American Society of Regional Anesthesia and Pain Medicine August 2016 - 34

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Use of Ziconotide as First Line Intrathecal Therapy?
continued...

Table 1: Direct comparison of IT opioids to ziconotide.
Opioids

Ziconotide

Respiratory depression

No reports of respiratory depression

Death from overdose

No reported deaths due to overdose

Granuloma

No reports of granuloma

Overdose related to pocket refill

Extremely limited ability to cross blood-brain barrier7

Overnight monitoring recommended for trialing6

Can be trialed in the office and discharged the same day5

Potential for withdrawal

No reports of withdrawal

Typically used conjunction with other medications (bupivacaine, clonidine, etc)

Efficacy established as monotherapy16

Tolerance3

No reports of tolerance

which opioids appear to be causing more problems than they solve,
our field is in desperate need of something new.
There will always be a need for
opioids on some level, orally as
well as intrathecally. However,
the use of opioids long-term in
the treatment of nonmalignant
pain is questionable at best
and extremely controversial.
In cases where all reasonable procedural interventions have been
exhausted, consideration of continuing pharmacologic solutions
is only logical-aka, the end-of-the-road. Before the advent of
ziconotide, the options were opioids given orally or opioids given
intrathecally. Putting pen to pad and writing for an opioid seems
to carry less inherent risk than managing a pump. It requires less
maintenance and demands considerably less expertise. As such,
many simply choose oral. The fact is, oral opioids carry just as
much risk, if not more, when one considers the effect a single pill
can have on the country as a whole in perpetuating the epidemic of
prescription drug abuse (eg, drug diversion, addiction).

tool for achieving that end and presents a fundamental piece to a
successful pain treatment algorithm. With the advent of so many
innovations and a seemingly
overnight emergence of
technological advancement
(dorsal root ganglion
stimulation, high frequency,
burst), it feels as though
the field of pain medicine is
entering into what can only
be described as a second renaissance. Ziconotide should be viewed
as a vital piece of this new era of neuromodulation and held in the
same regard-if not for being safer or easier to manage, then for
the simple fact that it is not an opioid.

"Ziconotide should be viewed as a vital
piece of this new era of neuromodulation
and held in the same regard."

Ziconotide presents an additional barrier before relegating a patient
to a life of opioids in some form. At face value, it seems to carry
less risk and is in keeping with the philosophy many pain doctors
ascribe to: procedure not prescription. It would appear to provide
some measure of safety to the use of IDDS that have plagued its
image and scared off many would-be users. For the first time,
IDDS can enter a conversation without being overshadowed by
certain stigmas or thoughts that it requires too much expertise to
employ safely. Perhaps ziconotide can revitalize IDDS by shedding
a positive light on this complex and useful therapy with new
discussions about safety and positive outcomes.
CONCLUSION
For many pain medicine physicians, decreasing or even eliminating
a patient's reliance on opioids through procedural means is at the
epicenter of our practicing philosophy; neuromodulation is powerful

34
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"Pro" continued on page 36

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2016

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