(790): botulinum toxins in the treatment of occipital neuralgia

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(787) Intra-articular Myobloc (botulinum toxin type b) may be effective in moderate knee osteoarthritis: Preliminary case series D Figa, A Lang; Emory School of Medicine, Lawrenceville, GA Myobloc® (Botulinum toxin type B or BT-B) is FDA-approved for the treatment of cervical dystonia (CD). However, BTs have also demon- strated utility in treating a number of chronic pain conditions. Prelimi- nary reports have demonstrated that intra-articular BT-A may be of benefit for joint pain. This is the first report of the use of intra-articular BT-B in moderate knee osteoarthritis (OA). Patient 1 is a 67yof with mod/severe OA of both knees, patient 2: 65yof/mod/both, patient 3: 57yof/mod/both, patient 4: 64yom/mod/right, patient 5: 62yof/mod/ right, patient 6: 52yof/mod/right, and patient 7: 72yof/mod/left. All had prior steroid and viscosupplementation injections and were tried on a variety of medications including NSAIDs and glucosamine. The injections were performed using a 25g needle (inferomedial or inferolateral ap- proach). The first 4 patients received BT-B 5,000U with 1mL of 0.5% bupivacaine into the affected knee joint (each knee if bilateral). The next 3 patients received 7,500U with 1mL of 0.5% bupivacaine. Patients were followed weekly and responses were assessed using pain VAS (0- 10), patient global subjective response (4 to 4) and pain interference scores (0-10) with various daily activities. Safety was assessed by sponta- neous adverse event reports. The first 4 patients had 3 month follow up data: 1 had a minimal response, 1- moderate response lasting for 1 month and 2 - substantial reduction in pain VAS lasting between 2-4 months (response still ongoing). The remaining 3 patients were demon- strating early substantial pain reductions at the time of submission. Subjective global responses and functional measures paralleled the VAS scores. The injections were well tolerated. Full data on these patients and additional ones planned for future injections will be presented. These cases demonstrate that BT-B may be of benefit in treating mod- erate knee OA pain. Randomized controlled trials are warranted. (788) Cannabis: A unique immunoanalgesic T Mikuriya; California Cannabis Research Medical Group, Berkeley, CA Diagnostic examinations of medically protected California cannabis self- users for management of chronic pain through the substitution of can- nabis for conventional drugs for treatment discloses a list of conditions of immunologic etiology or expression. These conditions control pain by increasing mobility and promoting vegetative functionality. Inhaling, oral, rectal and topical routes are utilized. The wide individual variability encountered in clinical experience is notable. (789) Analgesic efficacy and safety of oxycodone 5 mg/ibu- profen 400 mg compared with oxycodone 5 mg/acet- aminophen 325 mg and hydrocodone 7.5 mg/acetamin- ophen 500 mg in the dental and orthopedic pain models K Newman, J Carsi, S Han; Forest Research Institute, Jersey City, NJ The efficacy and tolerability of combination oxycodone 5 mg/ibuprofen 400 mg (OXY/IBU) was compared with oxycodone 5 mg/acetaminophen 325 mg (OXY/APAP), hydrocodone 7.5 mg/ acetaminophen 500 mg (HYD/APAP), and placebo in 2 double-blind, placebo- and active-con- trolled, single-dose studies, one following dental surgery (OXY MD-16) and the other following orthopedic surgery (OXY MD-14). The main outcome measures of these studies were 6-hour total pain relief (TOT- PAR6), 6-hour sum of pain intensity difference (SPID6), and adverse events. A total of 458 patients experiencing moderate to severe pain following their surgical procedures were randomized to receive OXY/ IBU (n 115), OXY/APAP (n 113), HYD/APAP (n 114), or placebo (n 116). In the 2 studies combined, OXY/IBU provided significantly greater analgesia than OXY/APAP, HYD/APAP, or placebo (P 0.002 OXY/IBU vs any other treatment for both TOTPAR6 and SPID6). When analyzed separately, only the dental pain study showed significantly greater an- algesia over placebo, perhaps highlighting the more sensitive nature of the dental pain model vs the orthopedic model. The typical opioid side effects of nausea and vomiting were lowest in the placebo (7.8 % and 3.4 %, respectively) and OXY/IBU (13.0 % and 4.3 %, respectively) groups. The rates of nausea and vomiting were comparatively higher in the OXY/APAP (20.4% and 14.2%, respectively) and HYD/APAP (14.8% and 6.1%, respectively) groups. In conclusion, in pooled data from den- tal and orthopedic studies, combination oxycodone 5 mg/ibuprofen 400 mg provided superior analgesia over the other opioid/nonopioid com- binations studied, with fewer adverse events. (790) Botulinum toxins in the treatment of occipital neuralgia M Ansarinia, B Carpentier; Pain Medicine Associates, Salinas, CA Myobloc® (Botulinum toxin type B) is FDA-approved for the treatment of cervical dystonia(CD). However, Myobloc has also demonstrated util- ity in treating a number of chronic pain conditions, including myofascial and low back pain, headache and neuropathic pain. The following case reports represent its use in the treatment of occipital neuralgia. GN was a 43 year-old right-handed female with a nine-year history of daily headaches localized to the forehead and occipital area. Initial neurolog- ical exam showed spasms tenderness over the occipitocervical junctions. MRI of the brain with and without contrast was normal. Numerous medications including nortriptyline, gabapentin, topiramate, levatirac- etam, nadolol, phenobarbital, tramadol were ineffective or not toler- ated. She had word-finding difficulty with topiramate. A series or three bilateral occipital nerve blocks (combination of local anesthetic and ste- roid) provided complete headache relief for two weeks each. Myobloc (5000 units) was added to local anesthetic and provided headache relief for greater than 2 months. PG was a 53 year-old female with right occipital neuralgia. She failed oral agents and was treated with BT-A 100 units and local anesthetic, which produced 6 weeks of pain relief with an onset 2 weeks after injection. Her next injection with Myobloc 5000 units (combined with local anesthetic) produced an increased duration of pain relief of 3 months. TW was a 55 year-old man with occipital neuralgia. His pain was intractable to oral agents and was injected with Myobloc 5000 units mixed with local anesthetic. His pain relief has lasted beyond 1.5 months. These 3 case reports demonstrate the potential use of BTs in treating occipital neuralgia. Additional clinical trials are war- ranted. S48 Abstracts

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Page 1: (790): Botulinum toxins in the treatment of occipital neuralgia

(787) Intra-articular Myobloc (botulinum toxin type b) may beeffective in moderate knee osteoarthritis: Preliminarycase series

D Figa, A Lang; Emory School of Medicine, Lawrenceville, GAMyobloc® (Botulinum toxin type B or BT-B) is FDA-approved for thetreatment of cervical dystonia (CD). However, BTs have also demon-strated utility in treating a number of chronic pain conditions. Prelimi-nary reports have demonstrated that intra-articular BT-A may be ofbenefit for joint pain. This is the first report of the use of intra-articularBT-B in moderate knee osteoarthritis (OA). Patient 1 is a 67yof withmod/severe OA of both knees, patient 2: 65yof/mod/both, patient 3:57yof/mod/both, patient 4: 64yom/mod/right, patient 5: 62yof/mod/right, patient 6: 52yof/mod/right, and patient 7: 72yof/mod/left. All hadprior steroid and viscosupplementation injections and were tried on avariety of medications including NSAIDs and glucosamine. The injectionswere performed using a 25g needle (inferomedial or inferolateral ap-proach). The first 4 patients received BT-B 5,000U with 1mL of 0.5%bupivacaine into the affected knee joint (each knee if bilateral). Thenext 3 patients received 7,500U with 1mL of 0.5% bupivacaine. Patientswere followed weekly and responses were assessed using pain VAS (0-10), patient global subjective response (�4 to �4) and pain interferencescores (0-10) with various daily activities. Safety was assessed by sponta-neous adverse event reports. The first 4 patients had 3 month follow updata: 1 had a minimal response, 1- moderate response lasting for 1month and 2 - substantial reduction in pain VAS lasting between 2-4months (response still ongoing). The remaining 3 patients were demon-strating early substantial pain reductions at the time of submission.Subjective global responses and functional measures paralleled the VASscores. The injections were well tolerated. Full data on these patientsand additional ones planned for future injections will be presented.These cases demonstrate that BT-B may be of benefit in treating mod-erate knee OA pain. Randomized controlled trials are warranted.

(788) Cannabis: A unique immunoanalgesicT Mikuriya; California Cannabis Research Medical Group, Berkeley, CADiagnostic examinations of medically protected California cannabis self-users for management of chronic pain through the substitution of can-nabis for conventional drugs for treatment discloses a list of conditionsof immunologic etiology or expression. These conditions control pain byincreasing mobility and promoting vegetative functionality. Inhaling,oral, rectal and topical routes are utilized. The wide individual variabilityencountered in clinical experience is notable.

(789) Analgesic efficacy and safety of oxycodone 5 mg/ibu-profen 400 mg compared with oxycodone 5 mg/acet-aminophen 325 mg and hydrocodone 7.5 mg/acetamin-ophen 500 mg in the dental and orthopedic pain models

K Newman, J Carsi, S Han; Forest Research Institute, Jersey City, NJThe efficacy and tolerability of combination oxycodone 5 mg/ibuprofen400 mg (OXY/IBU) was compared with oxycodone 5 mg/acetaminophen325 mg (OXY/APAP), hydrocodone 7.5 mg/ acetaminophen 500 mg(HYD/APAP), and placebo in 2 double-blind, placebo- and active-con-trolled, single-dose studies, one following dental surgery (OXY MD-16)and the other following orthopedic surgery (OXY MD-14). The mainoutcome measures of these studies were 6-hour total pain relief (TOT-PAR6), 6-hour sum of pain intensity difference (SPID6), and adverseevents. A total of 458 patients experiencing moderate to severe painfollowing their surgical procedures were randomized to receive OXY/IBU (n � 115), OXY/APAP (n � 113), HYD/APAP (n � 114), or placebo (n �116). In the 2 studies combined, OXY/IBU provided significantly greateranalgesia than OXY/APAP, HYD/APAP, or placebo (P� 0.002 OXY/IBU vsany other treatment for both TOTPAR6 and SPID6). When analyzedseparately, only the dental pain study showed significantly greater an-algesia over placebo, perhaps highlighting the more sensitive nature ofthe dental pain model vs the orthopedic model. The typical opioid sideeffects of nausea and vomiting were lowest in the placebo (7.8 % and3.4 %, respectively) and OXY/IBU (13.0 % and 4.3 %, respectively)groups. The rates of nausea and vomiting were comparatively higher inthe OXY/APAP (20.4% and 14.2%, respectively) and HYD/APAP (14.8%and 6.1%, respectively) groups. In conclusion, in pooled data from den-tal and orthopedic studies, combination oxycodone 5 mg/ibuprofen 400mg provided superior analgesia over the other opioid/nonopioid com-binations studied, with fewer adverse events.

(790) Botulinum toxins in the treatment of occipital neuralgiaM Ansarinia, B Carpentier; Pain Medicine Associates, Salinas, CAMyobloc® (Botulinum toxin type B) is FDA-approved for the treatmentof cervical dystonia(CD). However, Myobloc has also demonstrated util-ity in treating a number of chronic pain conditions, including myofascialand low back pain, headache and neuropathic pain. The following casereports represent its use in the treatment of occipital neuralgia. GN wasa 43 year-old right-handed female with a nine-year history of dailyheadaches localized to the forehead and occipital area. Initial neurolog-ical exam showed spasms tenderness over the occipitocervical junctions.MRI of the brain with and without contrast was normal. Numerousmedications including nortriptyline, gabapentin, topiramate, levatirac-etam, nadolol, phenobarbital, tramadol were ineffective or not toler-ated. She had word-finding difficulty with topiramate. A series or threebilateral occipital nerve blocks (combination of local anesthetic and ste-roid) provided complete headache relief for two weeks each. Myobloc(5000 units) was added to local anesthetic and provided headache relieffor greater than 2 months. PG was a 53 year-old female with rightoccipital neuralgia. She failed oral agents and was treated with BT-A 100units and local anesthetic, which produced 6 weeks of pain relief with anonset 2 weeks after injection. Her next injection with Myobloc 5000units (combined with local anesthetic) produced an increased durationof pain relief of 3 months. TW was a 55 year-old man with occipitalneuralgia. His pain was intractable to oral agents and was injected withMyobloc 5000 units mixed with local anesthetic. His pain relief has lastedbeyond 1.5 months. These 3 case reports demonstrate the potential useof BTs in treating occipital neuralgia. Additional clinical trials are war-ranted.

S48 Abstracts