AAPM Abstract Roundup (Part 3)


Roundup: Neuropathic cancer pain; spinal/peripheral neuromodulation; comorbid depressive disorder; morphine and prialt IT therapies; spinal cord stimulation.

Abstract #117Long-Term Management of Neuropathic Cancer Pain with Oxymorphone Extended ReleaseAuthors: Gould E, Slatkin N, Rhiner M, Ma T

Purpose: Opioid therapy has shown efficacy for patients with neuropathic pain in intermediate-term studies; but there is a paucity of long-term data in this population. The analysis included data from patients reporting neuropathic pain who participated in a 1-year open-label extension of a controlled trial of oxymorphone ER for moderate to severe chronic cancer pain. Patients were titrated to an optimal dose of oxymorphone ER every 12 hours, with dose adjustments as needed. Oxymorphone immediaterelease was available as rescue medication. Institutional review board approval and written consent of patients were obtained.

Results: Of 27 patients with neuropathic pain, 10 (37%) completed 1 year of treatment; 3 (18%) discontinued owing to diminished efficacy; 6 (35%) discontinued owing to adverse events including 1 considered treatment related (dry mouth); and the remainder discontinued owing to patient request (n=4), noncompliance (n=3), or other (n=1). Median (range) dose changed from 80 mg (40—327) at baseline to 160 mg (80–360) at month 12. Among patients who completed the study, mean (SD) average pain intensity (100-point scale) was stable over 1 year (32.9 [16.5] at baseline, 32.6 [17.4] at

final visit).

Funding: Endo Pharmaceuticals Inc., Chadds Ford, PA

Abstract #120Spinal and Peripheral Neuromodulation for Angina and MigraneAuthors: Hameed H, MD, Goff B, Ky P, et al

Purpose: Occipital nerve stimulators appear to successfully treat migraine headaches (1,2,3). Yet, acceptance of spinal cord stimulators as an established treatment for severe refractory angina is recent in Europe and awaited within the United States (4,5,6).

Results: This 51-year-old female patient had concurrent severe migraine and pseudotumor cerebri headaches, and Prinzmetal’s angina. Her migraines were severe and associated with ocular aura, nausea, photophobia and hyperacusis and typically lasted 3-4 days. She was seen at our hospital in 2003, for pseudotumor cerebri headaches associated with visual field defects treated with intermittent LPs. Her opening pressures were 200 to 300 mm Hg, but since she failed to show a daily ICP pressure epoch during a 5-day monitoring study, shunt placement was deferred. She was maintained on opioids until 2005, when after successful occipital nerve blocks she had placement of an occipital stimulator. For the following 2 years she had 100%

relief from headaches. In 2007, after several negative cardiac catheterizations she was diagnosed with Syndrome X angina for refractory chest pain, for which she had placement of a spinal cord stimulator. After the procedure she experienced 100% relief of chest pain, and is still currently experiencing at least 75% relief. She still currently experiences 100% relief of migraine-type headache pain. Though she has arelapse of her pseudotumor cerebri headache and is being referred to neurology for shunt placement.

Abstract #121Fibromyalgia and Comorbid Major Depressive Disorder: Assessment of Mood and Pain Response to Duloxetine Hydrochloride Compared to PlaceboAuthors: Iyengar S, Marangell L, Bradley L, Choy E, et al

Purpose: To better understand the clinical course of patients with fibromyalgia (FM) and comorbid Major Depressive Disorder (MDD) treated with duloxetine (DLX). Each site’s ethics committee approved the protocol in accordance with principles of Declaration of Helsinki. Data pooled from 4 double-blind, placebo-controlled, randomized trials of DLX 60-120 mg in patients with FM. Of 1332 patients, 350 (26% [147 placebo, 203 DLX]) had comorbid MDD and were included in these analyses.

Results: No difference was found in pain response across baseline MDD severities (treatment-by-severity interaction p>0.1) or MDD response across baseline pain severities (interaction p>0.1). Path analysis indicated 69% of improvement in pain was direct effect (p=0.09), with improvement in mood accounting for 31%. For mood improvement, 60% was direct effect (p=0.2), and 40% was due to pain improvement.

Funding: Funded by Eli Lilly and Company

Abstract #122Comparison of the Theoretical Cost of Morphine and Prialt IT Therapies with Oral Brand or Generic Medication for Chronic PainAuthors: Jones B, Webster L, Talbott A, et al

Purpose: A monthly and yearly cost comparison of either IT Morphine or Prialt monotherapies to oral brand-name and generic medication regimens was simulated. Doses of oral medications were based upon the author’s clinical experience. IT therapy cost included medication, physician and hospital reimbursement for an initial patient pump screening test, pump/catheter placement at year 1 and 6, and refill/reprogramming costs recurring on a monthly basis. All costs were used from Medicare Part B (ASP 6%) and a national average on oral medications from www.drugstore.com. Results: At year 1, oral brand-name therapy costs were $34,272.00, IT Prialt monotherapy costs were $31,613.40, IT Morphine monotherapy costs were $22,850.28, and oral generic therapy costs were $3,816.00. Generic oral medications remained the least expensive alternative during the 10-year simulation.

Funding: Research grants from Medtronic and Elan

Abstract #123Spinal Cord Stimulation for Pain Management in Chronic Pancreatitis PatientsAuthors: Kapural L, Bensitel T

Purpose: Spinal cord stimulation (SCS) may reduce pain scores and improve function in patients with pain from chronic pancreatitis. We present our retrospective data from the large clinical experience in SCS for visceral abdominal pain.

Results: 24 patients (80%) reported at least 50% pain relief on completion of the trial. Among these, pre-trial VAS pain scores averaged 8±1.6 (SD) and opioid use averaged 165±120 mg morphine sulfate equivalents. During the trial VAS pain scores decreased to 3.67±2 cm (p<0.001, Mann-Whitney Rank Sum Test), and opioid use decreased to 105±101 mg morphine equivalent a day. Six patients failed the trial; one was lost to follow-up; and 18 were followed for the whole year. Six patients were either followed for less than a year (n=3) or the SCS system was removed due to infection or lead migration (n=3). For 18 patients followed for the whole year VAS pain scores remained low (4.0±2.1 cm; p<0.001) at one year, as was opioid use (54±73mg morphine equivalents.

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