I recently attended the North American Neuromodulation Society (NANS) Meeting 2013, in Las Vegas, Nevada, held at the Mandalay Bay Resort. It was another amazing conference and I have much to report.
I was fortunate to attend the Intrathecal Pump Evaluation, Management and Refill Course on December 5th. This course had a fantastic lineup of speakers and very interesting topics. It was chaired by Dr. Lawrence Poree, who was also this year’s NANS annual meeting Co-Chair.
Dr. Poree was the first presenter. His topic, Past, Present and Future of IT Therapy and Pump Technology, was an overview of pump therapy, including a review of current implantable pumps on the market, drugs, PACC guidelines and clinical information. He opened the discussion with a slide showing a plane crash that occurred in San Francisco in 2013. It was a troubling image and I admit that, initially, I wasn’t sure how it would fit within the presentation. As he continued, however, it became abundantly clear that his discussion with regards to adverse events in implantable pump patients would focus on “Pilot” error, meaning physician error, and education.
Dr. Poree emphasized that treating patients with implantable pumps requires a significant amount of training and attention to detail. Innovation has brought forth many changes in the devices used to treat patients suffering from chronic pain. With this in mind, he presented a great review of the current pumps on the market, discussing the advantages and disadvantages in their varying designs. For example, he touched on differences between constant flow pumps and programmable pumps, stating that altitude can affect delivery rates in constant flow pumps more so than in programmable pumps. The physician must, therefore, be aware of how each type of pump operates under varying conditions and climates.
Dr. Poree also gave the audience an introduction to Prometra®, the FDA-approved pain pump by Flowonix™. This pump is said to be more accurate, but proves to be inconvenient during routinely scheduled MRI’s due to the simultaneous openings of its dual-valve system during the MRI process. This requires the physician to empty the pump before the procedure begins and refill the pump upon completion of the MRI. This process assumes that the pump has any medication left in it at all.
The discussion then turned to the medications utilized within the drug-delivery systems. The hot topic of late has been the debate between drugs that are FDA-approved and those that are off-label. As a compounding pharmacist who provides off-label medications for pain physicians across the United States, I was particularly curious to hear what a leader in the field of pain management had to say.
Dr. Poree touched on Medtronic’s warning letter regarding the use of off-label medications (more on this later), and their effect on the Synchromed II drug delivery system. He shared his personal experiences with these issues, telling the audience of a patient whose pump experienced motor stall due to the use of off-label medication. The pump was ultimately replaced. So, what did Dr. Poree do then? He filled the pump again with off-label medication. He asked that physicians NOT allow the warning to discourage them from using the best possible treatment. They must be aware, but not afraid, of the risks associated with off-label drug use. For me, this was a captivating statement.
In conclusion, Dr. Poree’s message was that doctors must become educated. Pilots receive rigorous training and log many hours of experience before being allowed to fly. Pain physicians utilizing sophisticated treatments such as those discussed at NANS must approach their work in similar fashion. Know the pumps, know the drugs, monitor the pumps, monitor the patients. Routine inspections of the pump device can and will help identify smaller issues before they develop into more serious problems. Finally, physicians must educate the patients. Don’t hide the truth. They trust you.