What are the factors that may lead to dose escalation?
There are many reasons for escalating dose requirements, frequently referred to as “tolerance.” True physiological/pharmacological tolerance may occur (i.e., alterations in drug receptors within the central nervous system). Drug diffusion through spinal fluid and into the spinal cord may become impaired (e.g., arachnoid scarring or cyst, granuloma, or inflammatory mass formation at the catheter tip). Increasing dose requirements can also signal changes in the patient’s pain disorder. The underlying disease for which the patient is receiving therapy may progress (e.g., cancer, osteoarthritis), new pain disorders may arise, and/or changes in psychosocial factors may exacerbate the pain disorder. Some patients, once having achieved a degree of pain relief, increase their level of activity and work up to their level of pain tolerance. Outcomes expectations may be unrealistic, leading patients to request increasing amounts of medication to achieve the degree of pain relief they hope for. Th
