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

Opioid Toxicity

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

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

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

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

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

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

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)

Thank You Any Questions