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Pain Management

pain


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.

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 prialt, 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.

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.


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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;60:1391-1392

Topical ketamine treatment of postherpetic neuralgia

Dianna Quan, MD, Mary Wellish, BS and Donald H. Gilden, MD
Departments of Neurology (Drs. Quan and Gilden, M. Wellish) and Microbiology (Dr. Gilden), University of Colorado Health Sciences Center, Denver.

No abstract available. Click here to purchase the full article on line.

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.

Br J Clin Pharmacol 2000 Jun;49(6):574-9

Topical application of doxepin hydrochloride, capsaicin and a combination of both produces analgesia in chronic human neuropathic pain: a randomized, double-blind, placebo-controlled study.

McCleane G
Pain Clinic, Craigavon Area Hospital, 68 Lurgan Road, Craigavon, BT63QQ5, N. Ireland.

Click here to access the PubMed abstract of this article.


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Migraine

The following article concludes: 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.

Headache. 2003 Sep;43(8):835-44

Efficacy of a fixed combination of indomethacin, prochlorperazine, and caffeine versus sumatriptan in acute treatment of multiple migraine attacks: a multicenter, randomized, crossover trial.

Di Monda V, Nicolodi M, Aloisio A, Del Bianco P, Fonzari M, Grazioli I, Uslenghi C, Vecchiet L, Sicuteri F.
Neurology Division I, Spedali Civili di Brescia, Italy.

Click here to access the PubMed abstract of this article.

The following article concludes: 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.

Funct Neurol. 2000;15 Suppl 3:196-201

The effectiveness of combined oral lysine acetylsalicylate and metoclopramide (Migpriv) in the treatment of migraine attacks. Comparison with placebo and oral sumatriptan.

Tfelt-Hansen P.
Department of Neurology, Glostrup Hospital, University of Copenhagen, Glostrup, DK-2600 Glostrup, Denmark.

Click here to access the PubMed abstract of this article.


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NSAID Therapy

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 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.?1 Topical NSAIDs have not been associated with renal failure.2

1 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.

Evans JM, McMahon AD, McGilchrist MM, White G, Murray FE, McDevitt DG, MacDonald TM.
Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee.

Free full text article available at bmj.com:
http://bmj.bmjjournals.com/cgi/content/full/311/6996/22

Click here to access the PubMed abstract of this article.

The following article concludes: ?Topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions.?

BMJ. 1998 Jan 31;316(7128):333-8

Quantitative systematic review of topically applied non-steroidal anti-inflammatory drugs.

Moore RA, Tramer MR, Carroll D, Wiffen PJ, McQuay HJ.
University of Oxford, Oxford Radcliffe Hospital, Headington, UK

Click here to access the PubMed abstract of this article.

The following article reports ?The systemic concentrations of ketoprofen have also been found to be 100 fold lower compared to tissue concentrations below the application site in patients undergoing knee joint surgery. Topically applied ketoprofen thus provides high local concentration below the site of application but lower systemic exposure.?

Pharm Res. 1996 Jan;13(1):168-72
Percutaneous absorption of ketoprofen from different anatomical sites in man.

Shah AK, Wei G, Lanman RC, Bhargava VO, Weir SJ.
Pfizer Inc., Central Research Division, Groton, Connecticut 06340

Free full text article available at bmj.com:
www.bmj.bmjjournals.com/cgi/content/full/316/7128/333

Sever disease is the most common cause of heel pain in pre-pubertal children. This inflammatory condition is a result of minor repetitive trauma and typically occurs during a growth spurt or at the beginning of a new sport season. A case report described the use of topical ketoprofen 10% gel to relieve pain and inflammation.

Phys Ther. 2006 Mar;86(3):424-33
Ketoprofen gel as an adjunct to physical therapist management of a child with Sever disease.

Click here to access the PubMed abstract of this article.


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Topical Anesthetics

B&O Suppositories

B&O Suppositories are used for relief of moderate to severe pain associated with rectal or bladder spasms that may occur postoperatively or secondary to cancer. Recently, these have been on back order. When medications are not commercially available, call our compounding pharmacy.

At Columbia- New York Presbyterian Hospital, physicians examined whether acetaminophen with codeine administered per rectum is an effective alternative for pain control compared with oral administration after an adenotonsillectomy. In a prospective, randomized control study, 75 children aged 1 to 5 years were assigned randomly to receive either rectal or oral postoperative pain medication. Equivalent postoperative pain control was achieved with suppositories and oral medication, with few side effects and good tolerance. Total number of doses given per day were similar. Furthermore, many parents preferred the suppositories to oral medication in maintaining postoperative pain control because of ease of administration. If given the choice for future surgeries, many parents would switch or consider switching from oral pain medication to suppositories.

Laryngoscope 2006 Aug;116(8):1485-8

Acetaminophen with Codeine: Oral vs. Rectal Administration in Postoperative Pediatric Patients

Owczarzak V, Haddad J Jr.
Department of OTO/HNS at Columbia, New York Presbyterian Hospital, 180 Fort Washington Avenue, New York, NY 10032, USA.

Click here to access the PubMed abstract of this article.

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

Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years.

Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT
Department of Medicine, Louisiana State University, New Orleans.

Click here to access the PubMed abstract of this article.

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.

Cosmetic Dermatology 2003 Apr;16(4):35-7

Topical Triple-Anesthetic Gel Compared With 3 Topical Anesthetics

Lee MWC
Department of Dermatologic Surgery, University of California, San Francisco


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Topical Opioids

The use of topical morphine gel is reported in two children with epidermolysis bullosa, where acute inflammatory pain is a major symptom and where effective analgesia is a major clinical problem.

Arch Dis Child. 2004 Jul;89(7):679-81
Peripheral opioids in inflammatory pain.

Click here to access the PubMed abstract of this article.

Morphine sulfate 10 mg in Intrasite gel was applied topically to skin ulcers of hospice inpatients. The topical morphine was not absorbed in the majority of patients, suggesting any analgesic effect was mediated locally rather than systemically.

J Pain Symptom Manage. 2004 May;27(5):434-9
The bioavailability of morphine applied topically to cutaneous ulcers.

Click here to access the PubMed abstract of this article.


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Examples of compounded medications

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.

  • 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

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