For patients with severe chronic pain who have had inadequate analgesia from more conservative therapies, ziconotide may be preferred as first-line intrathecal therapy for those without a history of psychosis or allergy, a new review article published in Pain Practice stated.

Intrathecal therapy is intended for patients who have not achieved adequate pain relief from therapies such as physical therapy, systemic opioids, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, and anticonvulsants. Jason E. Pope, MD, from Summit Pain Alliance, Santa Rosa, CA, and colleagues reviewed the appropriate use of intrathecal therapy for managing severe chronic pain. 

Currently, 2 drugs are approved by the Food and Drug Administration for intrathecal analgesia, 1) ziconotide, a non-opioid, selective N-type calcium channel blocker and, 2) preservative-free morphine. Both chronic intrathecal therapy and systemic opioid therapy “have inherent risks and should be thoroughly compared.” Long-term use of high-dose oral opioids is linked to known risks of overdose, fractures, addiction, intestinal blockages and sedation. 

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For the review, the Polyanalgesic Consensus Conference (PACC) convened an expert panel to discuss various topics such as patient selection, trialing, dosing and titration, adverse event profiles, long-term management, intrathecal therapy for cancer-related pain, and the placement of intrathecal therapy in the pain care algorithm. The PACC guidelines also recommend other first-line intrathecal agents such as morphine + bupivacaine for neuropathic pain, and hydromorphone or fentanyl for nociceptive pain. 

Dr. Pope and his team found that intrathecal therapy can offer substantial pain relief with improved functioning and quality of life in appropriately selected patients. For example, as the medication’s potency is significantly enhanced when converting from systemic to intrathecal delivery, patients in whom high-dose systemic opioid medications have failed to provide adequate pain relief should be considered for non-opioid ziconotide therapy.

Continued patient monitoring for changes in efficacy and adverse events, changes in dosing and titration, use of adjuvant intrathecal agents and oral therapies, are needed for successful long-term pain management. With clinical concerns regarding the risk of overdose, granuloma, and other opioid-induced complications, treatment with the non-opioid ziconotide may be a preferred first-line option, the authors concluded. 

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