When Should Epidural or Intrathecal Medications and Pumps Be Considered for Pain Management?

Most patients can achieve satisfactory pain control and tolerable side effects with the standard WHO Three-Step Analgesic Pain Ladder, which increases medication potency and dosages until pain relief is achieved. However, some patients simply cannot tolerate systemic pain medications regardless of route, because of (1) unacceptable side effects like sedation or delirium, or (2) refractory pain, meaning they never achieved adequate pain control, even with dose escalation. The number of patients who do not achieve satisfactory pain control varies from 10% to 20% and is likely dependent on who inquires about the patient’s pain, the patient’s expectations, and the level of attention paid to medication side effects. For those who are prescribed a pain regimen that follows the WHO recommendations and do not find relief, the question remains about what to do for them. For some patients, pain relief using peripheral nerve blocks may be an option, but others may benefit from neuraxial (intrathecal or epidural) administration of medication. For this group of patients, intrathecal (IT) and epidural catheter infusions may be a viable option, but should be considered based on current evidence. The use of epidural (alongside the epidural sac, with diffusion across the dura into the spinal fluid) and IT (intrathecal, with the catheter within the subarachnoid space and medication delivered directly to the cerebral spinal fluid) therapy can be a significant help to patients with refractory pain and/or unsatisfactory side effects, improving pain control, decreasing systemic toxicities of analgesic medications, and possibly prolonging survival. IT medication delivery has been shown to be effective for end-of-life care, cancer pain, and nonmalignant pain. Advantages of IT medication administration include lower doses of medications and fewer catheter migration issues.