Use of intrathecal bupivacaine in refractory chronic nonmalignant pain.

OBJECTIVE To demonstrate the efficacy and safety of the addition of bupivacaine in restoring pain control and improving quality of life and activity level in patients with chronic nonmalignant pain refractory to intrathecal opioids. DESIGN Retrospective study. SETTING Outpatient clinics. PATIENTS Seventeen patients with inadequate pain relief while receiving intrathecal opioids alone. Interventions. The intrathecal opioid dose was held constant at 14.19 mg/day following the addition of bupivacaine. The initial bupivacaine dose was 2.08 mg/day and 4.83 mg/day at final follow up. OUTCOME MEASURES Pain relief, activity, depression, and quality of life were measured by the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), EuroQol 5D (EQ-5D), and Short Form 36 (SF-36), respectively. Reduction in oral medication use, return to employment, and device-related complications were also analyzed. Outcomes were evaluated prior to pump implantation, before the addition of bupivacaine (baseline), and every 6 months thereafter. RESULTS Seventeen patients were followed for 29.60 +/- 19.01 months. The average pain reduction measured by the VAS was 32.2%. The ODI improved 19.1%; BDI improved 17.9%; EQ-5D improved by 0.56; and the SF-36 showed statistical improvement in six of eight domains. Mean oral/transdermal opioid use reduced from 49.01 mg/day to 23.02 mg/day and oral non-opioid medications reduced from 2.2 classes to 1.0 class after the addition of bupivacaine. Two additional patients returned to work. No neurological sequelae resulted from adding bupivacaine. CONCLUSIONS The addition of intrathecal bupivacaine restores pain control, improves activity level, quality of life, and mental health in this patient group.