Chronic Pain and Hypnotherapy

Source of Featured Image:

A pocket watch going through a hypnotizing motion

Dear Pain Matters blog readers,

Hypnosis including hypnotherapy and self-hypnotherapy has been used for pain management for thousands of years.  In fact, until the 19th century, hypnosis was the the sole treatment available to undergo surgery with reduced pain and suffering (Braid, 1847).

In essence, self-hypnosis may be a common experience involving an altered state of conscious awareness that may occur many times throughout each day.  Some people describe self-hypnotherapy as being similar to ‘tuning out’, daydreaming, being in a trance-like, or meditative, state or having an ‘out of body experience’.  A hypnotic experience may involve:

  • Disassociation, where the patient’s perception of his/her environment including pain is temporarily reduced;
  • Intense concentration or focused attention; and
  • Suggestibility, whereby the patient may involuntarily respond to verbal and non verbal communication.

Hypnotherapy treatment for pain management may be offered by medical hypnotherapists, and has proven to be particularly effective for treating children (e.g. during treatment of needle phobia, renal dialysis).  Clinicians may use hypnotherapy to help manage a range of conditions including phobias, addictions, anxiety, acute pain (e.g. childbirth pain, surgical pain, burns dressings) and chronic pain.  Anaesthetists in Belgium often use hypnosis as an adjunct to general anaesthesia during removal of the thyroid gland, mastectomy and plastic surgery.

Until recently, scientific evidence for (self-) hypnotherapy’s potential role in chronic pain management was virtually non existent.  Current studies report that intervention involving hypnosis may result in significant decreases in chronic pain, and that hypnotherapy was often more effective than non hypnotic interventions including physical therapy, education and attention (Elkins et al, 2007).

Imaging studies show that hypnosis can modulate activity in the anterior cingulate cortex (ACC).  The ACC links the sensory cortex (that processes the sensory part of pain) with the limbic brain regions (that process the affect, unpleasant or suffering aspect of pain as well as related negative emotions).

Autogenic Training:

In addition to hypnotherapy, a relaxation technique called Autogenic Training that involves self-hypnotherapy may also be useful for inducing the relaxation response.  For more details, please refer to my earlier Blog Post:   (Does Autogenic Training Lead to Less Pain?)


Hypnosis including self-hypnosis (e.g. Autogenic Training) can result in real and tangible physiological effects and may be able to reduce chronic pain.  As such, (self-) hypnotherapy may be a useful addition to an overall pain management strategy.

Hypnosis has no known adverse effects if properly done by qualified medical hypnotherapists who have the chronic pain patient’s best interests in mind.

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.



(1a) Explainer: How Does Hypnosis Relieve Pain?

The Conversation (21 June 2012)

(1b) Hypnosis for Chronic Pain Management

Oxford University Press Blog (16 March 2013)

Jensen, Mark

(1c) Hypnosis Takes Your Mind Off Chronic Pain

Scott, Sophie

ABC News (16 September 2011)

Peer-Reviewed Papers

(2a) Elkins G, Jensen MP, Patterson DR.

Hypnotherapy for the Management of Chronic Pain.

The International journal of clinical and experimental hypnosis. 2007;55(3):275-287.


(2b)  Elkins G, Johnson A, Fisher W.

Cognitive Hypnotherapy for Pain Management.

Am J Clin Hypn. 2012 Apr;54(4):294-310.

History of Hypnosis and Surgical Pain

(3) Braid, James

On Esdaile & Hypnotic Anaesthetic (from The Complete Writings of James Braid) – Letter to The Medical Times (1847)

For German readers

(4) Meichsner, Irene. Wenn der Schmerz Schmilzt. Bild der Wissenschaft (01.07.1999).


Medical Cannabis (Medical Marijuana) and Nerve Pain

Source of Featured Image:

Dear Pain Matters blog readers,

Cannabis has been used for medicinal benefits including pain relief by many cultures for hundreds of years or more.  While some patients smoke cannabis for medicinal purposes, others may prefer to make cannabis tea or bake cannabis cookies.


Is Medicinal Marijuana Effective for Nerve Pain?:

The use of marijuana for chronic pain relief is not new.  Many patients attest to its ability to relieve pain, while many physicians acknowledge its efficacy in patients with intractable pain who were otherwise left with few other options.

According to Mark Ware, Pain Clinician, McGill University, Montreal, Canada, endogenous cannabinoids bind with cannabinoid receptors presynaptically, blocking the release of neurotransmitters in pain-producing pathways, resulting in less pain.

As agonists, synthetic (e.g. nabilone – see earlier  Blog Post, referenced below) and plant-derived cannabinoids (i.e. derived from marijuana) bind with these same cannabinoid receptors, leading to reduced pain.   (Nabilone for Chronic Pain Including Nerve Pain (e.g. CRPS))

Sativex (Nabiximols, in US):

Sativex (Nabiximols), a cannabis-based mouth spray, was approved in the UK as adjunctive treatment for relief of neuropathic pain in multiple sclerosis (MS).  Some trials showed that Sativex significantly reduced neuropathic pain, spasticity, muscle spasms and sleep disturbances in some MS patients.  Care must be taken to manage adverse effects including dizziness, sleepiness, fatigue, dry mouth and drowsiness.  The long-term effects including risk of tolerance are unknown (Perras, 2005). 

Sativex (Nabiximols) is approved in Canada for the treatment of nerve pain and spasticity in MS as well as cancer pain.

Smokeless Delivery Systems Including Vaporizers and Cannabis Inhalers:

Due to the risk of lung damage that may be caused by smoking medicinal cannabis, smokeless delivery systems including vaporizers (and soon, cannabis inhalers) may be useful.

Vaporizers can avoid possible lung damage as they can be used to heat the medicinal cannabis herb sufficiently without burning it nor creating smoke.  Vaporized cannabis has analgesic efficacy at low dose with minimal and well-tolerated psychoactive effects (Wilsey et al, 2013).

Research into cannabis inhalers is currently being done that uses cannabis processed into granules.  This device ensures that dosages are better controlled and that blood tetrahydrocannabinol (THC) delivery levels remain well below ‘recreational levels’ (i.e. that can lead to a ‘high’).  This particular study involving 8 patients with chronic nerve pain showed a 45% reduction in pain intensity, 20 minutes post-inhalation (that returned to baseline within 90 minutes).  The only adverse effect was lightheadedness that lasted 15-30 minutes and that did not require intervention (Eisenberg et al, 2014).

Is Medicinal Marijuana Legal?: 

Please check with local authorities including local physicians regarding the legalities of medical marijuana. 

In Australia, marijuana is legal in most states and territories for certain medical conditions and only if prescribed by a doctor.

In the US, the sale and possession of cannabis was recently decriminalized for both medical and recreational users who are of legal age in 5 states (Alaska, Colorado, Oregon, Washington and Washington DC).  However, marijuana possession or use (medical or otherwise) is still illegal and considered a federal crime under federal law in the US.  

In Canada, medical marijuana use is legal as long as the patient has a licence for this.  As of 24 August 2016, medical marijuana patients can grow their own ‘limited amount’.

Medical marijuana via doctor’s prescription was legalized in March 2017 in Germany. The Federal Health Minister, Hermann Gröhe, stated:

‘Our goal is that seriously ill people are looked after to the best of our ability.’

Gröhe added that health insurance companies should cover the costs of medical marijuana in cases where treatment alternatives do not exist.

In Switzerland, marijuana is legal since 2016 as long as the tetrahydrocannabinol (THC) component is less than 1%.  Legally restricting THC in cannabis to very low levels will ensure that a recreational ‘high’ will not occur (as opposed to THC-rich cannabis that can cause a recreational ‘high’). Thus, THC-poor cannabis is legal in Switzerland.

On the other hand, the cannibinoid (CBD) component of marijuana (aka CBD-Cannabis) is legal as it does not lead to a recreational ‘high’. Importantly, it may offer pain relief, reduced nausea and other medical benefits.

Medical cannabis is legal in other countries including Uruguay, Israel and Jamaica.


Medical marijuana may offer pain relief today to patients with severe, intractable pain where other pain treatments have failed.

Quoting Mark Ware:

[The pharmaceutical approach is] “promising, highly protected with patents, and highly financially rewarding [and] will take 5 to 10 years.  We have patients struggling now and need to figure out how to use this [medical marijuana] today.”  


Source of photo:

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.



Is Medicinal Marijuana Effective for Nerve Pain?

(1a) Treating Neuropathic Pain With Cannabis: Pro and Con

Debate-Style Session at World Congress on Pain Focuses on Safety, Efficacy of Marijuana for Neuropathic Pain

Pat McCaffrey

Pain Research Forum (22 Dec 2014)

Attachment (Slides by Mark Ware):

(1b) Researchers Urge Medical Marijuana Over Opioids to Treat Neuropathic Pain

Mike Hager

Is Medicinal Marijuana Legal?

United States of America

(2a) State Medical Marijuana Laws

20 July 20 2016


(2b) Medical Marijuana Patients Can Grow ‘Limited Amount’ of Cannabis at Home Under New Laws – Change Comes After Federal Court Said Old Rules Were Unconstitutional

Andrew Foote

CBC News (11 August 2016)

(2c) Medical Marijuana Easier to Grow at Home With New Rules – Some Doctors Say Medical Cannabis is Safer than Opiates, While Others Say It’s Too Unpredictable

Julia Wright

CBC News (25 Aug 25 2016)


(2d) Senate passes medicinal cannabis legislation

Jane Lee

Sydney Morning Herald (24 February 2016)


(2e) Germany to Legalize Medicinal Marijuana by 2017

Joshua Berlinger

CNN (4 May 2016)

In German

(2f) Schmerztherapie – Hype um vermeintliche Wunderarznei: Was Cannabis kann – und was nicht.

Sabine Dobel, Gisela Gross

Stern (3 June 2017)–was-das-mittel-kann—und-was-nicht-7479856.html

This article also includes the following 2-minute video (also in German):–die-krux-des-freien-kiffens-6805902.html?utm_source=social&utm_medium=share&utm_campaign=artikel-video


(2g) Swiss cannabis entrepreneurs develop craving for low-potency pot.

Marina Depetris, John Miller

Reuters (22 March 2017).

In German

(2h) Kiffen light – so wirkt das legale Cannabis aus der Schweiz

Laila Keuthage

Stern (17 May 2017)—so-wirkt-das-legale-cannabis-aus-der-schweiz-7448666.html

Peer-Reviewed Papers

(3) Wilsey B, Marcotte TD, Deutsch R, Gouaux B, Sakai S, Donaghe H.

Low Dose Vaporized Cannabis Significantly Improves Neuropathic Pain.

The Journal of Pain (2013);14(2):136-148.


(4) Perras C.

Sativex for the Management of Multiple Sclerosis Symptoms.

Issues Emerg Health Technol. 2005 Sep;(72):1-4.

(5) Eisenberg E, Ogintz M, Almog S

The Pharmacokinetics, Efficacy, Safety, and Ease of Use of a Novel Portable Metered-Dose Cannabis Inhaler in Patients With Chronic Neuropathic Pain: A Phase 1a Study

Journal Of Pain & Palliative Care Pharmacotherapy (2014); 28(3)

Medical Cannabis Support Groups

(6) Medical Cannabis Users Association (MCUA) of Australia

Patient Anecdotes – Patient Testimonials

Patient Videos – Patients Speak Out

Menstrual Pain and Combined Oral Contraceptives

Dear Pain Matters blog readers,

I chose today’s topic because period pain affects more than half of all adolescent women and many young adult women.  It also used to be a dreaded part of my life until I went on ‘the Pill’ at 18 (shortly after meeting my husband-to-be).

I can tell you many personal stories about my painful menstrual cramps (prior to going on the Pill) including one time when I asked a fellow university student to please find a wheelchair and ‘just wheel me into the sick room’ (at the university) – which she did, and another time when I almost fainted during a university midterm exam – that coincided with the most intense part of my period pain that month.  Needless to say, my period pain had reduced my answers to an unintelligible scrawl on that particular exam.  My period pain was often so severe that I had to vomit and immediately lie down….no matter where I was at that time.  This would lead to some awkward moments not only for myself, but also for those around me at the time (to say the least).

Guess what?  All this misery stopped as soon as I went on the Pill!  The Pill did not take my monthly period pain away, but it certainly dropped the pain levels down by a good notch or 2.

A Swedish Study:

Up to 50-75% of all female teenagers suffer from painful periods.  The pain can be so severe that ~15% of adolescent and young women regularly miss school and work.  This monthly disability can result in 600 million hours of ‘sick leave’ and $2 billion in lost productivity in the USA alone. 

Quoting Ingela Lindh, lead author of a Swedish study that explored the effects of combined oral contraceptives on period pain:

“[Painful periods] can have a detrimental effect on these women’s lives, causing regular absenteeism from school and work, and interfering with their daily activities for several days each month….Therefore effective management of dysmenorrhea is beneficial for both the women affected and society.”

This Swedish study confirmed what many women (including myself) already know – that combined oral contraceptives may indeed offer relief from painful menstrual periods (dysmenorrhea).



Approximately 1,400 women born in 1962, 1972 and 1982, living in Gothenburg, Sweden, and who took combined oral contraceptives (i.e. that included both oestrogen and progestin) were randomly selected for inclusion in this longitudinal Swedish study.  Women who took progestin-only pills were excluded from this study.

The women in this study were surveyed twice, 5 years apart (once at 19, and once again, at 24).  The women agreed to complete written questionnaires including detailed questions about their:

  • Period pain;
  • Method(s) of contraception;
  • Pregnancy history; and
  • Height and weight.

The answers to these questionnaires were then properly compiled and analysed.


The study showed that combined oral contraceptives decreased the severity of painful menstrual periods (dysmenorrhea) more than increasing age and childbirth (Lindh et al, 2012).

Quoting Ingela Lindh, Institute of Clinical Sciences, Gothenburg University, Sweden:

“We found there was a significant difference in the severity of dysmenorrhea depending on whether or not the women used combined oral contraceptives.”

Please note:

Please allow yourself to be regularly monitored by your GP for any adverse effects if you decide to take combined oral contraceptives.

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.

PS  By the way, cannabis-derived cannabidiol (CBD) and Corydalis may also reduce the intensity of painful menstrual periods.  For more details, please refer to:




(1) Szalavitz, Maia

Birth Control Pills Provide Real Relief from Menstrual Pain – A New, Long-Term Study Finds that The Pill Really Does Help with Painful Periods.

TIME (20 January 2012)

(2) Conley, Mikaela

Combination Oral Contraception Pills Cut Menstruation Pain

ABC News (18 January 2012)

(3) Borland, Sophie

Yes, the Pill CAN Ease the Agony of Period Pain: Scientists Confirm What Millions of Women Already Know

Daily Mail UK (18 January 2012)

Peer-Reviewed Paper

(4) Lindh I, Andersson-Ellström A, and Milsom I.

The Effect of Combined Oral Contraceptives and Age on Dysmenorrhoea: An Epidemiological Study.

Hum. Reprod. (2012) 27 (3): 676-682.



Headache/Migraine and Constipation – Is there a Link?

Dear Pain Matters blog readers,

A Korean study found that 25% of young patients with ongoing headaches and migraines also had constipation that, when resolved, also resulted in improved symptoms concerning their headaches/migraines.

While young patients with constipation-predominant irritable bowel syndrome (constipation-predominant IBS; IBS-C) were excluded from this study, it is reported that 25%-50% of all IBS patients also suffered from persistent migraines or headaches.

Details of Study:

A total of 96 children (46 males, 50 females; aged from 3 to 17), who were treated for ongoing headaches/migraines and followed up for >100 days, were allocated into 2 groups:

  • Group A – Children (17 males, 7 females) with ongoing headaches/migraines who also had constipation, and whose headaches/migraines improved following treatment for constipation only (n=24; 25%).  Specifically, Group A included children with:
    • Tension-type headache (including probable tension-type headache) (n=16); and
    • Migraine (including probable migraine) (n=8),


  • Group B – Children (29 males, 43 females) whose headaches/migraines were not linked with constipation (n=72; 75%).


The Korean study found that the headaches/migraines automatically improved in all young headache/migraine patients following resolution of constipation, where their constipation was linked with their headaches/migraines in the first place (n=24/96, or 25% of all young patients).

This suggests a possible link between headache/migraine and constipation in ~25% of young patients (Park et al, 2015).

This is a sobering revelation, and one that should not be ‘glossed-over’ nor overlooked.  Instead, research should explore whether constipation (including constipation in IBS patients) may be linked with chronic headaches/migraines in some patients.

As a starting point, clinicians are urged to always ask their headache/migraine patients whether they also have constipation.  

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.


Park M-N, Choi M-G, You SJ.

The relationship between primary headache and constipation in children and adolescents.

Korean Journal of Pediatrics. 2015;58(2):60-63.


Successful Treatment of Primary Erythromelalgia with Ziconotide (Prialt)

Dear Pain Matters blog readers,

Here is an interesting case:

Primary Erythromelalgia Treated with Intrathecal Ziconotide:

A 31-year old woman suffered from primary erythromelalgia for most of her life.  Symptoms included:

  • Painful reddish skin and swelling in both feet and lower legs;
  • Loss of vision in right eye and severely impaired vision in left eye (due to bilateral congenital glaucoma, exophthalmos/abnormally protruding eyeballs and megalocornea);
  • Constant erythema and excessively warm lower legs;
  • Severe pain including:
    • Intense burning throughout both the lower legs;
    • Allodynia near the perimalleolar regions in both ankles; and
    • Hyperalgesia in bilateral gastrocnemius and instep (arched part of feet).

Physical examination confirmed warmer skin temperatures in the lower legs, very strong burning pain (10/10, when lying very still) and swollen ankles.  The skin on her feet was thickened, red and ulcerated, due to her habit of immersing her feet in cold water as often as possible (as part of self-medication).  Refer to (a) in first photo.  

March 2010 –

After trying ‘almost everything’, a decision was made to trial and implant an intrathecal pump drug delivery system in March 2010.

A low titration schedule from 0.3 mcg/die to 1.2 mcg/die of ziconotide was commenced.  This resulted in complete resolution of both allodynia and hyperalgesia.

Dosage was increased to 1.8 mcg/die.

It is noteworthy that the severe swelling and oedema in both lower legs and feet was significantly improved after 1 week of ziconotide treatment.  Refer to (b) in first photo.

CRIM2015-592170.001.jpgSource:   Russo et al, 2015

April 2013 (3 Years Later) –

In April 2013, the patient presented 4 days late for pump recharging.  This delay resulted in both legs and feet being swollen with burning pain.  Refer to (a) in below photo.  

Following (4-day-delayed) refill, her legs and feet were no longer swollen 2 days later, and there was nil burning pain 1 week later.  Refer to (b) in below photo.  

CRIM2015-592170.002.jpgSource: Russo et al, 2015


The woman no longer had to immerse her feet in cold water resulting in improved skin appearance.  She was able to rest in a bed now (instead of staying up in a chair for months).  Overall, ongoing intrathecal ziconotide treatment offered an improved quality of life for the patient.

Long-term use of intrathecal ziconotide does not lead to addiction or tolerance.


Ziconotide exerts its analgesic effects by potently and selectively blocking neuronal N-type voltage-sensitive calcium channels at the presynaptic level, hence inhibiting neurotransmitter release.


It is promising to see that severe pain including burning pain, hyperalgesia and allodynia, as well as swelling, redness and excessive warmth of lower legs and feet in patients with primary erythromelalgia may be managed by intrathecal ziconotide treatment in some cases.

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.


Russo R, Caroleo MC, Cione E, Perri M, Paparo MT, Russo A.

Dual Effect of Ziconotide in Primary Erythromelalgia.

Case Reports in Medicine (2015); Volume 2015, Article ID 592170, 4 pages.






Is There a Link Between Prolonged Psychological Stress And Physical Pain?

Featured Image of the ocean near the beach in the sun taken by myself. 

Dear Pain Matters blog readers,

Prolonged psychological stress can perpetuate chronic pain in some patients, while other people may be prone to chronic inflammatory diseases including cardiovascular disease, type II diabetes, depression, autoimmune diseases, upper respiratory infections and poor wound healing ability.

Immune cells are normally very sensitive to circulating stress hormones (glucocorticoids including cortisol), and as such, are usually able to shut down the pro-inflammatory response in the presence of glucocorticoids.

Chronic psychological stress can reduce the circulating stress hormone’s ability to interact with its receptor leading to glucocorticoid receptor resistance (GCR).

Repeated and ongoing exposure to a long-term threatening (real or imagined) and stressful experience can lead to insufficient glucocorticoid regulation (i.e. GCR), that in turn can lead to:

  • Insufficient control over the inflammatory response towards an infection;
  • Increased duration and/or intensity of the pro-inflammatory response; and
  • Increased pain levels and other signs and symptoms of chronic diseases.  

Studies have shown that some chronic stress sufferers (e.g. parents of children with cancer, spouses of patients with brain cancer and lonely people) present with GCR (Cohen et al, 2012).

Other Biomechanisms that Influence the Pro-Inflammatory Response and its Key Role in Maintaining Chronic Pain and Inflammation-Based Diseases:

See this Blog Post for more information:

What Can Done To Reduce Prolonged Psychological Stress?:

Steps must urgently be taken to reduce repeated and ongoing exposure to a prolonged threatening (real or imagined) and stressful experience.

This brings us to all those therapies that may induce the ‘relaxation response’ and/or lead one to a calmer disposition including:


Any therapy that can induce the ‘relaxation response’ is key to diverting attention away from repeated and ongoing psychological stress.

This will strengthen the immune cells’ ability to interact with circulating stress hormones (glucocorticoids including cortisol) and shut down an exaggerated pro-inflammatory response.

Conventional pharmacological treatment also plays an important role in reducing excessive inflammation.  The effectiveness of pharmacological drugs may be further enhanced by the body’s ‘relaxation response’, leading to lower drug dosages and fewer adverse effects.

The body’s innate ability to properly control a pro-inflammatory response is key to warding off chronic pain and disease.

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.



(1) Study Finds Link Between Stress And Physical Pain

Huffington Post (03 April 2012)


(2) Clynes, Manfred

Sentics: The Touch of Emotions

250 pp, Doubleday/Anchor, New York, 1977 – Chapter 9 only

Peer-Reviewed Paper

(3) Cohen S, Janicki-Deverts D, Doyle WJ, et al.

Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk.

Proceedings of the National Academy of Sciences of the United States of America. 2012;109(16):5995-5999.



Ziconotide (Prialt) and Complex Regional Pain Syndrome – 2 Successful Cases

Dear Pain Matters blog readers,

Almost 2 years ago, I wrote a Blog Post called:

Ziconotide (Prialt) for Nerve Pain Including CRPS?

Quoting from my older Blog Post:

“….Ziconotide for 7 CRPS Patients ….. 2 patients had complete pain relief and as such, discontinued Ziconotide treatment altogether…… (Kapural et al, 2009).”

I find it fascinating that intrathecal (IT) ziconotide treatment resulted in complete pain relief for these 2 patients.

It is worthwhile elaborating further on these 2 former CRPS1 patients here:

(1) Patient 1 –

A male patient (Patient # 1, 16 years old, male) had CRPS1 in both of his legs following an Achilles tendon tear 2 years earlier.  He suffered burning pain, hypersensitivity to touch/temperature changes and loss of proprioception in both feet.  Pain management treatments including lumbar sympathetic blockade and various oral medications were unsuccessful.  The patient used a wheelchair for mobility.

During a ziconotide trial, dosages were titrated from 2.4 mcg/d to 24 mcg/d over 3 months.  His VAS score reduced from 100 mm to 40 mm by the 4th month of the ziconotide trial, and he was able to upgrade from a wheelchair to a cane for mobility.

The patient underwent IT pump implantation, and dosages were titrated from 5 mcg/d to 7.5 mcg/d over a 7 month period (with some side effects that were treated).

During the 2nd year, ziconotide dosage was reduced to 4.5 mcg/d.  The patient was finally pain-free, and he was able to resume normal activities.

By the 3rd year, ziconotide dosage was further reduced to 1.2 mcg/d, and he stopped taking oral medications altogether.  The patient continued ziconotide treatment (ranging from 1.2 to 1.4 mcg/d) for another 4 years, and this enabled him to be pain-free and active.

Post-7 years ziconotide treatment, during which he remained pain-free, (quoting from page 299) ‘his IT pump was filled with normal saline in preparation for an explanation’ (Kapural et al, 2009).

(2) Patient 2 – 

A female patient (Patient # 2, 32 years old, female) had CRPS1 in both of her legs due to a fall 5 years earlier.  The patient suffered burning pain and hypersensitivity to touch/temperature changes, and she preferred to use a wheelchair for mobility.  Pain management treatments had failed her completely including multiple oral medications, lumbar sympathetic blockade and spinal cord stimulator, SCS (VAS score, 100 mm).

Following a successful ziconotide trial, she agreed to IT pump implantation.  Dosages were gradually titrated upwards from 10 mcg/d to 145.5 mcg/d over 2 years, with no adverse events.  The patient continued at this dosage of 145.5 mcg/d for another 6 years.

After 8 years of ziconotide treatment, the IT pump no longer worked.  While waiting for a new IT pump, the patient noticed that she no longer had any pain.  As such, she stopped taking systemic opioid medication.  She was also able to walk without an assistive device.  Her defective IT pump and SCS were surgically removed one month later.

A year following removal of her IT pump and SCS, the patient remained pain free (VAS score, 0 mm) and had returned to college (Kapural et al, 2009).


Ziconotide treatment (via a spinally-implanted pump) can offer significant pain relief, and may even, at appropriate dosages, lead to full recovery from CRPS1 for selected CRPS patients.  

It is paramount that ziconotide be titrated to avoid serious side effects.  The importance of correct dosage was discussed at great length in an earlier Blog Post:

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.

PS For those of you who want to learn more about cone snails (that inspired medical research into ziconotide), here is a 2 – 3 minute YouTube called ‘Killer Cone Snails’.  

NB If you find aggressive animal behaviour disturbing, please refrain from watching this YouTube:


(1) Kapural L, Lokey K, Leong MS, Fiekowsky S, Stanton-Hicks M, Sapienza-Crawford AJ, Webster LR (2009)

Intrathecal Ziconotide for Complex Regional Pain Syndrome: Seven Case Reports.

Pain Practice (2009), 9: 296–303.


More on Intrathecal Delivery of Ziconotide –

(2) Palca, Joe

Snail Venom Yields Potent Painkiller, But Delivering The Drug Is Tricky

3 August 2015