1. Role of Intrathecal Polyanalgesia- Its Cost Impact and Role in Recapturing Pain Control Dr. Krishna Kumar, M.B., M.S., F.R.C.S. (C), F.A.C.S. Syed Rizvi Sharon Bishop BNurs., MHlthSci.

2. Practice is changing: increasing use of polyanalgesia Which patient groups require monotherapy vs polyanalgesia? When is the introduction of a second agent indicated? The cost implication of polyanalgesia and does it pay off with improved pain control? Objective

3. Study Design 110 patients Mean IDT duration: 94.2 months Chronic Pain: 81 Spasticity : 29 Males: 62 Females: 48 We present a retrospective study of 110 patients receiving IDT for treatment of spasticity and CNMP

4. IDT Drug Regimens Monotherapy: 110 patients 63: monotherapy 51: same drug 12: different drug 47: dual-drug admixture 36: dual-drug admixture 11: triple-drug admixture Avg 500 days Avg 240 days Avg 79 days 43% of patients require polyanalgesia

5. Relationship between IDT & Pain Type Nociceptive Monotherapy (morphine or hydromorphone) Mixed Dual-drug therapy (morphine or hydromorphone) + (bupivacaine or ropivacaine) Neuropathic + spasticity (± myclonus) Triple-drug therapy (fentanyl or hydromorphone) + baclofen + bupivacaine

6. Monotherapy- Morphine # of patients 20 20 16 13 12 10 9 7 Baseline

7. Dual-admixture dosage escalation eg. Hydromorphone+Bupivacaine Monotherapy # of patients 9 9 9 8 8 6 Mean dose per day In most cases, patients are able to reduce narcotic doses and restore effective pain control

8. Baseline Prior to initiating IDT patients were reporting high levels of pain

9. Trends in Polyanalgesia Prescribing trends have changed over time Patients implanted pre-2004 ▫Initiated dual-drug admixture at 28.01 months (average) ▫Avg. Time Diagnosis  IDT: 6.23 years COMPARED TO Patients implanted post-2004 ▫Initiated dual-drug admixture at 5.38 months (average) ▫Avg. Time Diagnosis  IDT: 4.56 years On average patients implanted post 2004 reported 30% better pain relief at the 5 year mark when compared to those pre 2004.

10. Subgroup Analysis: Pain Relief Monotherapy

11. Oral Analgesia: Post IDT 20 (18%) patients discontinued the usage of oral narcotics The remainder of patients used low dose oral narcotics daily to manage breakthrough pain: Typical: hydromorphone 4-7 mg BID Morphine IR 10 mg BID

12. hydromorph

13. Comparative Costs Conventional Pharmacotherapy Triple-drug IDT Dual-drug IDT Single-drug IDT At 10 years compared to monotherapy Dual-drug therapy: 27% higher cost Triple-drug therapy: 54% higher cost ARIMA (Autoregressive Intermediate Moving Average) model

14. Conclusion Over the longterm ▫IDT monotherapy is effective in 57% of cases ▫Dual drug admixtures were required in 33% of cases, triple drug admixtures in the remaining 10% ▫Polyanalgesia escalates the average daily cost (20- 200% depending on the drugs used) ▫Polyanalgesia is effective in restoring decay in pain control ▫It appears better results are achieved when polyanalgesia is initiated earlier in treatment planning (30% better pain control at 5yrs)