What is the best way to relieve severe left upper quadrant pain in a person with pancreatic cancer unresponsive to morphine, radiation therapy, celiac plexus neurolysis, and ketamine infusion?

Intrathecal Drug Delivery System for Refractory Pancreatic Cancer Pain

For severe left upper quadrant pain from pancreatic cancer that has failed morphine, radiation, celiac plexus neurolysis, and ketamine infusion, an intrathecal drug delivery system (IDDS) is the recommended next intervention. 1

Rationale for IDDS Selection

The ESMO guidelines specifically indicate that intrathecal (IT) administration should be considered when patients have: 1

• Inadequate pain relief despite systemic opioid escalating doses (which applies to this morphine-refractory case)
• Non-effective response to switching the opioid or route of administration as well as when side effects increase with dose escalation
• Life expectancy >6 months justifies the implantable IT pump, but only after a trial using a temporary epidural or spinal catheter 1

Why Other Options Have Been Exhausted

Your patient has already failed the standard algorithmic progression: 1

• Celiac plexus neurolysis typically provides effective palliation in approximately 70% of patients 1, with pain relief lasting 3-6 months 1, but this has already failed
• Radiation therapy for pancreatic pain typically provides temporary relief in 40-80% of patients 1, but has been ineffective here
• Ketamine infusion has limited evidence for intractable pain 1 and has not provided relief in this case

IDDS Technical Approach

Intrathecal administration has the advantage of being less affected by the presence of extensive epidural metastasis. 1 The drugs most commonly used are: 1

• Morphine (first-line intrathecal opioid)
• Ziconotide (non-opioid calcium channel blocker for severe refractory pain)
• Baclofen (for muscle spasm component)
• Local anesthetics such as bupivacaine 0.125%-0.25% (can be combined with opioids)
• Subanesthetic doses of ketamine (limited evidence supports its use intrathecally for intractable pain) 1

Implementation Strategy

A trial using a temporary epidural or spinal catheter must be performed before implanting a permanent pump. 1 This allows assessment of:

• Efficacy of intrathecal analgesia for this specific pain syndrome
• Optimal drug combination and dosing
• Patient tolerance and side effects
• Whether the invasive approach is justified

Critical Caveats

Intraspinal techniques monitored by a skilled team should be included as part of cancer pain management strategy, but widespread use should be avoided. 1 This means: 1

• Referral to an interventional pain specialist or anesthesiologist experienced in IDDS is mandatory
• The technique requires ongoing monitoring and pump refills
• Infection risk and technical complications must be managed by experienced providers

Alternative Consideration

If IDDS is not feasible due to patient factors, very short life expectancy (<6 months), or lack of technical expertise, consider: 1

• Intrathecal phenol neurolysis for unilateral pain syndromes
• Cordotomy for unilateral pain
• Reassessment of systemic therapy with opioid rotation (e.g., switching to hydromorphone, fentanyl, or methadone) combined with adjuvants like gabapentin/pregabalin and tricyclic antidepressants for neuropathic components 2, 3

Contraindications to Monitor

Avoid IDDS if the patient has: 1

• Active infection or coagulopathy
• Very short life expectancy (weeks rather than months)
• Distorted spinal anatomy from metastases
• Patient unwillingness to undergo the procedure
• Medications that increase bleeding risk such as bevacizumab or other antiangiogenesis agents