Hi there -
Dr. Richeimer has been my doctor since 2003, first as a consultant and then as my primary pm following the announced retirement of my neurolgist of many years in January, 2008 or so.
He's compassionate, brilliant and utterly self-effacing, which is an unusual combination. The only draw-back is that he's stretched pretty thin, and can only see you every 60 - 90 days. That said, his office is great about refilling prescriptions and in the event of any crisis, either he or his clinical fellow will get back to you within hours.
The only thing I know about Dr. Wallace, is that he's been doing some work of late with a relatively low dose of ziconotide (Prialt) for chronic pain - the FDA approved dosing, while serving as a consultant to the manufacturer: which often means that the researcher is charged with bringing in patients to the study with as few other illnesses as possible, so as to minimize the chance for any untoward side-effects that would have to be reported to the FDA. See, "Intrathecal ziconotide for severe chronic pain: safety and tolerability results of an open-label, long-term trial." Wallace MS, Rauck R, Fisher R, Charapata SG, Ellis D, Dissanayake S; Ziconotide 98-022 Study Group,
Anesth Analg. 2008 Feb;106(2):628-37, free full text at
http://www.anesthesia-analgesia.org/...full/106/2/628
Center for Pain Medicine, University of California, San Diego, La Jolla, California 92093, USA. mswallace@ucsd.edu
ABSTRACT
BACKGROUND: Ziconotide is a non-opioid drug indicated for management of severe chronic pain in patients for whom intrathecal (IT) therapy is warranted and who are intolerant of or refractory to other treatments.
METHODS: Six-hundred and forty-four patients with severe chronic pain participated in this open-label, multicenter study. Ziconotide titration was followed by long-term infusion. Efficacy assessments included the Visual Analog Scale of Pain Intensity. Safety was assessed via adverse events (AEs), vital signs, and routine laboratory values.
RESULTS: One-hundred and nineteen patients received ziconotide for > or = 360 days; total exposure was 350.9 patient years. Median duration of ziconotide therapy was 67.5 days (range, 1.2-1215.5 days); mean dose at last infusion was 8.4 microg/d (range, 0.048-240.0 microg/d). Median Visual Analog Scale of Pain Intensity scores at baseline, month 1, and the last available observation up to month 2 were 76 mm (range, 4-100 mm), 68 mm (range, 0-100 mm), and 73 mm (range, 0-100 mm), respectively. Most patients (99.7%) experienced > or = 1 AE. Most AEs were of mild (43.5%) or moderate (42.3%) severity; 58.6% of AEs were considered unrelated to ziconotide. The most commonly reported AEs (> or = 25% of patients) included nausea, dizziness, headache, confusion, pain, somnolence, and memory impairment. Clinically significant abnormalities (> 3 times the upper limit of normal) in creatine kinase levels were reported in 0.9% of patients at baseline, 5.7% at month 1, and 3.4% at ziconotide discontinuation. No drug-related deaths, IT granulomas, or permanent adverse sequelae occurred with ziconotide therapy.
CONCLUSION: We conclude that long-term IT ziconotide is an option for patients with severe, refractory chronic pain.
PMID: 18227325 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
AND
"Long-term intrathecal ziconotide for chronic pain: an open-label study," Webster LR, Fisher R, Charapata S, Wallace MS,
J Pain Symptom Manage. 2009 Mar;37(3):363-72.
ABSTRACT
This open-label multicenter study evaluated the long-term safety and efficacy of intrathecal ziconotide and included 78 patients with chronic pain who had completed one of two previous ziconotide clinical trials. Each patient's initial ziconotide dose was based on his or her dose from the study of origin and was adjusted as necessary on the basis of adverse events and analgesic effect. The median ziconotide dose was 6.48 mcg/day (range, 0.00-120.00 mcg/day) at the Initial Visit and ranged from 5.52 to 7.20 mcg/day across all study visits. The most commonly reported new adverse events that were considered ziconotide related were memory impairment (11.3%); dizziness, nystagmus, and speech disorder (8.5% each); nervousness and somnolence (7.0% each); and abnormal gait (5.6%). There was no evidence of increased adverse event incidence at higher cumulative ziconotide doses. Elevations in creatine kinase were noted, but the proportion of patients with creatine kinase elevations did not change from the Initial Visit to the Termination Visit (4.1% each). Stable mean Visual Analog Scale of Pain Intensity scores during the three years of the study suggested no evidence of increased pain intensity with increased duration of ziconotide exposure. Long-term treatment with ziconotide appeared to be well tolerated and effective in patients whose response to ziconotide and ability to tolerate the drug had been previously demonstrated.
PMID: 18715748 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
This, while the real action with CRPS and Prialt appears to be at significantly higher dosages. See, "Intrathecal ziconotide for complex regional pain syndrome: seven case reports," Kapural L, Lokey K, Leong MS, Fiekowsky S, Stanton-Hicks M, Sapienza-Crawford AJ, Webster LR,
Pain Pract. 2009 Jul-Aug;9(4):296-303.
ABSTRACT
Ziconotide is a nonopioid analgesic currently indicated as monotherapy, but frequently used in combination with opioids, for the management of severe chronic pain in patients for whom intrathecal (IT) therapy is warranted and who are intolerant of, or whose pain is, refractory to other treatments. There is a paucity of information regarding ziconotide use in patients with complex regional pain syndrome (CRPS). Seven cases in which IT ziconotide was used in patients with CRPS were analyzed. All patients (4 male, 3 female; age range, 14 to 52 years) had experienced inadequate pain relief with multiple conventional and interventional treatments. Three patients received ziconotide monotherapy exclusively; 4 patients received ziconotide monotherapy initially, then combination IT therapy. The mean ziconotide dose was 5.2 mcg/d (range, 0.5 to 13 mcg/d) at initiation and 24.7 mcg/d (range, 0.06 to 146 mcg/d) at the last available assessment. The mean duration of ziconotide therapy was 3.1 years (range, 26 days to 8 years). At ziconotide initiation, the mean visual analog scale (VAS) score was 89.3 mm (range, 75 to 100 mm); VAS scores decreased by a mean of 47.5% (range, 5% to 100%) at last assessment. Of the 5 patients who experienced substantial improvement in pain, edema, skin abnormalities, and/or mobility with ziconotide therapy, 2 have discontinued ziconotide and are pain free. Another patient experienced marked reversal of both edema and advanced skin trophic changes. Adverse events included urinary retention, depression, anxiety, and hallucinations. Adverse events generally resolved spontaneously, with treatment, or with ziconotide discontinuation/dose reduction. Although further studies are required, ziconotide holds promise as an effective treatment for CRPS.
PMID: 19500276 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
AND
"An Effective Treatment of Severe Complex Regional Pain Syndrome Type 1 in Child Using High Doses of Intrathecal Ziconotide (Letter to the Editor)," Stanton-Hicks MD, Kapural L,
J Pain Symptom Manage. 2006;6:509-510 free full text (including some amazing before and after pictures) at
http://www.rsds.org/2/library/articl...32_6_pg509.pdf
That said, I'm not sure how significant that distinction ("high" vs. "low dose" Prialt) is, where Lynn Webster M.D., Medical Director of the Lifetree Clinical Research and Pain Clinic, Salt Lake City UT, was listed as an author of both one of the "high" and "low dose" papers. (For an article Dr. Webster wrote four years ago in the RSDSA Review for the CRPS community on the use of Prialt in the treatment of CRPS, pre-dating Dr. Stanton-Hicks' case report, above, see, "Ziconotide in Complex Regional Pain Syndrome," October 7, 2005 at
http://www.rsds.org/3/research/Ziconotide.htm) That, and I know that experimental therapies are only available where there is enough money, grant or otherwise to justify taking a year or more to push through a study proposal before the hospital's Insitutional Review Board. No money, no study. The one exception I had with Dr. Richeimer was in a small "proto-study" of the use of a powerful intestinal antibiotic to knock out a particular type of bacterial fuana that thrived in the gut on opioids, and itself produced neurotoxins. (While the treatment worked, it's my understanding that the NIH grant in support of a larger study never came through.)
Other people may have direct experience with Dr. Wallace, so I would keep asking around. That said, I don't believe you could go wrong with Dr. Richeimer. I've spoken to a number of CRPS patients in LA who've have seen a lot of doctors (including one guy who takes virtually no insurance can only be described as a legend in his own mind) and it's universally agreed that Dr. Richeimer (Chief of Pain Medicine, USC; Director, USC Pain Center: Assoc. Prof Psychiatry and Anesthesiology, USC) is the best overall pm doc in LA.
I hope this is helpful.
Mike