Unique low-dose intrathecal opioid trial, still in need of a feasibility check.

462 www.painphysicianjournal.com To The ediTor: It is with great interest that we read the article by Grider et al, “Patient selection and outcomes using a low-dose intrathecal opioid trialing method for chronic nonmalignant pain”, published in the 2011 July/August issue of Pain Physician (1). We are much enlightened by the novel approach employed by the authors in conducting their intrathecal (IT) opioid trials. The novelty is that only a fraction of the opioid was utilized during their trials, after a preceding, gradual opioid tapering and a subsequent opioid-free period of 6 weeks. This is very different from neuroaxial trials by others reported in the literature (2). It appears that, as a result of this unusual approach, the authors were able to achieve satisfactory and persistent analgesia with only a minute dose of IT opioid, both during the trials and one year afterwards, without needing dose escalation in the permanent pumps. The timing of this article is also of significance because the utility of intrathecal opioid trials was seriously questioned. The recently published “Consensus guidelines for the selection and implantation of patients with noncancer pain” recommended reconsideration of the mandatory IT trial, based on the impression that the predictive value of trials was unsubstantiated, the absence of long-term efficacy, and the lack of demonstrated safety sufficient to outweigh trial risks, etc (3). Thus the panel recommended the decision, whether to conduct the trial or not, be left to the treating physician. Additionally, the panel recommended the development of a less expensive pump for IT trial, with a life span of 6-12 months, so that various agents could be tried, to better simulate IT therapy (3). Although the trialing method introduced by Grider et al (1) represents a revolutionary approach that seems to provide adequate analgesia with much lower opioid dosages, we wonder if it would be a pragmatic approach in our practice. Our concern is how feasible it is to wean patients off any opioid and keep them opioid free for 6 weeks, which was the prerequisite prior to the initiation of the low dose IT trial based on their protocol. Unique Low-Dose Intrathecal Opioid Trial, Still in Need of a Feasibility Check