1. OPIOID TOXICITY AND SPINAL ANALGESIA
By Jennifer Gray
Specialist Clinical Pharmacist
Neurosurgery, Pain and Palliative Care
Ninewells Hospital
24/09/18

2. Opioid Toxicity

3. Signs of Opioid Toxicity
Respiratory Depression
Decreased level of consciousness
Pin point pupils
Seizures
Muscle spasms

4. Strategies to avoid opioid toxicity
Opioid avoidance/sparing
Utilise non-pharmacological interventions
Utilise non-opioid medications
Opioid rotation – attempt to find right drug
Spinal analgesia
Other interventions
Nerve blocks
Neuro-ablative procedures e.g. Cordotomy

5. Background
Intrathecal Drug Delivery is a method of giving medication directly into the spinal cord.
It’s an option when most other treatment options have failed
As the medications are delivered directly into the spinal cord, symptoms can be controlled with much smaller doses than would be required orally
Side effects are reduced
It is an unlicensed product
As intrathecal bipasses the path that oral medication takes through the body
Roughly 1/300 the amount of oral medication reqd
Medications are released slowly over a period of time

6. The Patient
Patient requires to be relatively fit prior to procedure (e.g. no infections and blood counts satisfactory)
Improvement in pain and quality of life is the end goal
Other Analgesia will be stopped or reduced prior to insertion
Patient is followed up by the chronic pain team every month

7. The Team Palliative Care Consultant(s) Pain Consultant(s) Neurosurgeon
Palliative Pharmacist
Palliative Technician
Aseptic Pharmacist
Who is involved in the process

8. Medications Commonly Used
Hydromorphone – Is a potent opioid with increasing intraspinal “off-label” use to treat cancer and non-malignant pain. Side effects are less common compared to morphine
Clonidine – Is an a2 Agonist that enhances the analgesic affect of the opioid. It is often effective for neuropathic pain. Side effects include hypotension and sedation
Levobupivicaine /Bupivicaine – Is a sodium channel blocker used as an anaesthetic. Side effects include motor weakness and urinary retention
Medications Commonly Used
Commonly used for palliative patients
May also have heard of baclofen pumps

10. Ordering
Order product from ITH Pharma (company that specialises in the provision of aseptic compounding services for all therapy areas)
Manufacturing and delivery is roughly a one week process
They request a copy of the prescription
Product is labelled for the patient specifically with name and CHI
The cost is around £400 per syringe
Monday – Friday Service (no orders to ITH Pharma out with this time)

11. Thank You Any Questions