Pain Management
Pain is inevitable. Suffering does not have to be. Everyone experiences some sort of pain at a point in their lives, but for some, pain can be chronic and something they live with daily. There are many commercially available pain relief medications that help with the chronic pain of conditions such as arthritis, fibromyalgia, migraine headaches, and other nerve and muscle pains, but they can also have unwanted side effects like drowsiness, dizziness or stomach irritation. While many patients accept these side effects as the cost of relief, we at La Quinta pharmacy offer an alternative solution by compounding various medications which would produce none of the dreaded side-effects of the commercially available medications.
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.
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. 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.
Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically. Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. When medications are administered transdermally, they are not absorbed through the gastrointestinal system and do not undergo first-pass hepatic metabolism.
We work together with prescriber and patient to solve problems by customizing medications that meet the specific needs of each individual. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate for your patient.
What is Neuropathic Pain?
Neuropathic pain is a complex, chronic pain state that usually is accompanied by tissue injury. With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional, or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury.
One example of neuropathic pain is called phantom limb syndrome. This rare condition occurs when an arm or a leg has been removed because of illness or injury, but the brain still gets pain messages from the nerves that originally carried impulses from the missing limb. These nerves now misfire and cause pain.
Managing Neuropathic Pain
The following article discusses the use of topical ketamine 0.5% (5 mg/ml) gel, applied as a thin film two to three times daily over the skin where pain was severe. Topical ketamine reduced pain for patients with postherpetic neuralgia with no systemic side effects.
Neurology. 2003 Apr 22;60(8):1391-2
The following randomized, double-blind, placebo-controlled study assessed the analgesic efficacy of topical administration of 3.3% doxepin hydrochloride, 0.025% capsaicin or a combination applied daily for 4 weeks in 200 adult patients with chronic neuropathic pain, and reported that all three preparations significantly reduced overall pain.
The following article concluded: a fixed combination of indomethacin 25 mg, prochlorperazine dimaleate 4 mg, and caffeine 75 mg is significantly more effective than sumatriptan in the acute treatment of migraine attacks versus sumatriptan 25 mg, both rectal suppositories. It is notable that the combination is also less expensive than sumatriptan per unit dose.
Headache. 2003 Sep;43(8):835-44
The following article concluded: oral therapy with a combination of LAS (equivalent to 900 mg ASA) and metoclopramide 10 mg was superior to placebo with therapeutic gains of 30% and 31% for the first treated attack, and was comparable to 100 mg sumatriptan. This highlights the effectiveness of combined oral lysine acetyl salicylate and metoclopramide (Migpriv) in the treatment of migraine attacks.
- Ketoprofen topical or transdermal gel
- Ketamine transdermal gel
- Ketamine/Ketoprofen/Gabapentin transdermal gel
- Lidocaine/Prilocaine topical gel
- Triple-Anesthetic gel – benzocaine/lidocaine/tetracaine (“BLT”)
- Gabapentin/Clonidine in PLO (Pluronic Lecithin Organogel)
- Piroxicam tablet triturates
- Ibuprofen suppositories
- Ketoprofen/Cyclobenzaprine topical gel
All formulations are customized per prescription to meet the unique needs of each patient. Please call us to discuss the dosage form, medication, and strength which are most appropriate for your patient.
To avoid the risks of COX-2 inhibitors, our pharmacy can compound topically applied NSAIDs such as ibuprofen and ketoprofen. 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 NSAIDs for Acute & Chronic Pain
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
The following article concluded: “topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions.”
Many options to deliver anesthesia have developed over the last several decades. Administration of topical anesthetics to control pain associated with procedures such as laceration repair may avoid the need for infiltrative local anesthesia injections and associated pain from the injections. Topical anesthesia also avoids the risk of wound margin distortion that exists with infiltrative injection administration. Many dosage forms exist (e.g. gels, sprays, creams, ointments, patches) and provide the clinician with precise options for application under various circumstances.
The following article concludes: “LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) worked as well as TAC gel (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT gel appears to be better suited than TAC gel for topical anesthesia in laceration repair in children.”
Pediatrics. 1995 Feb;95(2):255-8
The following article reported that a triple-anesthetic gel containing benzocaine, lidocaine, and tetracaine (“BLT”) applied prior to treatment with a 532-nm KTP laser resulted in significantly lower pain scores than with 3 other topical anesthetics at 15, 30, 45, and 60 minutes after application.