Developments in the Treatment of Chronic Pain

2 | MDT Confidential

Agenda

• Welcome• Types of pain• Common chronic pain conditions• Introduction to Medtronic neurostimulation• Introduction to Medtronic intrathecal drug

delivery• Patient selection• Neurostimulation clinical evidence • Intrathecal drug delivery clinical evidence • Role of interventional pain specialist• Case study


Welcome

• <Insert name(s) of physician presenter(s), practice name/logo, physician photo(s)>

• <Insert patient speaker(s) name(s), type of therapy>

Types of Pain


Types of Neuropathic Pain

• Results from damage to nerves– Direct nerve root injury: Radiculopathy

• Battered root syndrome• Perineural fibrosis• Intrafascicular fibrosis• Adhesive arachnoiditis

– Peripheral deafferentation• Phantom limb pain• Sympathetic-mediated pain syndrome• Herpetic neuralgia• Diabetic polyneuropathy

– Central deafferentation-thalamic stroke

Cole AJ. In Low Back Pain Handbook, 2nd ed. 2003; pg 361-374


Types of Nociceptive Pain

• Results from damage to muscle, tissue, and organs– Cuts and bruises– Bone fractures– Burns– Mechanical low back pain– Most postsurgical pain


Combined Nociceptive and Neuropathic Pain

• Failed back surgery syndrome (FBSS)*• Idiopathic chronic pain syndrome• Cancer pain

*Also referred to as “postsurgical chronic back pain”

Cole AJ. In Low Back Pain Handbook, 2nd ed. 2003; pg 361-374.


Some Chronic Pain Conditions

• Postsurgical chronic back pain or failed back• Radicular pain syndrome or radiculopathies • Fibromyalgia• Peripheral causalgia• Arachnoiditis • Complex regional pain syndrome


Rethinking the Pain Treatment Ladder

In contrast to earlier thinking on the order of treatments in the pain treatment continuum,1 it

has been proposed that device therapies be considered at an

earlier stage.2

1Krames ES. Intraspinal Opioid Therapy for Nonmalignant Pain: Current Practices and Clinical Guidelines. J Pain Symptom Manage 1996;11:333-352.

2Stamatos JM, et al. Live Your Life Pain Free, October 2005. Based on the interventional pain management experience of Dr. John Stamatos.

Introduction to Medtronic Neurostimulation


Neurostimulation Therapy

• Delivers electrical signals to the epidural space

• Inhibits pain signals before they reach the brain and replaces them with a tingling sensation that covers the specific areas where pain is felt

• Indicated for management of chronic, intractable pain of the trunk and/or limbs, including unilateral or bilateral pain


Benefits of Neurostimulation

• An effective method of pain control for many patients when used as directed

• May reduce the need for pain medications• Less invasive than surgical alternatives• Reversible—can be discontinued or, if desired by the

patient, surgically removed• Systems reprogrammable without surgery• Trial helps assess patient response • Patient control within preprogrammed limits

Kumar K, Taylor R, Jacques L, et al. Neurosurgery. 2008;63:762-770. Burchiel KJ, Anderson VC, Brown FD, et al. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine. 1996;21:2786-2794.


Neurostimulation Trial

• Neurostimulation therapy trial provides an opportunity to assess the effectiveness of neurostimulation without making a long-term commitment– Gauge patient response– Provide an adjustment period– Explore therapy parameters– Improve therapy cost-effectiveness

• The goal is at least a 50% reduction in pain – Patient-specific goals may include less pain reduction

but improved quality of life

Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain. Challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006;58(3):481-496.


Neurostimulation Risks

The most frequently reported problems following the spinal cord stimulator implant surgery include:

• infection, • lead movement, • pain at the implant site, • loss of therapy effect, and • therapy which did not meet the patient's expectations.

Some of the most severe reported problems following spinal cord simulator implant surgery include epidural hemorrhage, spinal fluid leakage, and paralysis.

For more details on risks/complications, refer to product package insert or visit www.medtronic.com.


Information sources:

Medtronic Neurostimulation Therapy for Chronic Pain: Percutaneous Lead Implantation Guide. Minneapolis, MN: Medtronic, Inc.; 2008.

Medtronic Implantable Systems Performance Registry (ISPR) 2007 Annual Report: Protocol NSP0010-10000. Minneapolis, MN: Medtronic, Inc.; October 2, 2008.

Medtronic Neurostimulation Systems for Pain Therapy Brief Summary; Minneapolis, MN: Medtronic, Inc.; December 2004.

Neurostimulation Risks (cont.)

Introduction to Medtronic IntrathecalDrug Delivery (IDD)


Intrathecal Drug Delivery (IDD) Therapy

• IDD therapy involves the delivery of pain medicine into the intrathecal space

• The pump is connected to a thin, flexible catheter; both are implanted under the skin

• Smaller doses of medication are needed for effective pain relief because drug is delivered directly to the pain receptors


Synchromed® II Drug Infusion System Indications

• Chronic intrathecal infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain

• Also indicated for chronic intrathecal infusion of preservative-free ziconotide sterile solution for the management of severe chronic pain


Approximate Equivalent Daily Doses of Morphine

Route of Administration

Relative Potency (mg)*

Oral Intravenous

EpiduralIntrathecal

300100201

*Relative approximations based on clinical observations.

Lamer TJ. Treatment of cancer-related pain: when orally administered medications fail. Mayo Clin Proc. 1994;69:473-480.


Benefits of IDD Therapy

• Pain relief for patients who have not received adequate relief with conventional therapies

• May reduce adverse effects from oral opioids such as nausea, vomiting, sedation, and constipation

• May decrease or eliminate use of oral analgesics• Increased ability to perform activities of daily living• Patient control of medication within physician-set limits• May be effective for patients who do not experience relief

from neurostimulation therapy

Lamer TJ: Mayo Clin Proc. May 1994;69(5):473-80.Paice JA. Intraspinal morphine for chronic pain: a retrospective, multicenter study. J Pain Symptom Manage. 1996;11:71-80.


IDD Trial

• The purpose of the trial is to assess the efficacy and side effects of intrathecal morphine

• Trialing methods include:– Continuous epidural– Continuous intrathecal– Bolus epidural– Bolus intrathecal

• Patients who report at least 50% reduction in pain may be candidates for long-term therapy


The most frequently reported problems following drug infusion system implant surgery include:

IDD Therapy Risks

For more details on risks/complications, refer to product package insert or visit www.medtronic.com.

Other complications may occur, and may require surgery to correct.

Some of the most severe reported problems associated with intrathecal drug delivery therapy for chronic pain include inflammatory mass, spinal cord damage, meningitis, life threatening drug adverse effects due to over infusion as a result of programming or patient monitoring errors or device malfunction, and complications due to use of unapproved drugs and/or not using drugs in accordance with drug labeling.

• infection • spinal fluid leak• pump inversion• dislodged or blocked catheter• skin erosion

• drug side effects • loss of therapy effect• therapy which did not meet the

patient’s expectations


IDD Therapy Risks (cont.)

Information sources:

Medtronic Synchromed II Programmable Infusion System Clinical Reference Guide: Intrathecal Morphine for Pain Management. Minneapolis, MN: Medtronic, Inc.; May 2007.

Medtronic Implantable Systems Performance Registry (ISPR) 2007 Annual Report: Protocol NSP0010-10000. Minneapolis, MN: Medtronic, Inc.; October 2, 2008.

Synchromed II Drug Infusion System Brief Summary; Minneapolis, MN: Medtronic, Inc.; January 2008.

Coffey R. Mortality Associated with Intrathecal Opioid Drug Infusion to Treat Non-Cancer Pain: Risk Factors and Mitigation. Paper presented at the North American Neuromodulation Society 12th Annual Meeting; December 4-7, 2008; Las Vegas, NV.

Patient Selection


Indications for Neurostimulation and Intrathecal Drug Delivery Therapy

Cole AJ. In Low Back Pain Handbook, 2nd ed. 2003; pg 362. Refer to full prescribing information for Medtronic Neurostimulation Systems and Synchromed® II Drug Infusion Systems.


Patient Selection Considerations

• Patients who have neuropathic pain in a concordant anatomic distribution usually respond best to neurostimulation (NS) therapy.

• Patients who have nociceptive pain in a concordant distribution usually respond best to intrathecal drug delivery (IDD).

• Patients who do not respond well to NS may be candidates for IDD therapy.

Cole AJ. In Low Back Pain Handbook, 2nd ed. 2003; pg 362.


Patient Selection Checklist

Failure of oral/transdermal opiate use or intolerable side effects

More conservative therapies have failed An observable pathology exists that is concordant

with the pain complaint Further surgical intervention is not indicated No serious untreated drug habituation exists Psychological evaluation and clearance for

implantation has been obtained No contraindications to implantation exist Refer Patient for a Pain Therapy Trial

Cole AJ. In Low Back Pain Handbook, 2nd ed. 2003; pg 362.

Neurostimulation Clinical Evidence


Medtronic PROCESS Study Results

Primary outcome Number of SCS + CMM patients with ≥ 50% leg pain relief (≥ 50% reduction in leg VAS) is:

– at 6 months, 23 of 42 or 55%– at 12 months, 16 of 42 or 38%– at 24 months, 17 of 42 or 40%

Kumar K, Taylor R, Jacques L, et al. Neurosurgery. 2008;63:762-770.


Medtronic PROCESS Study Results

• Secondary outcomes evaluated at 1, 3, 6, 9, 12, 18 and 24 months (24 month data presented)Leg pain relief (leg VAS) Leg: Significant improvement

(p<0.0001)

Back pain relief (axial back VAS) No significant difference

Quality of life (SF-36 and EQ-5D) SF-36: significant improvement for 7 of 8 dimensionsEQ-5D: significant improvement

Function (Oswestry Disability Index)

Significant improvement (p=0.0002)

Patient satisfaction 93% satisfied with treatment

Need for drug or nondrug therapy for pain

No clear pattern of change

Work status Increased from 21% to 27%

Adverse events See Adverse Events slide



Significant Improvement in Function

Key Findings: Significant improvement in function (Oswestry Disability Index) in SCS+CMM group over 24 months.



More Effective than Repeat Surgery

Key Findings:

Among patients available for long-term follow up, SCS was significantly more successful than reoperation: 9 (47%) of 19 patients randomized to SCS and 3 (12%) of 26 patients randomized to reoperation achieved at least 50% pain relief and were satisfied with treatment.

North RB, Kidd D, Shipley J, et al. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurg. 2007;61:361-369.


Efficacy of Spinal Cord Stimulation Neurostimulation Improves Quality of Life

Van Buyten JP, Van Zundert J, Vueghes P, Vanduffel L. Efficacy of spinal cord stimulation: 10 years of experience in a pain centre in Belgium. Eur J Pain 2001;5:299-307. n=125 pain cases; P<0.01 for all activities

• Subjects were implanted with SCS over a period of 10 years at one pain center

• Efficacy assessed after an average follow-up of almost four years

Intrathecal Drug Delivery Clinical Evidence


Decreased Use of Pain Medications

Key Findings:

At 6 months, 65% of patients decreased their use of systemic opioids from baseline.

At 12 months, 42% of patients decreased their usage compared with the 6-month follow-up.

Deer T, Chapple I, Classen A, et al. Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004;5:6-13. n=136

88.2% of patients were taking systemic opioids at baseline.


Overall Global Pain Relief

Key Findings:

Overall pain relief of ≥ 50% was reported by 82% of patients (40 of 49).

Roberts LJ, Finch PM, Goucke CR, et al. Outcome of intrathecal opioids in chronic non-cancer pain. Eur J Pain. 2001;5:353-361. n=88

Role of InterventionalPain Specialist


Practice Management Collaboration


Interventional Pain SpecialistPain Management Approach

• Recognizes unique benefits of technological advances and interventions

• Communicates with all concerned parties to ensure best treatment possible

• Develops follow-up plan once pain successfully treated

• Collaborates with referring physician when treatment overlaps with general health care

• Follows up with referring physician when pain is under better control


Interventional Pain Specialist Referral Considerations

• Intractable pain• Intolerable side effects from systemic analgesics• Conservative therapies ineffective• Patient’s functional status declines• Uncomfortable prescribing or monitoring opioids


Case Study – Sample Referral Profile

Male, 45, office manager, no major psychosocial issues• One spine surgery to treat herniated disc• Referred from primary care physician to address axial back pain

and secondary radicular pain that persists 6 months following anatomically corrective surgery

• Average back pain score (VAS) of 80/100 with diminished functional capacity

• Relief from physical rehabilitation therapy was not satisfactory• Unsuccessfully treated with neuropathic pain agents and two

systemic opioids, patient experienced extreme sedation and constipation

• Treated with nerve block series but relief was temporary


Device Therapy Referral Interventional Pain Specialist Role• Conduct a thorough patient history and physical exam• Develop an interventional pain treatment plan• Conduct a Medtronic pain therapy trial• Perform the Medtronic pain therapy implantation or

refer after the trial• Develop a follow-up plan with the patient and

primary/referring physician


Summary

• Patients should not have to wait for effective pain relief.

• By partnering, we can help patients find the right pain treatment.

• Together we can improve the quality of life for chronic pain patients.

• Our decisions may change the course of a patient’s life.


SynchroMed® Infusion SystemBrief SummaryProduct technical manuals and the appropriate drug labeling must be reviewed prior to use for detailed disclosure.

Indications: US: Chronic intraspinal (epidural and intrathecal) infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain, chronic intrathecal infusion of preservative-free ziconotide sterile solution for the management of severe chronic pain, and chronic intrathecal infusion of Lioresal® Intrathecal (baclofen injection) for the management of severe spasticity; chronic intravascular infusion of floxuridine (FUDR) or methotrexate for the treatment of primary or metastatic cancer. Outside of US: Chronic infusion of drugs or fluids tested as compatible and listed in the product labeling.Contraindications: When infection is present; when the pump cannot be implanted 2.5 cm or less from the surface of the skin; when body size is not sufficient to accept pump bulk and weight; when contraindications exist relating to the drug; drugs with preservatives. Do not use the Personal Therapy Manager accessory to administer opioid to opioid-naïve patients or to administer ziconotide.Warnings: Comply with all product instructions for initial preparation and filling, implantation, programming, refilling, and injecting into the catheter access port (CAP) of the pump. Failure to comply with all instructions can lead to technical errors or improper use of implanted infusion pumps and result in additional surgical procedures, a return of underlying symptoms, or a clinically significant or fatal drug under- or overdose. Refer to the appropriate drug labeling for specific under- or overdose symptoms and methods of management. Avoid using short wave (RF) diathermy within 30 cm of the pump or catheter. Diathermy may produce significant temperature rises in the area of the pump and continue to heat the tissue in a localized area. If overheated, the pump may over infuse the drug, potentially causing a drug overdose. Effects of other types of diathermy (microwave, ultrasonic, etc.) on the pump are unknown. An inflammatory mass that can result in serious neurological impairment, including paralysis, may occur at the tip of the implanted catheter. Clinicians should monitor patients on intraspinal therapy carefully for any new neurological signs or symptoms. For intraspinal therapy, use only preservative-free sterile solution indicated for intraspinal use. Use only Medtronic components indicated for use with this system. Failure to firmly secure connections can allow drug or cerebrospinal fluid (CSF) leakage into tissue and result in tissue damage or inadequate therapy. A postoperative priming bolus should not be programmed if the pump is a replacement and the catheter has not been aspirated.


SynchroMed® Infusion SystemBrief Summary continuedRefer to appropriate drug labeling for indications, contraindications, warnings, precautions, dosage and administration information, and screening procedures. Physicians must be familiar with the drug stability information in the technical manual and must understand the dose relationship to drug concentration and pump flow rate before prescribing pump infusion. Implantation and ongoing system management must be performed by individuals trained in the operation and handling of the infusion system. Inform patients of the signs and symptoms of drug under- or overdose, appropriate drug warnings and precautions regarding drug interactions, potential side effects, and signs and symptoms that require medical attention. Instruct patients to notify their clinician of travel plans, to return for refills at prescribed times, avoid activities such as strenuous exercise or contact sports that jar, impact, twist, or stretch the body, to always carry their Medtronic device identification card, to avoid manipulating the pump through the skin, and to notify healthcare professionals of the implanted pump before medical tests/procedures. Patients must consult their physician before engaging in activities involving pressure or temperature changes (e.g., scuba diving, saunas, hot tubs, hyperbaric chambers, flights, skydiving, etc.) Inform patients that pump has an Elective Replacement Indicator (ERI) that sounds when the pump is nearing its end of service. When the alarm sounds, patients must contact their doctor to schedule pump replacement.Precautions: The pump is ethylene oxide sterilized. Do not use if the product or package is damaged, the sterile seal is broken, or the “Use By” date has expired. Do not reuse or resterilize the pump; it is intended for “single use only.” Do not expose the pump to temperatures above 43°C or below 5°C. Consider use of peri- and post-operative antibiotics for pump implantation, for any subsequent surgical procedure, or if infection is present. For patients prone to CSF leaks, clinicians should consider special procedures, such as a blood patch. Follow instructions for emptying and filling the pump during a replacement or revisions that require removal of the pump from the pocket. Explant the pump postmortem if incineration is planned (to avoid explosion), or if local environmental regulations mandate removal. Return explanted devices to Medtronic for analysis and safe disposal. Do not implant a pump dropped onto a hard surface or showing signs of damage. Implant the pump less than 2.5 cm from the surface of the skin. Ensure pump ports will be easy to access after implant, that the catheter is not kinked and secured well away from pump ports before suturing. Keep the implant site clean, dry, and protected from pressure or irritation. If therapy is discontinued for an extended period of time, fill the reservoir with preservative-free saline in intraspinal applications or appropriate heparinized solution (if not contraindicated) in vascular applications.


SynchroMed® Infusion SystemBrief Summary continuedThe magnetic field or telemetry signals produced by the programmer may cause sensing problems and inappropriate device responses with an implantable pacemaker and/or defibrillator. Electromagnetic interference (EMI) is an energy field generated by equipment found in the home, work, medical, or public environments. Most EMI normally encountered will not affect the operation of the pump. Exceptions include: injury resulting from heating of the pump which can damage surrounding tissue (diathermy, MRI), system damage which can require surgical replacement or result in loss/change in symptom control (defibrillation, electrocautery, high-output ultrasonics, radiation therapy), and operational changes to the pump causing the motor to stop, loss of therapy, return of underlying symptoms, and require confirmation of pump function (diathermy, high magnetic field devices, hyperbaric/hypobaric conditions, magnetic resonance imaging (MRI)). MRI will temporarily stop the pump motor’s rotor due to the magnetic field of the MRI scanner and suspend drug infusion during MRI exposure which will cause the pump alarm to sound. The pump should resume normal operation upon termination of MRI exposure. Prior to MRI, the physician should determine if the patient can safely be deprived of drug delivery. If not, alternative delivery methods for the drug can be utilized during the MRI scan. Prior to scheduling an MRI scan and upon its completion, pump status should be confirmed.Adverse Events: Include, but are not limited to, cessation of therapy due to end of device service life or component failure, change in flow performance due to component failure, inability to program the device due to programmer failure, CAP component failure; inaccessible refill port due to inverted pump, pocket seroma, hematoma, erosion, infection, post-lumbar puncture (spinal headache), CSF leak, radiculitis, arachnoiditis, bleeding, spinal cord damage, meningitis (intrathecal applications), anesthesia complications, damage to the pump, catheter and catheter access system due to improper handling and filling before, during, or after implantation; change in catheter performance due to catheter kinking, disconnection, leakage, breakage, occlusion, dislodgement, migration, or catheter fibrosis; body rejection phenomena, surgical replacement of pump or catheter due to complications; local and systemic drug toxicity and related side effects, complications due to use of unapproved drugs and/or not using drugs in accordance with drug labeling, or inflammatory mass at the tip of the catheter. USA Rx Only Rev 0209


Neurostimulation Systems for Pain Therapy DisclosureBrief Summary: Product manuals must be reviewed prior to use for detailed disclosure.Indications Implantable neurostimulation systems - A Medtronic implantable neurostimulation system is indicated for spinal cord stimulation (SCS) system as an aid in the management of chronic, intractable pain of the trunk and/or limbs-including unilateral or bilateral pain associated with the following conditions:

• Failed Back Syndrome (FBS) or low back syndrome or failed back• Radicular pain syndrome or radiculopathies resulting in pain secondary to FBS or herniated disk• Postlaminectomy pain • Multiple back operations• Unsuccessful disk surgery• Degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and surgical interventions• Peripheral causalgia • Epidural fibrosis • Arachnoiditis or lumbar adhesive arachnoiditis• Complex Regional Pain Syndrome (CRPS), Reflex Sympathetic Dystrophy (RSD), or causalgia

Contraindications Diathermy - Do not use shortwave diathermy, microwave or therapeutic ultrasound diathermy (all now referred to as diathermy) on patients implanted with a neurostimulation system. Energy from diathermy can be transferred through the implanted system and cause tissue damage at the locations of the implanted electrodes, resulting in severe injury or death.

WarningsSources of strong electromagnetic interference (eg, defibrillation, diathermy, electrocautery, MRI, RF ablation, and therapeutic ultrasound) can interact with the neurostimulation system, resulting in serious patient injury or death. These and other sources of EMI can also result in system damage, operational changes to the neurostimulator or unexpected changes


Neurostimulation Systems for Pain Therapy Disclosure continuedin stimulation. Rupture or piercing of the neurostimulator can result in severe burns. An implanted cardiac device (eg, pacemaker, defibrillator) may damage a neurostimulator, and the electrical pulses from the neurostimulator may result in an inappropriate response of the cardiac device.

PrecautionsThe safety and effectiveness of this therapy has not been established for pediatric use (patients under the age of 18), pregnancy, unborn fetus, or delivery. Patients should be detoxified from narcotics prior to lead placement. Clinicians and patients should follow programming guidelines and precautions provided in product manuals. Patients should avoid activities that may put undue stress on the implanted neurostimulation system components. Patients should not scuba dive below 10 meters of water or enter hyperbaric chambers above 2.0 atmosphere absolute (ATA). Electromagnetic interference, postural changes, and other activities may cause shocking or jolting.

Adverse EventsAdverse events may include: undesirable change in stimulation described by some patients as uncomfortable, jolting or shocking; hematoma, epidural hemorrhage, paralysis, seroma, CSF leakage, infection, erosion, allergic response, hardware malfunction or migration, pain at implant site, loss of pain relief, chest wall stimulation, and surgical risks.

For further information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com.

USA Rx Only Rev 0209

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Developments in the Treatment of Chronic Pain

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