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Objective. This article presents an overview of the use of intrathecal bupivacaine (with and without opioid), focusing on laboratory data and clinical use for chronic pain. Some background on epidural use is included to support the intrathecal literature. Materials and Methods. Currently available literature (MEDLINE) regarding the use of intrathecal bupivacaine is reviewed. Prior to presenting the intrathecal bupivacaine data, an overview of data related to bupivacaine stability, microbiology, preclinical toxicology, and pharmacokinetics is presented, along with a brief review of the epidural bupivacaine literature. Results. Based on the current available literature, intrathecal bupivacaine appears to be a safe and acceptable method of treatment for chronic pain in both cancer and noncancer patients. The stability and bacteriologic studies support the use of bupivacaine in external or implantable drug administration devices. Toxicity studies in laboratory animals suggest complications only at plasma levels that would not be seen at clinically relevant doses of intrathecal administration. Bupivacaine is a clinically effective addition to intrathecal opioids. Bupivacaine administration is more effective intrathecally, providing better pain relief than epidural administration. Reports of complications are infrequent. Further studies are needed to define the use of intrathecal bupivacaine and should include long-term safety. Compatibility studies will also be needed when bupivacaine is used in combination with other agents. In addition, outcome studies are needed specifically to differentiate use of intrathecal bupivacaine based on the source and mechanism of pain. Conclusions. While there are few long-term randomized prospective studies at this point, we conclude that intrathecal bupivacaine appears to be a safe and efficacious treatment in both cancer and noncancer pain.

Evidence-based medicine depends on the existence of controlled clinical trials that establish the safety and efficacy of specific therapeutic techniques. Many interventions in clinical practice have achieved widespread acceptance despite little evidence to support them in the scientific literature; the critical appraisal of these interventions based on accumulating experience is a goal of medicine. To clarify the current state of knowledge concerning the use of various drugs for intraspinal infusion in pain management, an expert panel conducted a thorough review of the published literature. The exhaustive review included 5 different groups of compounds, with morphine and bupivacaine yielding the most citations in the literature. The need for additional large published controlled studies was highlighted by this review, especially for promising agents that have been shown to be safe and efficacious in recent clinical studies.

Consensus guidelines developed by an expert panel are helpful to clinicians when there is variation in practice and lack of a firm evidence base for an intervention, such as intraspinal therapy for pain. An internet-based survey of practitioners revealed remarkable variation in practice patterns surrounding intraspinal therapy. This prompted an interdisciplinary panel with extensive clinical experience in intraspinal infusion therapy to evaluate the results of the survey, the systematic reviews of the literature pertaining to this approach, and their own clinical experience with long-term spinal infusions. The panel proposed a scheme for the selection of drugs and doses for intraspinal therapy, and suggested guidelines for administration that would increase the likelihood of a successful outcome. These expert panel guidelines were designed to provide an initial structure for clinical decision making that is based on the best available evidence and the perspectives of experienced clinicians.

Opioids form the cornerstone of the pharmacologic armamentarium for the treatment of pain. Despite their long history of use, much confusion and misperception still surrounds their use. This short review will focus on pharmacodynamic and physiologic considerations in the clinical use of oral and parenteral opioids.

Study Objective: To test the hypothesis that alkalinization of lidocaine decreases the pain of skin infiltration in surgical patients., Design: Double-blind, randomized, prospective study., Setting: Preoperative holding units, Brigham and Women's Hospital., Patients: 184 adult surgical patients., Interventions: We compared the efficacy of 1% lidocaine with and without 0.1 mEq/ml of sodium bicarbonate (NaHCO3) for relief of pain of (1) skin infiltration and (2) intravenous (i.v.) catheterization prior to surgery., Measurements and Main Results: Patients evaluated the intensity of pain using a 100 mm visual analog scale (VAS). There were no differences between study groups (lidocaine with NaHCO3, n = 89; lidocaine alone, n = 95) with respect to site of catheterization or catheter gauge used. Lidocaine plus NaHCO3 caused significantly less pain on skin infiltration (median VAS = 4; range = 0 to 51) than did lidocaine alone (VAS = 8; range = 0 to 48; p < 0.008). Pain of i.v. catheterization also did not differ between groups. There was a weak correlation between catheter gauge and pain of i.v. catheterization (r = -0.19; p = 0.01)., Conclusions: Pain resulting from skin infiltration of lidocaine solutions can be diminished by adding NaHCO3. However, catheter size is more important than the presence or absence of NaHCO3 in determining the pain of i.v. catheterization.