Pain Management

Pain Management

 

Pain management is essential because even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation, or taking pleasure in their usual roles in the family and society.
Chronic pain may have a myriad of causes and perpetuating factors, and therefore can be much more difficult to manage than acute pain, requiring a multidisciplinary approach and customized treatment protocols to meet the specific needs of each patient.

Oral Pain Killers are absorbed systemically, which often cause the following side effects:

  1. Stomach Discomfort
  2. Constipation
  3. Dizziness
  4. Confusion
  5. Drowsiness
  6. Dry Mouth
  7. Addiction/Dependence in some cases

Although oral painkillers may sometimes be necessary, it is best to take the least possible amount needed. This would lower the risk of side effects and dependence on drugs.
A person living with pain might not need to take oral medications that will affect the whole body systemically when a topical cream/gel could treat pain by offering high local concentrations at the site of application or trigger point application. Studies have shown when topical compounded pain relievers are applied transdermally, they are not absorbed through the gastrointestinal tract and do not undergo first-pass hepatic metabolism. First-pass hepatic metabolism often limits the effect of oral painkillers.

Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents, and NMDA (N-methyl-D-aspartate) antagonists. NMDA-receptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. [Anesth Analg 2001 Mar;92(3):739-44] By combining various agents which utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used.

Neuropathic Pain

Neuropathic Pain Symptoms
Symptoms of neuropathic pain often include persistent burning pain in areas involving affected nerves, along with swelling and muscle damage. Foot neuropathy is a common type of neuropathic pain among diabetics and patients often describe it as “walking on pins and needles”.

Topical Analgesics for Neuropathic Pain in the Elderly

Elderly patients exhibit a higher incidence of several neuropathic pain conditions than younger individuals. Systemic treatment of neuropathic pain in the elderly usually requires lower dosing, slower titration, and more monitoring (for efficacy, adverse effects) than in younger patients due to drug factors (altered pharmacokinetics and pharmacodynamics) and patient factors (comorbidities, polypharmacy, frailty). “Despite the availability of several options, treatment of neuropathic pain is not optimal, as medications provide only a partial effect and adverse effects can limit dose escalation, resulting in suboptimal dosing. An often quoted perspective is that less than 50% experience satisfactory pain relief, and side effects are common.”

Summary of perspectives on topical analgesics and relevance to the elderly:
1. Topical analgesics are beneficial in a proportion of those with neuropathic pain, and can produce a degree of analgesia that is comparable with that of oral agents.
2. Topical analgesics are well tolerated, with adverse effects being mainly due to localized skin reactions. Low systemic levels occur following topical administration, and do not contribute to systemic adverse effects or drug interactions.
3. Topical analgesics may be used as alternative analgesics (when systemic analgesics are not tolerated) or as add-on analgesics when an oral agent produces a partial effect (their addition does not increase the side effect burden).
4. Only a limited number of topical analgesics are currently approved, but there is interest in investigational agents that recruit several potential mechanisms of action, and additional options may become available.
5. Topical analgesics have the potential to contribute to improved pain management in the elderly based on their efficacy, adverse effect profile, potential for use as add-on therapies, and potential for oral analgesic-sparing effects with ensuing reduction in adverse effects.

Drugs Aging. 2014 Dec;31(12):853-62.

Topical analgesics for neuropathic pain in the elderly: current and future prospects.
Click here to access the PubMed abstract of this article.

NSAID Therapy:

“Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of pain associated with a variety of indications, including arthritic conditions, but their usefulness is often limited by dose-dependent adverse events such as gastrointestinal disturbances, cardiovascular events, and renal toxicity. The risk of such effects could be reduced by the use of topical formulations, which offer the potential to deliver analgesic concentrations locally, at the site of inflammation, while minimizing systemic concentrations… Meta-analyses have confirmed the efficacy and safety of these [TOPICAL] preparations. However, it is important to recognize that pharmacokinetics [and] absorption from topical formulations can vary markedly, even between different formulations of the same drug, depending on the agent, the underlying disorder, and the site of application. It is therefore essential to consider the patient, the drug, and the drug delivery mechanism when selecting a topical NSAID preparation.”

Am J Ther. 2012 Feb 22. [Epub ahead of print]
Topical Nonsteroidal Anti-Inflammatory Drugs: The Importance of Drug, Delivery, and Therapeutic Outcome.
Click here to access the PubMed abstract of this article.

To avoid the risks of COX-2 inhibitors, our pharmacy can compound topically applied NSAIDs such as ketoprofen or Diclofenac. Topical NSAIDs have a safety profile which is superior to oral formulations. Topical NSAID administration offers the advantage of local, enhanced delivery to painful sites with a reduced incidence of systemic adverse effects.
Topical preparations can be customized to contain a combination of medications to meet the specific needs of each patient.
“Topical non-steroidal anti-inflammatory drugs have a lower incidence of gastrointestinal adverse effects than the same drugs when they are taken orally. The low incidence of systemic adverse effects for topical NSAIDs probably results from the much lower plasma concentration from similar doses applied topically to those administered orally. Topical application of ibuprofen resulted in measurable tissue concentrations in deep tissue compartments, more than enough to inhibit inflammatory enzymes.”

BMJ. 1995 Jul 1;311(6996):22-6
Topical non-steroidal anti-inflammatory drugs and admission to hospital for upper gastrointestinal bleeding and perforation: a record linkage case-control study.
Free full text article available at bmj.com:
http://bmj.bmjjournals.com/cgi/content/full/311/6996/22

A double-blind placebo-controlled crossover trial showed that in patients with Complex Regional Pain Syndrome (CRPS; also known as Reflex Sympathetic Dystrophy), topical application of ketamine 10% cream caused a reduction in allodynia, a most unpleasant aspect of this condition. This study shows promise for the use of topical ketamine as opposed to parenteral and oral forms which often result in undesirable side effects.

Pain. 2009 Nov;146(1-2):18-25.

Reduction of allodynia in patients with complex regional pain syndrome: A double-blind placebo-controlled trial of topical ketamine.                                                                                     

Click here to access the PubMed abstract of this article.