Cancer is a killer and everyone knows it. What probably few realize, unless they have seen one of their loved ones during their last days of cancer is how the inexorable pain sap away the last bit of life and energy and vestiges of dignity from them. Intrathecal drug delivery is a treatment modality that is not one that offers “cure” from Cancer, but one that“comforts” the patient with pain.
Everyone has probably heard of Morphine and chances are that it is for the wrong reasons. It’s addictive property has been highlighted disproportionately and the palliative care community is only now seeing the fruits of its advocacy bearing fruit with increased availability for the ones who need it.
Morphine and other pain killers can be directly administered to the fluid around the spinal cord by a catheter placed into the spine – a modality called Intrathecal drug delivery.A pump is placed in the abdominal wall which can be programmed to deliver doses of medicine continuously or when required by the patient, or by a combination of the two. The dose can be programmed in such a way to deliver more during the waking hours and less at night. Such sophistication, tailored to the patient’s need is truly a boon.
Apart from morphine, a combination of local anaesthetics, clonidine, baclofen, ziconotideetc have all been used in patients suffering from Chronic Pain. When compared to the Oral Morphine dosage, only 1/100 the dose is needed to be administered intrathecally. When we use a combination of other medicines, the effect is a further reduction in the dose of each medicine taken in isolation, thereby reducing the side effects further.
So, if all this is hunky dory, why is it that this modality has not taken off in a big way?
1. Lack of awareness: I refer not only the lack of awareness of the patients or their caregivers, but the lack of awareness among the doctors treating the patients with cancer. All it would require is to see the significant drop in pain scores and the comfort of the patient during the last days of life for them to be convinced! Once the curative treatment options like surgery, radiotherapy and chemotherapy have been tried and failed, the physician will do well to think of the palliative procedures like this which may help his/her patient.
2. Lack of importance: the patient and his family have been through treatment already which may have included surgery, chemo or radiation and now the prospect of another operation and that too only to minimize the pain may seem an option not worth taking.
3. Cost: By the time the patient reach the stage of Palliation- they have been so stretched financially that such an option is out of their financial reach.
4. Technical issues: The tight regulation of Opiate medications like Morphine by the Government has had the effect of disincentivising the manufacturers of these drugs so much that it is indeed nearly impossible to lay ones hands on a good quality injectable Morphine suitable of being used in the pump. Apparently, the pumps get stalled within a year’s time! However, when we keep in mind that the patient’s we are talking here about are those whose life span is likely to be weeks and months, this may not such a big problem.
However, having seen at close quarters patients with incurable cancer benefitting immensely from this treatment, having seen their smiles, having seen their peaceful end, I remain an optimist. I am hopeful of the day when the thought of having a dignified end is atleast given half the importance to having the cancer cured!