Botox Jabs: A New Weapon Against Chronic Pain

Jan. 17, 2008 — -- People will try almost anything to get rid of pain: heat, ice, nasty smelling oils, magnets or even the potentially toxic chemicals found in spores of deadly bacteria.

That's right — for some, a purified form of the botulinum toxin, better known by the brand name Botox, may be a solution for recurring pain.

For the past five years, a growing number of pain specialists have found that the same injections used to relax wrinkles can also relax painful muscle spasms. And there's even an added benefit in that while standard injections for pain relief numb a muscle for three days, Botox may work for three months without many side effects.

But before anyone with a pulled muscle or tension headache decides to begin feeding the billion-dollar-a-year Botox business, it might be time for a reality check — and a price check.

For starters, botulinum toxin type A has only won the U.S. Food and Drug Association's approval for treatment of wrinkles and a handful of rare medical conditions, not including muscle pain. A patient must decide whether ending the pain relief is worth the risk of going "off label," not to mention the $600-per-bottle price tag rarely covered by insurance.

Surprising Relief

The cost was worth it if for Adrienne Groza, 42, a retired San Diego police officer who suffered with pain for more than a decade.

Groza's painful past could match any episode of "Miami Vice." In 1993, a drunken driver ran a red light and T-boned her new police cruiser. She went into a 360-degree spin before slamming sideways to a stop.

Three months later, a drunk who confused Groza with his ex-girlfriend became violent, and the altercation revealed that her bad neck pain from the accident was much more than whiplash.

"We were wrestling with him on the ground and my back locked up," said Groza.

The pain after the incident led her to see a doctor, who diagnosed her as having three bulging disks in her neck — one of which was on the verge of rupturing into her spinal cord. She was forced to retire.

For several years, Groza searched to find relief. Eventually an orthopedic surgeon successfully fused the three discs. But in 2004, another traffic collision broke her neck again, forcing her to go through a second, more extensive, disc fusion surgery.

"Unfortunately, even when the surgeries go well, people are left with severe muscle spasms where they can't even turn their heads," said Groza's pain specialist, Dr. Joe Shurman, chairman of the pain committee at Scripps Hospital in La Jolla, Calif.

"I was in so much pain, I had so much muscle tension that my muscles were like rubber bands," said Groza. "The minute he got [the Botox injection] in me, it was like instant relief."

Groza says the surgery, followed by the Botox procedure, was what brought her pain down to a tolerable level.

Even her doctor was surprised. "I personally didn't think it was going to work that well, especially with a patient who had two [neck] surgeries," said Shurman.

Finding a New Use

Pain specialists can't predict how patients will respond to pain treatment, and frequently they have to improvise to find the best medicine with the fewest side effects.

"Often the [health-care] provider must be creative — the art of medicine — in order to come up with an option that might just work for their patient," said Dr. Lloyd Saberski, editor in chief of the journal The Pain Clinic.

"Much of the practice of pain medicine makes use of off-label approaches," said Saberski.

Dr. Joshua Prager, director of the Center for the Rehabilitation of Pain Syndromes at UCLA Medical Plaza, started using botulinum toxin in 1994, eight years before it was approved for cosmetic wrinkle removal. Back then botulinum toxin was used to treat muscle spasms responsible for crossed eyes, as well as rare neurological disorders with involuntary muscles spasms called dystonia.

"If it relaxes muscles when you have dystonia, it's going to relax your muscles anytime," Prager recalled thinking.

He says that people suffering from intense pain often have a combination of nerve pain and muscle pain. Therefore, reducing muscle pain may either stop a spiraling cycle of pain, or at least relieve it temporarily.

Prager estimates he's treated muscle pain with Botox close to 1,000 times over the years. Though he says that the procedure is safe and that he's never seen any major side effects in his patients, he has heard tales where botulinum toxin injections for pain have gone wrong.

Inject botulinum toxin into the wrong part of the neck, says Prager, and a person can suffer from vocal cord paralysis for three months. Inject it into the wrong part on both sides of the neck, and theoretically a patient could suffocate from a collapse of their vocal cords on both sides. And of course, doctors can't use botulinum toxin in the muscles you need to move, like your legs.

For now, at least, the risks of side effects are only part of the list of considerations for patients. Until botulinum toxin gets FDA approval for use in pain relief, the price of treatment might be more painful than the pain.

"When I started using it in 1994, it was $250 a bottle," said Prager. "Now it's $600 a bottle, and they just keep raising the price."