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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

Management of Intrathecal Therapies by Interprofessional Teams

Inside the expanding roles of PAs, RNs, and NPs in quality pain management, using IT drug delivery as an example.

Background — Due to a shortage of physicians in the United States, many other types of healthcare professionals have filled this gap.1 Today’s interprofessional team-based practice often includes physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) working together to enhance quality of care. As of 2013, there were an estimated 200,000 PAs/NPs in clinical practice,2 and as of 2010, there were 2.8 million RNs, in the US.3 Historically, PAs have focused on primary care needs, but the latest estimates reveal that 72% of PAs now practice in specialty areas of medicine,4 and RNs now have the ability to earn certification for pain management nursing. Recognizing this expanding role, specifically in pain management,5 the authors attempt to further describe these professionals’ roles in pain-management teams, using advanced pain therapy via intrathecal drug delivery as an example.6

Physician Assistants and Nurse Practitioners commonly participate in the total care of the intrathecal (IT) pump patient, including initial patient assessments, treatment formulations, medication and procedural management, and ongoing monitoring. Functioning under orders, Registered Nurses are directly involved in IT pump management, programming and refills, ongoing patient assessment, and psychosocial management of the patient. In a high-functioning interprofessional team, each provider type practices at the top of their professional licensure and seamlessly collaborates for greater patient access and care. IT drug delivery serves as an excellent example of how such team-based practice may be coordinated to deliver optimal care.

Patient Selection

Intrathecal drug delivery systems offer an important management option for patients with chronic refractory pain. Refractory chronic pain exists when:

  • “multiple evidence-based biomedical therapies used in a clinically appropriate and acceptable fashion have failed to reach treatment goals that may include adequate pain reduction and/or improvement in daily functioning or have resulted in intolerable adverse effects;” and when
  • “psychiatric disorders and psychosocial factors that could influence pain outcomes have been assessed and appropriately addressed."7

The administration of medications in the IT space may offer several advantages over other medication delivery methods for chronic pain. All medications, and medication delivery methods, must balance efficacy with safety and tolerability. IT administration for some patients provides an improved balance of efficacy, generally achieved at a considerably lower dose and, in turn, improved tolerability.8 Clinical practice guidelines produced by the Polyanalgesic Consensus Conference (PACC)9 include considerable evidence-based medical recommendations to assist all provider types in delivering safe and effective IT therapies. These guidelines focus of the provision of intrathecal medications, rather than the composition of the treatment team.

To start, successful IT therapy revolves around patient selection.10 A variety of factors must be considered by the therapy team, including the patient’s pain-related diagnosis, mental health status, economic factors, social support system, and the ability for the patient to adhere to their requirements for post-operative care and IT system maintenance.11 Patients should also have reasonable therapeutic expectations for pain relief, functionality, and overall quality of life with IT therapy.11

Often, a mental health specialist may conduct a preliminary evaluation with a specific focus on psychopathology and substance use disorders. Life expectancy is an important factor in the depth of psychological assessments as well.12 Concurrently, certain health payors have specific pre-IT therapy requirements that must be met to obtain coverage. The PACC guidelines provide additional details regarding factors that may influence patient selection.

Overall, many practices may rely on the interprofessional team when making final decisions about patient selection. The collaboration of physicians, PAs, NPs, and RNs is crucial given the complexity of this patient population and its circumstances.

Dose Trialing

Intrathecal dose trialing frequently follows patient selection. Although controversial, the objectives of IT trialing are to evaluate a patient’s potential response and tolerability to spinally administered medication prior to surgical implantation of the drug delivery pump. The trialing period offers a valuable time for assessing allergic or untoward reactions to selected IT medications.13 The amount of medications and trialing methods available have increased considerably since advanced drug delivery pumps were developed in the late 1980s.14

Debate continues to exist among healthcare professionals regarding which medications may be optimal for a trial (eg, morphine, ziconotide, or medication admixtures).13 Furthermore, there is limited data on the predictive value of long-term treatment outcomes based on IT trialing.13 The PACC guideline serves as an excellent reference for additional trial details.13

Medication Selection

The PACC guidelines also provide recommendations for IT medication selection and dosing. Both morphine and ziconotide are recommended first-line options for either neuropathic or nociceptive pain, including localized or diffuse pain, and cancer- or noncancer-related pain.15 The medication selected for long-term treatment may or may not necessarily be the same medication administered during an IT trial. It is common for additional medications to be provided off-label with IT therapy.9

Team members must be knowledgeable about these distinctions. Their collaboration is particularly useful in determining which therapeutic options to select for improved outcomes.

Patient Education & Post-Op Care

Comprehensive patient education is another vital component of successful IT patient selection, trialing, and pump management. Throughout the process, a team model of care often relies upon PAs, NPs, and RNs to help patients establish reasonable and realistic expectations.16 Patients must understand that IT therapy is an advanced pain management tool, rather than a disease-modifying treatment or cure for their underlying condition. Additionally, patients selected for IT are rarely pain-free,16 and this type of drug delivery carries additional surgical risks, medication risks, and device related risks.17,18

Post-operative wound care and medication titration is often managed by PAs, NPs, and RNs, including the medical, technical, and psychosocial aspects of the therapy. Responsibilities range from medication selection, medication dose, refill procedures, the workup of system malfunctions, and patient tracking in the event of community disasters. Team communication is key as multiple healthcare professionals become increasingly responsible for IT patient care. The healthcare professionals involved must be cognizant of proper care techniques, risks, and management strategies for potential complications, regardless of the team member providing the initial service.


Physicians – in collaboration with physician assistants, nurse practitioners, and registered nurses – frequently represent the front-line workforce within a pain specialty practice managing intrathecal therapy. Additional professionals (eg, pharmacists, psychologists, and physical therapists) may be involved as well to enhance total biopsychosocial care. As a result of these multidisciplinary teams, patient improvements in quality of life, functionality, and pain relief are frequently enriched.19

IT therapy represents just one area within pain practice in which team members may serve a variety of growing roles. While the physician may conduct the IT trial and implant, PAs, NPs, and RNs often provide follow-up treatment, patient education and monitoring, and technical care of the pump, including the management of any complications. While many permutations of team-based care exist in today’s healthcare system, the implementation of evidence-based treatment guidelines (eg, PACC) are likely to be most successful when the expertise of the team is optimally supported and strong communication exists among all members.

Last updated on: April 12, 2019
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Intrathecal Drug Therapy for Cancer-Related Pain
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