Background: Intrathecal drug delivery has undergone a revitalization following a better
understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes,
clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and
indications. We review the current understanding of the pharmacology of commonly employed
intrathecal agents and the clinical relevance.
Methods: Search strategies for data acquisition included Medline database, PubMed, Google scholar,
along with international and national professional meeting content, with key words including
pharmacology of opioids, intrathecal therapy, ziconotide, pharmacokinetics, and intrathecal drug delivery.
The search results were limited to the English language.
Results: Over 300 papers were identified. The literature was condensed and digested to evaluate the most
commonly used medications in practice, sto serve as a foundation for review. We review on-label
medications: ziconotide and morphine, and off label medications including fentanyl, sufentail, and
Conclusion: Intrathecal therapy has level-one evidence for use for malignant pain and nonmalignant pain,
with continued cost savings and improved safety. To most effectively serve our patients, a clear
appreciation for the pharmacology of these commonly employed medication is paramount.