Comprehensive Consensus Based Guidelines
on Intrathecal Drug Delivery Systems in the
Treatment of Pain Caused by Cancer Pain
Authors: Deer Timothy R. 
Published: March 2021

Background: Chronic persistent pain as a result of terminal illness, either as a consequence of
the disease or the necessary treatment, is common in patients with cancer. For these patients with
moderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effective
option for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathy
and nociceptive pain in the cancer population. However, there is a scarcity of comprehensive
guidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer.
Objective: This article outlines consensus guidelines for the implementation of intrathecal therapy
in patients with cancer-related pain and other end of life states causing pain. We highlight the
multidisciplinary criteria that warrant careful consideration to ensure meaningful analgesia.
Methods: Evidence was compiled, ranked, and strength considered by an invited panel of wellpublished and innovative clinician research leaders in pain medicine. Based on that analysis, an
accumulation of evidence from observational and randomized prospective trials supports the use
of intrathecal (IT) drug delivery to provide effective analgesia for patients with cancer-related pain,
including individuals at the end of life. Although not all patients are candidates for this invasive
treatment modality, clinicians can determine the appropriateness of proceeding with device
implantation by carefully evaluating the individual’s overall medical status, psychological stability,
social support system, and prognosis of disease. Further, consumption of health care resources and
cost-effective treatment is becoming more of a priority; not only is this therapy appropriate medically,
but also economically. This multifaceted approach to patient selection assists in maximizing treatment
effect and avoiding unintended consequences of therapy.
Limitations: The limitations of these guidelines include that these are of expert panel guidelines.
The literature describes appropriate preparation of guidelines based on evidence derived from
randomized trials and systematic reviews. However, there is also value for consensus-based guidelines
due to non-availability of evidence from either systematic reviews of randomized trials or randomized
trials alone. In addition, the evidence is not available on many aspects of intrathecal infusion systems
even with observational studies and case reports. Thus, the present approach with expert consensus
guidelines is acceptable.
Conclusions: These consensus guidelines are intended to assist clinicians in identifying the
candidacy of patients with cancer-related pain and end of life diseases causing pain that may benefit
from intrathecal drug delivery. With careful consideration of the patient’s medical comorbidities and
prior therapies, communication with the oncologist, proper psychological evaluation, and appropriate
trialing technique, clinicians can effectively optimize the use of IT therapy for cancer pain. The panel
advocates for a much wider application of IT therapy to provide meaningful analgesia for patients
with cancer pain, including those at the end of life from a variety of causes.
Key words: Intrathecal, cancer, palliative, pain, guidelines, opioids, consensus, selection, evidence