, an incalculable number of reasons, other than pain, profoundly influence the quality of life. In very conservative settings, as deduced by the low opioid dose escalation after 1 month of treatment (mean dose of 32 mg of oral morphine equivalents), pain intensity decreased from 6.1 to 2.6.3 The outcome obtained with such low level intensity of care raises the question of why or when an IDDS would be considered in a treatment plan. Finally, what is intractable pain? Is it just a state of pain intensity, regardless the level of analgesic treatment, or after “optimization” of opioid therapy according to the “best” palliative care (pain does not live alone!)? I published a case of a patient treated with an intrathecal pump unsuccessfully that was resolved with simple therapeutic measures … by telephone.4 Sebastiano Mercadante, MDMain Regional Center for Pain Relief and Palliative/Supportive CareLa Maddalena Cancer CenterPalermo, Italy[email protected]; [email protected]