Understanding the Intrathecal Pain Pump: A New Era in Chronic Pain Relief

Welcome back to The Kentucky Pain Reversal Show! In today’s episode, pain management expert Dr. Ajith Nair to take an in-depth look at one of the most advanced and often misunderstood, tools in modern pain care: the intrathecal pain pump. After covering the journey of chronic pain from injury to treatment in previous episodes, this conversation pivots to real-world solutions. Dr. Ajith Nair explains how pain pumps work, why delivering medication directly into the spinal fluid is so revolutionary, and what kinds of patients stand to benefit most from this life-changing therapy. If you or a loved one has ever wondered about alternatives to pills and surgery for chronic pain, this episode is full of valuable insights and actionable information.

00:00 Introducing the pain pump topic

04:45 How pain pumps work

06:53 Discussing pain pump trials

10:28 Discussing medication tolerance and delivery

15:09 Preemptive pain management strategy

18:51 Pain pump success stories

21:52 Challenges with pain pump management

25:41 Accessing and managing the catheter

26:45 Patient's recovery and risky behavior

Podcast Website - https://thekentuckypainreversal.com/

Dr. Ajith Nair Clinic - https://kentuckianapainspecialists.com/

Media Partner - https://tophealth.care/

Transcript

SPEAKER_01 0:00

When a medicine is delivered through the gastrointestinal system or through the blood system, a lot of that medicine can get metabolized and it doesn't reach the N receptors, which in this case are in the brain and spinal cord. So much so, with a pain pump, you only need to deliver a fraction of the amount that you would be delivering compared to what you would take by mouth. While using a pain pump, the amount of drug that's delivered is one over 300 of the oral dose. And that's a very, very small dose.

SPEAKER_00 0:59

From the initial injury to medications, to early treatment decisions, to surgery, and even the broader opioid landscape here in Kentucky. Today we begin shifting from understanding the problem to exploring real solutions. One of the most advanced and often misunderstood tools in modern pain care is the intrathecal pain pump. In this episode, Dr. Nyer explains how the pain pump works, who they're for, and why they can be a life-changing option for the right patients. So let's continue. Hi, Dr. Nyer. How's it going?

SPEAKER_01 1:31

Hi there, Jamie. Going great, and I'm glad to be here today.

SPEAKER_00 1:34

Awesome. Excited to dive into the pain pump. You've talked about this uh before many times in our past episodes. I'm excited to unpack this a little bit more today. Um, all right, so we've obviously talked about pills, surgeries, and the system and kind of the process and how it goes to um, you know, treat an injury or long-standing pain that a patient has. But today we're going to start talking more about those solutions. So, what exactly is the intrathecal pain pump?

SPEAKER_01 2:04

Well, actually, I brought along a uh model of the pain pump. So a little bit like a show and tell here. So, this is the actual pump that is implanted. Attached to this part of the pump is a small tube that goes into the spine and into the spinal fluid. So, this is what it looks like, and it's got a reservoir inside and a computer that can regulate the total amount of medications going through every hour. So, it's pretty precise. This device has been around for nearly 40 years, so the technology is pretty ripe and up to date and accurate. So, what is the pain pump? The pain pump is a device that will deliver pain medication directly into the spinal fluid. Now, the spinal fluid is in contact with the brain and spinal cord, and this is where all the pain receptors in the body are located. The benefit of a pain pump over pain pills is that the pain pump will allow medications for pain management to be delivered right to where the receptors are, compared to when you take it orally, which involves passing through the gut and passing through the bloodstream. And in that process, the potency and the availability of the drug diminishes dramatically because of lack of absorption and metabolism that occurs in the liver. So when a medicine is delivered through the gastrointestinal system or through the blood system, a lot of that medicine can get etabolized and it doesn't reach the N receptors, which in this case are in the brain and spinal cord. So much so that with a pain pump, you only need to deliver a fraction of the amount that you would be delivering compared to what you would take by mouth. So, for instance, while using a pain pump, the amount of drug that's delivered is one over three hundredth of the oral dose. And that's a very, very small dose, and it causes fewer side effects and it prevents the patient from developing a tolerance and dependence.

SPEAKER_00 4:39

That is tremendous. And I'm gonna um I have some follow-up questions for you on the difference in the medication dosage and why that's important in just a little bit. But first, I think it could be potentially a little intimidating for a patient to hear the word implant as a solution. Um, I know you just showed us what the pump looks like, but how is it actually looked? What's inside the body, what's outside the body, how is it placed? What is that process like?

SPEAKER_01 5:10

Well, the process, let's say when a patient comes in and they've told me that they have chronic pain, you know, I I first thing that I would do is ascertain what types of treatment they've already had. Now, if they've already done the conservative treatments like physical therapy, muscle relaxants, anti-inflammatory injections, or even surgeries, and if they still continue to have chronic pain, that's when I start the conversation with the patient regarding a pump. The first thing we would do is we would do a pain pump trial, which is a small test dose that we would deliver, again, in the spinal fluid, and we want to see whether this works for the patient. Does it control their pain? Does it have any side effects like itching? And if they don't have any side effects and they've got good control of pain, that's when we talk about the surgery that's involved in implanting the pump. Now, as I said earlier, the pump consists of this reservoir along with a catheter. Both of these will be implanted right under the skin. So it's not major surgery, but it does involve general anesthesia. There will be two incisions, one in the midline, which is about maybe three centimeters in length, and one is in the side of the low back, which would be about five centimeters in length. The longer incision is where the pump will reside, which is the reservoir, and the one in the middle would be where the catheter will enter. It's a pretty straightforward surgery. I usually am done within about 35 to 40 minutes, and um therefore the the anesthesia time is very low, also. Um, the entire procedure is done under X-ray guidance, so I know precisely where the needle is going, where the catheter is going. And, you know, because the patient is under genital anesthesia, they are not going to feel any of the surgery.

SPEAKER_00 7:15

Of course. And so very routine, pretty standard, um, kind of like almost like riding a bike a little bit. So nothing to really fear, as it's as it's it seems like a pretty straightforward, quick, uh, and painless uh procedure. Obviously, because there's an incision, there will be a little bit of recovery time, but not probably nothing significant. So again, nothing to be fearful or intimidated by uh from what you just described.

SPEAKER_01 7:43

Right. I always tell my patient, all you got to lose is your pain.

SPEAKER_00 7:48

I love it. I love it. All right. So you mentioned um a few minutes ago that the pain pump only uses a fraction, I believe you said uh one three hundredth of the medication compared to taking a pill orally. So tell us more about how that works.

SPEAKER_01 8:05

Well, because the medicine that's going through the pain pump bypasses the gastrointestinal system, it bypasses the circulation, that's the reason why you don't have to give that much of medicine because now it's directly reaching the pain receptors in the spinal cord and brain. So that's the reason why we don't have to use that much.

SPEAKER_00 8:30

Excellent, excellent. So, why is delivering that medication directly into the spinal fluid so much more effective? Um why why is it a perhaps a preferred method uh than just taking pills?

SPEAKER_01 8:45

Well, what I've seen is when you take pills for an extended period of time, there is bound to be some tolerance. And as we discussed before, tolerance is when you need more of the medicine and it doesn't last as long. So here, the tolerance occurs because part of that drug that you're taking by mouth is either metabolized in the liver or it doesn't get fully absorbed into the bloodstream from the stomach. So there's quite a lot of wastage. Whereas when the medicine is delivered through the pump, there is absolutely no wastage. It's directly going to the receptors and less amount of medication, fewer side effects, better pain control, and happier patients.

SPEAKER_00 9:30

Happier patients is important. Um, because we're giving the patients less medicine, right? Do you see that it's an extended period of time, or even maybe they don't even build up tolerance in, or they build up tolerance in a fraction of the time that they would with pills?

SPEAKER_01 9:48

Well, you know, I would be lying if I say that the patient doesn't develop tolerance, but they develop tolerance very, very slowly. And therefore, what I've seen is after the implant, we will slowly titrate the medicine to where the patient's pain is around one to two out of ten, or maybe no pain. And then I don't really need to see the patient getting the medications elevated thereafter. They very rarely require increases in dose. So that itself tells you that there's very little tolerance that's built, and we can still control their pain using very small amounts of medicine.

SPEAKER_00 10:31

Right. That sounds like a win all the way around for my ears. Um, many patients too can worry about side effects like feeling sedated or confused or high, right? How does uh the pump and does the pump change that experience for them?

SPEAKER_01 10:48

Well, because of what we discussed earlier, very small amounts of medicine are going into the spinal fluid every hour. In fact, when we look at what the total dose is in a day, it is so small that we're not able to detect it if we did a urine toxicology. Because so little of that drug spills into the systemic circulation and therefore it doesn't appear in the urine. So that's how low the amount is.

SPEAKER_00 11:18

That's tremendous. Uh, who would you say is the ideal candidate for pain pump? Is there an ideal candidate? Um, and at what point in that pain journey should someone start considering that as an option?

SPEAKER_01 11:33

Well, I I think uh that patients should talk to their pain specialists, discuss what are the treatment options, and also to evaluate what things that they've already done. If they've done the things that I mentioned earlier on, like physical therapy, chiropractic, injections, surgeries, and if there doesn't seem to be a way to reduce the amount of pain pills that they're taking despite these treatments, then it is time to consider the pain pump. Even patients who have cancer, if let's say the cancer has spread, I think just that event itself is enough to consider a pain pump, especially if they're having a fair amount of pain, which is not controlled by the pain pills that they're being prescribed. There is a concept called preemptive analgesia. Essentially, what it is, is that you try to control the pain before it flares up. So very often, when we're treating patients, we know that there's certain conditions where the pain will eventually flare up. So, for example, if you've got a patient who's got cancer, let's say cancer of the lungs, and they have now found out that there has been spread to a distant organ, especially to the spine. Now we know that can be painful. So before the pain gets out of control, it would be a good idea to talk to the patient about a pain pump. Because if we talk to the patient after they've developed this spread to the spine and now the pain is unbearable at 10 out of 10, then you would need to give more medications for pain to control it. But if you anticipate this and talk to the patient about a pump and do the trial and maybe even the implant, we notice that the overall amount of pain medications used is much lower. Let's give another example. Let's say a patient has been involved in a pretty horrific car accident where they've suffered multiple fractures. Of course, they would have to first get treatment for the acute situation, the multiple acute fractures. And most often rather than not, these patients will end up having chronic pain. And this chronic pain is unlikely to get better with any forms of treatment, whether it's pain pills or surgical intervention. They're bound to have residual chronic intractable pain. And these patients will also benefit significantly from a pain pump.

SPEAKER_00 14:18

Okay, so Dr. Nyer, we just talked about a few different conditions where the pain pump would be helpful. Uh, what other conditions respond particularly well to the pain pump therapy treatment?

SPEAKER_01 14:29

Well, I've had many patients who've had multiple back surgeries, neck surgeries, and they still rate their pain at about eight or nine out of ten. Those patients would benefit from a pain pump. I've had patients who've had multiple sclerosis, who've had pain pump, uh, rheumatoid arthritis. Any condition that causes chronic pain that patients are receiving pain pills for would be a good condition to be treated with a pain pump. Because at the end of the day, the patient who now has a pain pump will be taking fewer pain pills, fewer drugs like gabopentin or uh pregablin or antidepressants, muscle relaxants, or non-steroidal anti-inflammatories? All of those medications can be replaced because now with the pain pump, your pain's better controlled.

SPEAKER_00 15:22

All right. We love to see that. Um, from a long-term perspective, how does a pain pump uh impact quality of life compared to ongoing oral medication usage?

SPEAKER_01 15:36

Well, one of the most common things I hear patients say is I wish I knew about the pain pump 10 years ago. Um, many patients who have come to see me that have had failed treatments, I've had a number of patients who've come with failed uh uh treatments for headaches. So they continue to have chronic intractable pain, they are you know shut up in their homes in a dark environment because of their chronic migraines. And once we talk about a pain pump because they failed all the other uh conservative treatments, they are willing to consider the pain pump. They go through the trial, they get the pump implanted, and their their headaches are controlled. And it gives them such a new lease on life. They're able to spend time with their family, play with their children or grandchildren, and just go about doing their daily business without pain. So that's what I've seen occur more often than not. Um, we watch our patients after the pain pump very carefully for the first four to six weeks. So we minimize any type of uh untowards events, make sure their incisions heal well, make sure they're having good improvement in their pain quality. And so overall, that's what I've seen make the patient's journey and their quality of life better.

SPEAKER_00 17:00

I love to hear that. It sounds like 10 out of 10 from the patient reviews all the way around. Um, so that's really excellent that you've had such success with that as uh a treatment. So, everyone, the pain pump, if you're a great candidate, it might be the way to go. Um, thanks so much, Dr. Nyer, for those wonderful answers and information today. Today's conversation highlights something really important that sometimes the most effective solutions in medicine aren't necessarily about doing more, but they're about doing things more precisely. For many patients, the idea that pain can be controlled with a much smaller, targeted dose of medication is both surprising and encouraging. And for those who have struggled with long-term pain or side effects from oral medications, it opens the door to a different kind of possibility. The message here is still loud and clear lower the pills, lower the surgeries, stop the pain. We'll see you next time. Thank you, Dr. Nyer.