A 38-Year-Old Man With Pancreatic Cancer

Case Presentation

Michael H. Levy, MD: This 38-year-old white male first came to his physician in January of 1993 complaining of epigastric and low back pain. In March of 1993, he was diagnosed with pancreatic cancer that was metastatic to his liver and his retroperitoneal lymph nodes. He came to Fox Chase for treatment in May and was placed on a phase I protocol looking at topotecan (Hycamtin) as a chemotherapeutic agent. We saw the patient in consultation at the time of his first chemotherapy admission and he said that the pain was localized to his abdomen, rated at a 5 out of 10 on MS Contin (morphine sulfate) 60 mg every 12 hours, which he was supplementing with 15 mg of short-acting morphine in the form of Roxanol (morphine sulfate) four times a day. He described the pain as throbbing, cramping, stabbing, and radiating into the back. He said there was a constant component to the pain, but there were also unbearable spasms and exacerbations. The patient reported urinary hesitancy and bladder spasms. In addition, perhaps due to noncompliance or inappropriate laxative therapy, he was alternating between constipation and diarrhea.

One of the things that we try to do in evaluating patients is to get a sense of the pain etiology. We knew about his cancer—where and what it was—and how it was going to be treated. But, what did we know about his pain? We thought it was predominantly visceral, and by its central location and the radiation into the back location, empirically we thought it probably involved the celiac plexus. We also thought that perhaps the patient’s pain had either a neurogenic or a neuropathic component. We thought that his urinary hesitancy and the constipation/diarrhea cycles were due to opioid toxicity, though it was possible that the diarrhea also might be caused by pancreatic insufficiency.

As a first step, we decided to stick to simple things. We increased his MS Contin to 90 mg q12h and his Roxanol to 30 mg q4h as needed. He received his first dose of chemotherapy. Topotecan has very minimal side effects, and does not cause a lot of nausea or sedation. When the patient came in the next day for another reason, we saw him. Unfortunately, he was sedated and nauseated. So, we said, OK, where do we go from here? Topotecan is a phase I drug, so it was not even clear that his cancer was going to respond to it.

I would like to open this case to discussion. How would each of you proceed at this point?

Discussion

Russell K. Portenoy, MD: What did the CT scan show?

Dr. Levy: The CT scan showed a large mass in the head of the pancreas. There was retroperitoneal lymphadenopathy. The scan did not show any encasement of the celiac plexus. There was involvement of the lymph nodes next to the pancreas, and there were a number of liver metastases.

Dr. Portenoy: The reason I asked that question is because the obvious decision for most of us here, I think, would be whether or not to proceed to celiac plexus neurolysis for this patient. However, in patients who are totally socked in, whose tumor has spread retroperitoneally, a celiac plexus block is not going to have much effect.

Dr. Levy: One of our concerns was not knowing how much of the pain was due to the pancreas, how much was due to the retroperitoneal lymph node involvement, and how much was due to the liver involvement. We have had some difficulty obtaining an adequate response from celiac plexus block in patients with pain due to liver metastasis. On the other side, we have found celiac plexus block to be the easiest, most effective neurolytic procedure, with the least side effects, to relieve the pain from advanced pancreatic cancer. The procedure might also help the patient’s constipation. We have also found that, in a patient like the one in this case report, the sooner we did the block, the better—that is, before his blood counts went down and he became infected from his chemotherapy.

Peter S. Staats, MD: Given the CT scan, proceeding with the celiac plexus block has a lot of advantages. It would decrease the opioid requirements. It also would relieve the constipation because you would have a decrease in the sympathetic tone of the gut. About a year ago, we published data showing that, across the board in pancreatic cancer patients, celiac plexus block increases life expectancy by about a month.

Dr. Portenoy: The issue in our center would be whether or not to first try an alternative opioid. Two major points on our decision tree would be 1) to change to a different opioid and administer it by perhaps a nonoral route—given the concerns that you’d have about absorption in someone with alternating diarrhea and constipation, and possibly malabsorption due to pancreatic insufficiency—or 2) go to a celiac plexus block. The decision, to me, at that point would be dependent on what was going to happen in terms of the antineoplastic therapy. If there was an expectation that his blood counts might start to drop rapidly, that would be an indication to choose celiac plexus block quickly. If there was concern about chemotherapy toxicity, but not about opioid toxicity, then you might want to hold off on the block to see whether or not the pain cleared over the next few days, or perhaps wait until you obtained a topotecan level to see whether he was metabolizing the drug normally.

Elliot S. Krames, MD: In my opinion, celiac plexus block absolutely would be indicated here, but on the other hand, because the patient was sedated on 180 mg of MS Contin per day, which is not an extremely high dose of MS Contin, switching to another agent might control his pain and decrease the sedation.

Not Without Complications

Stuart Du Pen, MD: We have to remember that celiac plexus block is not without complications. One of my patients developed paralysis following the procedure due to arterial spasm and lack of blood supply to the cord. I discuss this with each patient because I think they must be aware of this possibility, even though it is very rare.

In addition, hypotension is common, due to the vasodilation. Diarrhea is another possible side effect from celiac plexus block, although patients with pancreatic cancer are usually accustomed to having diarrhea because of the pancreatic involvement. There is also another possible late side effect due to the vasodilation—I have found that, when patients who have had celiac plexus block become dehydrated or cachectic, they develop postural hypotension earlier than patients who have not undergone a block.

Dr. Portenoy: True, and there is also the possibility of other rare but serious complications, like renal puncture with hemorrhage and renal injury by phenol injection, or alcohol injection into the kidney.

Dr. Krames: It depends on the skill of the one who does the procedure. When you talk about celiac plexus block, did you mean as a local anesthetic or did you mean neurolysis?

Dr. Du Pen: I agree. In my 31 years of practice and 2,000 celiac plexus blocks with alcohol, I have never encountered a renal injury. I attribute this to my training with Dr. D.C. Moore.

The Next Step

Dr. Levy: We made our assessment and we thought that he did not have pancreatic insufficiency. He really was having more constipation than diarrhea. His constipation and his urinary hesitancy were due to opioid toxicity. In fact, it was quite clear that this patient was having opioid toxicity and he was very much in favor of having a block. So, on May 28 the celiac plexus block was performed. Our anesthesiologist used a transaortic approach with 100% alcohol. The procedure was fluoroscope-guided; there was good spread of the dye; and 50 mL of 100% alcohol was injected on both sides.

Another question is what to do with the opioids around the time of the block. We usually reduce them by 50% to 75%. We continue patients on some opioid dosage to prevent opioid withdrawal and to control the back pain that patients often have for a day or two after plexus block. So the patient was continued on MS Contin 30 mg q12h, and the next day his pain measured 1.5 on a scale of 10. His urinary flow was good.

His pain was still centered in the abdomen and back; it was not clear whether it was from the procedure or if it was still the boring, penetrating pain of pancreatic cancer.

Controversy Concerning Diagnostic Block

Dr. Krames: This raises an important issue. The anesthesiologist went ahead and did an alcohol block without a diagnostic block, and that is controversial in the literature. Personally, I support that approach. I think there is no good reason for a diagnostic block in this setting. In pancreatic cancer, either it works or it doesn’t work, and submitting a patient to two procedures is not cost-effective, in both money and quality of life. It is a painful procedure and I see absolutely no reason to do two procedures.

Dr. Du Pen: The problem is we do not have an accurate diagnostic tool. The local anesthetic agents will spread rapidly and far. The effect of the high concentration of alcohol is limited to a very small area. Therefore, a test dose with bupivacaine (Marcaine, Sensorcaine) or lidocaine (Xylocaine) is not a good predictor of response to full celiac plexus block; both drugs diffuse less extensively than the alcohol block. The test will tend to provide more relief than you will ever get with the alcohol.

Dr. Portenoy: Some people would say that the only advantage to testing is for a negative result. If it does not work, then you do not go ahead and do the neurolysis, but even if it does work, it is unpredictable. It does not predict whether the full block will work.

Dr. Staats: In our institution, we used to always do a diagnostic test first. But then we realized that, in pancreatic cancer patients, we almost invariably proceeded to a neurolytic block. The protocol that I use now is to place the two needles in the right places. I inject some local anesthetic and sit there with the patient until I see a change in the level of his or her pain. If there is any kind of pain relief, I proceed immediately to the neurolysis with 100% alcohol. If there is no pain relief from the local anesthetic, I proceed to a full diagnostic block because a negative result may mean that the needles are in the wrong place, not where I think they are. If the patient cannot wiggle his toes after I put in a little bit of local anesthetic, there is still opportunity to abort the procedure if the local anesthetic has spread to the somatic nerve roots. That is how I make use of the negative result, and I watch for the possibility of side effects.

Dr. Portenoy: Are you saying that if you get a negative response, you still go ahead with the alcohol?

Dr. Staats: No, if I get a negative response, I inject local anesthetic and do a full diagnostic block, and pull the needles out. But having said that, I need to point out that I have not had a negative result with a pancreatic cancer patient in the last 2 years. That is my protocol.

Dr. Krames: There are multiple ways to do celiac plexus blocks and neurolysis. One way is the way you talked about, under fluoroscopic guidance. This is the transaortic approach, going through the aorta and injecting dye and seeing a crescent of dye under fluoroscopy. But you also want to see spread of that dye. You want to see spread in the right area on the fluoroscopy. Some people do celiac plexus blocks under CT guidance. There are also single-needle techniques. There are two-needle techniques. Some people do splanchnic nerve blocks rather than celiac plexus block, which accomplishes the same thing; basically this is a retrocrural block.

I used to do celiac plexus blocks alone, and now I do celiac plexus blocks and retrocrural blocks (splanchnic) at the same time. On the left side, my needle goes transaortic, and I inject the alcohol transaortically. On the right side, I am at the anterolateral border of the vertebral body, and I do a splanchnic nerve block. As I pull my transaortic needle back into the retrocrural space, I inject 5 mL of alcohol there. My success in combining these two techniques is about 25% to 30% greater than when I perform a celiac plexus block alone.

Continue Opioids

Dr. Levy: Another issue is, what do you do with the opioids around the time of the block? We typically reduce them by 50% to 75%. Leave some opioid, and that morning before the block, have another 25% for breakthrough—because we do find with alcohol that patients often get some back pain for the first day or two. For this patient, we reduced his MS Contin from 90 to 30 mg. The next day his pain, which had been a 5 out of 10, was a 1.5 out of 10. His urinary flow was good though his pain was still in his abdomen and back. It was not clear whether the back pain was from the procedure or was still that penetrating, boring pancreatic pain.

The patient went home, and when he came back the following week, his pain had shifted and increased. He now complained of left flank pain. It turned out that his liver metastases were more in the left lobe than in the right. We had to increase MS Contin to 90 mg q12h, and we were concerned. Did he perhaps have a new spinal metastasis?

We did an MRI and there was no spine metastasis, but the retrosplenial lymph nodes looked like they were actually somewhat larger. We wouldn’t have expected an antitumor response yet from the chemotherapy, and he was again having nausea and was sedated. He also said it took a half-hour before he could start his urinary stream. This is unusual. True, we often we see some urinary hesitancy, but usually it is in the more senior gentlemen who already have some prostatic hypertrophy. We often treat that, if the blood pressure is okay, with terazosin (Hytrin) or other agents that will open the bladder neck. But that was not the case with this patient. He was a young man.

Now his liver was tender. At this point, we thought we had controlled at least part of his pain. When you do the blocks, sometimes you can “get a piece of the pain,” so to speak, which can lower the opioid requirement. We consider that somewhat of a therapeutic victory. Unfortunately, his liver pain was becoming worse. We tried Decadron as a coanalgesic, because sometimes reducing the swelling of the liver capsule can relieve the stretching effect and therefore reduce pain.

These maneuvers did help, and over the next couple of days the patient’s pain declined to about a 2 out of 10. To avoid sedation, he found it more desirable to reduce his dose of MS Contin and take his Roxanol as needed. However, a few days later his pain was worse. He needed more Roxanol now to the point that he was becoming sedated, the 30-minute delay in his urinary flow returned, and he also was experiencing some mental cloudiness.

This case occurred about 6 years ago, at which time we did not have another long-acting oral opioid to try, such as oxycodone, as we would today. If that had been available, it would have been my next step. Another option today would be to go to the transdermal fentanyl system—Duragesic. But that, too, was not available then.

Alternative Drugs

F. Michael Ferrante, MD: What were the patient's liver function tests at this point? How bad was his liver function?

Dr. Levy: His liver function was still pretty good. His bilirubin was normal. His liver function tests were maybe two or three times normal, but as an oncologist, I’m stunned by how bad a liver CT scan can look and yet the patient still has good liver function.

Dr. Ferrante: The liver is an amazing, resilient organ. At this particular point, if I was not afraid of compromising his liver function, I might try a psychostimulant in very low doses to see if I could reverse some of the mental cloudiness and sedation.

Dr. Levy: That would not help the urinary retention.

Dr. Ferrante: No, it wouldn’t, but it would at least relieve two of the three symptoms.

Dr. Portenoy: This is a decision point. You have to decide whether the morphine is a favorable therapy worth trying to preserve, or if the morphine is not a favorable therapy and it is time to move on. The patient has a very limited therapeutic window to morphine. This is the second point at which a dose this high produced somnolence and mental clouding, and now you have had urinary hesitancy.

What are the options to get this patient off morphine and onto another effective therapy? One option would be antineoplastic therapy. Some people would talk about radiation at this point, radiating the liver to reduce the capsular pain or radiating the pancreatic bed. Some clinicians would consider opioid rotation. We would certainly consider this. Treatment of the side effects seems reasonable, but the urinary hesitancy seems like a major issue for this young man. So I probably would want to get him off the morphine.

Profile of the Patient

Dr. Levy: Let me paint the picture of this young man. At 38, he was a laborer, who had a club foot deformity as a kid, some surgery, and then special shoes. So he had really been sort of a survivor of a lot of calamity, and he just wanted everything that could be done right away to get him back to his level of quality of life. Typically at our first visit with a patient, we discuss the menu. The menu is different opioids and coanalgesics and then because you have pancreatic cancer, a celiac plexus block might work. If this all does not help you, we could consider a spinal opioid trial. At his initial visit, we offered him this menu. He was very interested in getting as well as he could as quickly as he could.

Dr. Krames: This is only anecdotal, but I have found that levorphanol in this situation decreases mental clouding and is much more tolerable than morphine. It has less sedation. The patient with pancreatic cancer with major metastases to the liver is not going to last a long time, so the issue here is what delivery system to use.

Catheter vs Pump

Dr. Levy: These are all issues, and another oncologic issue is that we could not radiate his liver because he was on a phase I study and that would be a study violation. Obviously, if he were really crashing, we would break the study, but this was only a week after things were started. The chemotherapy had not really had a chance to work.

To continue with the case, in the middle of June we did a spinal opioid trial—morphine with an intrathecal catheter. At that point, the anesthesiologist was doing daily spinal taps. He was concerned, because inserting a temporary catheter could potentially infect that space and create a problem before you insert the permanent system. With the test spinal taps we gave 3 mg, then 4 mg, and the patient had a good response. We were able to reduce his systemic opioids to 30 mg q12h.

So we elected to place an intrathecal pump; we started with a morphine dose of 6 mg per day. At that point, his left flank pain was 0 out of 10. He had a headache from the procedure, so we prescribed 1 or 2 Percocet (oxycodone and acetaminophen) tablets every 4 hours as needed, then switched to Motrin (ibuprofen), 400-800 mg every 4 hours as needed. The plan was that he continue his weekly chemotherapy and have his pump refilled every 3 weeks. We had received preapproval from his health maintenance organization for the pump insertion and also for the pump refills. At his first pump refill, he had no pain, and no side effects.

At the end of July, approximately 2 months into his chemotherapy, the patient was shown to have a partial response to his topotecan—a 50% reduction in the size and number of liver metastases—and was functional enough to go fishing, even to take a trip to Canada.

Dr. Krames: I would not have put the pump in this patient because he could be dead the next week—we have certainly seen patients progress that fast with pancreatic cancer. I would have used an external intrathecal catheter to achieve the same results.

Dr. Portenoy: Would you pull out the temporary catheter and then wait a couple of weeks?

Dr. Krames: No, I would have used my temporary intrathecal catheter as my therapy in this patient and I would have continued to use it. Most of these patients are not going to live much more than a month, and a continuous intrathecal temporary catheter works just fine.

Dr. Levy: But we had a 50% reduction in tumor volume from his chemotherapy. We were quite concerned that 2 months out we might start seeing neutropenia. Would we then have problems inserting the permanent system? Would we have to delay his chemotherapy to let his counts recover before we put the pump in? Or would putting a pump in now, with its lower risk of infection, be the best thing for him, as opposed to a temporary system that we could have problems with later?

Dr. Du Pen: If in fact the plan is to proceed with implantation of a pump, my choice would be to consider putting in a port—one single entry into the intrathecal space—and to use the port for the testing. I would convert from the port to the pump if that process works. This avoids a second entry into the intrathecal space.

Dr. Portenoy: What kind of port?

Dr. Du Pen: Just a subcutaneous port, Port-a-Cath, that type of device. That way you enter the intrathecal space once. You don’t have to go back in. But I probably would not have chosen that. My choice would have been the epidural route.

Dr. Portenoy: If you had chosen the epidural route, you would have done that with a percutaneous catheter?

Dr. Du Pen: I would have put in a permanent percutaneous catheter, like one of my catheters (a Du Pen catheter).

Dr. Portenoy: For a trial?

Dr. Du Pen: I would not use a trial. I would simply gain access to the space because then I would have so many drug choices I could use.

Dr. Portenoy: But suppose, for whatever reason, that this patient was being evaluated for implantation of a pump. Would you do an epidural trial to determine the value of a pump?

Dr. Du Pen: On a long-term basis, yes, if I am dealing with a chronic pain patient where I can evaluate the patient for 3 months, 3 weeks—however long it is appropriate to determine the patient’s response. But if I am dealing with an oncology patient, I need to use a different plan. With an oncology patient, if I am planning to determine if the pain is responsive to intrathecal therapies, then I am going to try to put in one device and augment that device—move from the temporary approach to the permanent approach.

Dr. Staats: It is important to note that in 1993, when this patient was treated, 34% of people were given a trial of a single shot of spinal opioids.

Dr. Portenoy: Today, would you do a trial with a percutaneous catheter?

Dr. Staats: Yes, I would try a percutaneous intrathecal catheter, and if it worked, would leave it be. The patient we are discussing has a very short life expectancy. So, in this case I would have done another celiac plexus block. If in fact I have made the decision that this person is going to respond to an intrathecal opioid—potentially be a candidate for intrathecal opioids—I would do an intrathecal trial with a tunneled catheter that is done at the bedside, not a surgical approach.

I would evaluate the response over several days and then I would make a decision based on the person’s life expectancy. If someone has a 2-month life expectancy, I might put in a Du Pen catheter. If somebody has a 6-month life expectancy, I would put in a pump. If somebody has a 1-month life expectancy, I would just leave the catheter where it is.

Dr. Portenoy: If you are putting in the pump, do you pull out the temporary catheter?

Dr. Staats: That is an important point. When I place my temporary catheter, I ask the patient, “If I put in a pump where do you want it?” And they may tell me, “I want it on my right side, over here.” Then I tunnel over to the left and I will pull it out one morning and that afternoon go in and place the catheter. I do not consider that a significant risk of infection.

Epidural vs Intrathecal

Dr. Levy: Would anyone on the panel have done epidural instead of intrathecal?

Dr. Krames: When I started out in 1979, I was doing intrathecal injections. Actually, we were doing daily intrathecal injections until we had access to a pump and that’s why I got into pump therapy, but most people did epidural trials. Now, clearly the question is: Does an epidural trial reflect what’s really happening intrathecally? We do know that the drug crosses the dura and reaches the intrathecal space, but we also know that much of the drug is absorbed in the vascular epidural space, especially if it is a lipophilic drug like fentanyl, and a lot of people are doing fentanyl trials. In effect you are mainly getting a systemic response.

In patients who have opioid responsive pain, and this patient we are discussing certainly does, a trial is not going to tell you anything more other than toxicity. Will the patient be able to tolerate intrathecal therapy? We know it is going to be effective, we just want to know the toxicity. So, my choice in this patient is to put in an intrathecal catheter—and there is no evidence that tunneling the catheter reduces your incidence of infection.

Dr. Staats: It certainly reduces the risk of catheter migration.

Dr. Krames: But there’s no evidence that it reduces the risk of infection. So in this patient I would have placed a percutaneous 24-gauge pediatric spinal catheter through a 20-gauge two-way needle. I would have placed that catheter tip up around T8 because that’s where you need to be. Then I would have attached it to a pump for continuous infusion. This is not a trial. For me, this is therapy.

Dr. Levy: Maybe we were over-optimistic, but this patient’s performance status was really good. He had had no weight loss, and we did not think he was going to die in a month or two. In fact, other than for a short bout with pneumonitis in September of 1993, when we had to give him a short course of antibiotics, he had this pump in place without any change of dose through September of 1994.

Perhaps the reason we did not have any problems was that his tumor responded. So was it the opioid or was it the fact that we stemmed the tide of the tumor? Or was it some combination of the two? He had a little bit of increased pain as his disease started to slowly progress. Still we went 2 months without increasing his dose.

He then was placed on another phase I drug. Now, his pain was a 0.5 out of 10, and he was starting to take a little more breakthrough medicine, orally. In October 1994, the patient clearly had progressive disease, with new lung and liver metastases. His pain was increasing. We started to titrate his intrathecal morphine, first to 12 mg a day, then 16 mg a day. He was starting to feel fatigued. So, we added methylphenidate (Ritalin), thinking that his fatigue was as much from his disease and its therapy as it was from opioids. We continued to increase the intrathecal dose to keep his systemic opioid requirements low.

He completed a couple more chemotherapy courses. Then he started to have pain in other areas, although scans didn’t document progressive disease. We actually thought some of the shoulder pain was referred pain from phrenic nerve distribution.

The Patient Died Quietly at Home

The patient completed another course of chemotherapy. We continued to use his daily requirement for immediate-release morphine to guide our intrathecal morphine dose adjustment. By April of 1995, he was taking 100 mg of morphine a day intrathecally, which controlled his pain. He was taking Ritalin, and a low dose of Decadron (dexamethasone). He finished his chemotherapy and started to have some nausea and delirium from his disease. As his liver failure worsened he developed jaundice. He received care from a local hospice in his community and he died very comfortably at home, approximately 2 years after he had first come to see us.

Dr. Du Pen: Did you have any problems with myoclonic activity?

Dr. Levy: Where we have most often seen myoclonus is when the patient develops some spinal cord compression and then some local concentration below the block. He did not develop any spine metastases. Typically, each time we refilled his pump and increased his dose, we saw an improvement in his pain control. We did not see an acceleration of pain. We did not see any of the classical neuropathic symptoms, and we were looking for them. We were ready to make a change.

The observation by the hospice nurse and the family was that the patient died quietly at home. I think he died from his liver metastases. He needed haloperidol (Haldol) for his delirium, so perhaps that aspect of coanalgesia helped control whatever existential pain he had. We did not see neuropathic symptoms and he did die comfortably.

Hyperalgesia Syndrome

Dr. Portenoy: The so-called hyperalgesia syndrome is a complication of high-dose intrathecal opioid therapy. It typically has been reported at doses above 20 mg/day, and it can come on rapidly without any forewarning. Because of that, there is a hesitancy about rapidly pushing the dose up above a level of 20 mg/day; this is in contrast to systemic therapy, during which we would escalate the dose because the toxicity is overt and cumulative, and you know you are getting into trouble as side effects gradually get worse. The hyperalgesia syndrome is terrible for the patient when it occurs, and it can occur in a full-blown fashion very quickly. It can be very difficult to manage and, in an effort to avoid that, some clinicians will be hesitant at these high doses.

Dr. Krames: If you find that your intrathecal therapy is no longer working, then just like oral therapy, don’t beat a dead horse into the ground. You need to do something for your patient rather than just increase the dose. A well-placed epidural catheter with local anesthetic blocking the splanchnic nerves would have relieved him of a tremendous amount of discomfort at the end.

Dr. Levy: I guess I would go back to what was said earlier—if it is not broke, do not fix it. He was kept comfortable. When we refilled his pump, he did well for another week or so.

Samuel J. Hassenbusch, MD: This was in 1993, and that was appropriate. But in 1999, I think when it starts to go above 20 mg/day, you should seriously consider going to either another opioid or more likely adding bupivacaine or clonidine (Duraclon) to that, rather than escalating the intrathecal dose. You might do better, long term, to switch. In 1993, there were not many options, but in 1999 there are options.

Dr. Levy: I think today I would have gone with bupivacaine. Would you have added, say, 0.75% to the intrathecal mix, or gone to the epidural and titrated?

Dr. Staats: It is important to realize that when you have a situation where you escalated very quickly and were not seeing good results, you may have a catheter malfunction. You might need to disconnect. One has to stop and think about that. Frequently, using a side access port, shooting some dye to assess the situation to make sure the patient is actually getting the drug is important.

The second thing is that you could use a side access port of a Medtronic 8617 pump and connect via Huber needle. Then you do not need to place another epidural catheter. You can use the device that’s already in place if you’ve placed the right device to start with.

Dr. Krames: In our 1993 study that we published in the Journal of Pain and Symptom Management on the addition of bupivacaine, when we looked at nociceptive pain, neuropathic pain, and mixed pain syndromes, we found that the addition of bupivacaine was least beneficial in nociceptive pain syndromes in patients with chronic pancreatitis. It didn’t seem to add anything. I think, however, that clonidine would add something.