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 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 patient and practitioner 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.

Topical and transdermal “pain formulations have wide popularity among health care providers and patients when they are used, but  there are indications that not all providers are familiar with how to  best prescribe them and use them. A study of 120 pain clinicians  revealed that only 27% reported frequently prescribing compounded  topical pain medications, with a success rate of 47%.” Topical and  transdermal preparations are often preferred to oral medications due to  decreased systemic side effects and the avoidance of first-pass hepatic  metabolism. Dosage forms include creams, ointments, and gels; medication  sticks; solutions, and sprays.

Topics in Pain Management: February 2016 – Volume 31 – Issue 7 – p 1–8

Use of Topical Pain Medications in the Treatment of Various Pain Syndromes

Click here to access the PubMed abstract of this article.

In this study, both in patients and controls, topical application of  prazosin 1% cream increased sensitivity to skin cooling but reduced  hyperalgesia to sharp stimulation and allodynia to brushing. Topical  therapy uses smaller doses compared to oral medications, and can help to  prevent systemic side-effects.

Eur J Pain. 2016 Jul;20(6):926-35.

Topical prazosin attenuates sensitivity to tactile stimuli in patients with complex regional pain syndrome.

Click here to access the PubMed abstract of this article.

When compounding medications, a compounding pharmacy must continually  expand its armamentarium of bases, from which the most appropriate base  is selected for the intended use of a compounded preparation.

The results from the in vitro study showed that the ricinoleic acid  PLO gel possessed significantly higher anti-inflammatory activity than  isopropyl palmitate PLO gel. Further testing of the formulation showed  that the ricinoleic acid PLO gel formulation significantly reduced pain  and edema when compared to the isopropyl palmitate PLO gel. In addition,  the ricinoleic acid PLO gel formulation markedly inhibited the  synthesis of prostaglandin E2.

Int J Pharm. 2015 Feb 1;479(1):207-11.

Click here to access the PubMed abstract of this article.

Topical drug treatment aims at providing high concentrations of drugs  at the site of application so as to avoid adverse systemic effects  associated with oral administration. Smart polymers, or  stimuli-responsive polymers, are able to respond to a stimulus by  showing physical or chemical changes in the delivery of the drug carried  by them. The thermo-responsive nature of certain gels such as Pluronic®  F-127 and pluronic lecithin organogels (PLO), makes them excellent  candidates for the delivery of drugs at various application sites. These  bases have attracted particular interest in the formulation of topical  and transdermal delivery systems with regard to promoting, improving or  retarding drug permeation through the skin, bearing in mind that for  topical delivery systems, accumulation in the skin with minimal  permeation is desired, while for systemic delivery, the opposite  behavior is preferred.

J Pharm Pharm Sci. 2012;15(4):592-605.