Patient Optimization for IDD

The section on “Patient Optimization for IDD” emphasizes the importance of psychological screening for patients undergoing Intrathecal Drug Delivery (IDD), particularly for those with chronic non-cancer pain. Psychological factors play a critical role in the long-term success of IDD therapy, and thus preoperative psychological assessment has become a standard practice for these patients^15,16.

Key points include

• Psychological evaluations are recommended for all non-cancer, non-terminal pain patients but not mandatory for cancer or end-of-life patients.

• Evaluations should be conducted by trained mental health professionals, and counseling or aftercare should be provided when necessary ^4-12.

• Recent studies on Spinal Cord Stimulation (SCS) have identified several psychological predictors of poor outcomes, including depression, sleep interference, substance abuse, trauma history, and more ^{17, 18, 19, 20, 21, 22}.

• A new scored Psychological Evaluation Tool has been developed to better predict SCS outcomes ²³.

• A recently created e-health tool helps assess patient eligibility for SCS based on clinical and psychological factors ^{24, 25}.

• The COVID-19 pandemic introduced challenges but also increased the use of telehealth, making assessments more accessible ²⁶. However, live evaluations are still recommended until further data on telehealth effectiveness is available.

Consensus Point 1: Psychologic evaluation, preferably by a trained and experienced psychologist, is indicated when considering IDD for nonterminal/non–cancer-related chronic pain. USPSTF grade B; level of certainty moderate; evidence level IB.

Optimizing Current Medications

• Systemic opioid reduction or elimination before or after IDD implantation is recommended for patients who are not achieving acceptable pain relief, developing tolerance, or experiencing intolerable side effects from opioids ^{11, 12}.

• Long-term use of systemic opioids for non-cancer pain is questioned due to lack of evidence supporting effectiveness and associated dose-dependent risks ^{28, 29, 30, 31, 32, 33, 34, 35}.

• Recent research explores interventions for opioid tapering, such as group-based self-management programs and cognitive behavioral therapy (CBT). Studies indicate that these interventions can help patients reduce opioid use but may not significantly improve pain or function scores ^{36, 37, 38, 39, 40, 41, 42}.

Consensus Point 2: When considering IDD for nonterminal/ noncancer chronic pain, opioid reduction should be attempted by clinicians. USPSTF grade B; level of certainty moderate; evidence level II.

Reduction or Elimination of Adjunctive Medications

• Adjunctive medications (e.g., antidepressants, anticonvulsants) can complicate IDD therapy, especially with intrathecal ziconotide exposure, which may increase adverse events ^{44, 11}.

• Depression is common among patients with chronic pain, making a multidisciplinary approach crucial for managing comorbidities ^{45, 46}.

• Medication discontinuation should be balanced against the risk of worsening psychiatric or neurologic conditions.

Consensus Point 3: When considering IDD, the discontinuation of antidepressant or anticonvulsant medications should be balanced against the risk of exacerbating preexisting psychiatric or neurologic illness. USPSTF grade B; level of certainty low; evidence level II.

Non-medication Strategies

• IDD provides targeted analgesia but may not always improve physical or emotional functioning. Functional impairments (e.g., muscle weakness, limited range of motion) should be addressed using rehabilitation strategies, including physical therapy ^{47, 48}.

• A biopsychosocial approach should be used to optimize overall health, including nutrition, weight loss, and smoking cessation, which can help improve chronic pain management ^{49, 50, 51, 52}.

Consensus Point 4: When considering IDD, clinicians should attempt to optimize patient health and functional status. USPSTF grade B; level of certainty low; evidence level II.

On- and Off-Label Use of Intrathecal Drugs

• The FDA acknowledges that off-label medications may be needed for some patients but advises caution due to increased risks such as pump failures or dosing errors ⁵³.

• Off-label medications are commonly used in IDD, with high prevalence in both non-cancer and cancer pain patients ^{54, 55, 56}.

• Adherence to sterile compounding standards is critical when using off-label drugs to ensure safety ^{57, 58}.

Consensus Point 5: Decision-making on intrathecal drug use should be guided by both labeling in the jurisdiction of practice and by evidence and consensus guidance in the PACC documents. USPSTF grade A; level of certainty high; evidence level II.

Consensus Point 6: If off-label medications are used, strict adherence to sterile compounding procedures should be followed. USPSTF grade A; level of certainty high; evidence level II.