Paaven Patel, Operations and Quality Assurance Pharmacist at Specialist Pharmacy discusses pain management.
Pain is the main reason patients seek healthcare, affecting more than 1.5 billion people worldwide, and, despite innovations in pain research and knowledge, pain is still inadequately treated. (1)
Current challenges in pain management include harmful systemic side effects, insufficient therapeutic efficacy, poor patient compliance and the need for greater understanding by the medical community on how to appropriately target pain pathways. (2)
The predominant goal of personalised pain management is to address these major challenges patients are experiencing. This can be achieved by reducing systemic harmful events, through topical and local analgesic applications. Therefore, optimising therapeutic outcomes by carefully targeting pain at its source, selecting right pain medications based on pharmacodynamics, safety and efficacy profiles and applying combination therapy. Through all of this, patient compliance would naturally improve, and treatment regimens would become more simplified.
Targeting pain at the source
It is important to differentiate between topical and transdermal routes of delivery when personalising pain treatment. Transdermal uses the skin as an alternative medium for reaching vasculature and systemic uptake. Topical routes of delivery are not intended for systemic effect and is used for the application of medication to the skin/membranous tissue, with the intention of producing local effect within the skin or underlying tissue. (3) Topical treatment to the pain site may reduce adverse side effects and improve overall therapeutic efficacy. It allows you to target the immediate site, being the skin and with certain permeation, the underlying joints, and muscles, with negligible systemic absorption. Local application allows you to address peripheral sensitisation processes. Limiting peripheral sensitisation would in turn reduce central sensitisation, meaning less pain originating from the brain and spinal cord. (4) Unlike peripheral sensitization, central sensitization may also affect other senses. Many pain patients with central sensitization issues may also experience sensitivity to light, sound, and odours.
Multimodal pain therapy involves using or combining ‘groups’ of medications and non-medications for pain relief. By combining medications and other interventions for pain relief that work differently in the body, we can better control the pain. Other interventions may include non-medication therapies, like physical therapy and counselling, to treat the pain and improve overall function. (5)The groups of medications used in pain management each have different mechanism of actions within the body. Examples include non-steroidal anti-inflammatory drugs (NSAIDS), corticosteroids, anaesthetics, and muscle relaxants. Growing evidence supports the use of multimodal topical therapies as a safer and more efficacious choice for targeting multiple pain pathways.
How pharmaceutical compounding can help?
Personalised pain management through pharmaceutical compounding allows the prescriber, patient, and pharmacist to work together to create a more optimised treatment plan. Pharmaceutical compounding is the practice of preparing customised medications to address a patient’s unique set of conditions, tolerances, and preferences. (6) Pharmaceutical compounding allows healthcare professionals the flexibility to address unmet needs such as:
- Personalised dosing: Effective dosage strengths that are suitable to the patient, without restriction to fixed dosing increments set by commercial products.
- Tailored dosage forms: Selecting a dosage form based on compatibility and stability with the ingredients chosen, therapeutic intent, application site, and patient preference.
- Eliminating unwanted ingredients: Choosing ingredients that are better tolerated by the patient and avoid ingredients common in commercial medication products that a patient may be intolerant, sensitive, or allergic to.
- Combining multiple ingredients: Certain ingredients may be best suited together. This would maximise treatment efficacy, tolerability, and safety. Reduce treatment regimen complexity and enhance patient compliance.
- Addressing product unavailability: Create solutions where the commercially available product is not available.
At compounding pharmacies pain medications can be customised to patient and prescriber specifications. An effective treatment plan can be created, whilst collaborating more closely with a specialist pharmacist. Formulations are continually being developed at the pharmacy, and include common pain ingredients such as amantadine, amitriptyline, benzocaine, baclofen, clonidine, diclofenac, lidocaine, ketoprofen and tetracaine. They also include uncommon ingredients, current not used in pain management, due to insufficient research into their efficacy and safety. Verapamil (a voltage gated calcium channel blocker) is an example of one. Formulated into a 15% topical gel at the pharmacy, to help patients suffering from fibrotic tissue disorders such as plantar fibromatosis. Another uncommon ingredient is Loperamide (an opioid agonist), which is commonly known to treat diarrhoea. However, patients may not know that topical loperamide 5% cream can reduce neuropathic pain within 30 minutes, lasting 2.5 hours. Therefore, patients have been able to reduce oral intake of harmful ingredients. (7)Either combined or alone, pain ingredients can be compounded into a topical hypoallergenic drug delivery system, which can offer tailored, effective pain management, optimising multiple pain pathways, whilst also providing the opportunity to reduce adverse side effects, increase efficacy, reduce opioid use, and improve patient compliance.
Due to differences in pain conditions and patient-specific needs, responses, and tolerances, pain management may need to be highly personalised. Providers and patients need topical options as an alternative, due to the challenges with mainstream pain management using oral pain medications. Direct access to the target site is key, and the clinical evidence supporting topical application directly to the pain site, shows improvement in therapeutic efficacy with lower or negligible systemic absorption. Topical therapy is optimal for multimodal pain therapy and has revolutionised pain relief with the provision of effective synergistic analgesia. Personalised pain management is to guide the prescriber and pharmacist in a joint approach, to effective local pain treatment.
1. Borsook D. A Future Without Chronic Pain: Neuroscience and Clinical Research. Cerebrum [Internet]. 2012 [cited 2023 Jul 8]; Available from: http://dana.org/news/cerebrum/detail.aspx?id=39160
2. Mills S, Torrance N, Smith BH. Identification and Management of Chronic Pain in Primary Care: A Review. PSYCHIATRY IN PRIMARY CARE [Internet]. 2016 [cited 2023 Jul 8]; Available from: http://www.keele.ac.
3. The Difference Between Topical and Transdermal Medications | Gensco Pharma [Internet]. [cited 2023 Jul 8]. Available from: https://genscopharma.com/difference-topical-transdermal-medications/
4. Latremoliere A, Woolf CJ. Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity.
5. Hamrick KL, Beyer CA, Lee JA, Cocanour CS, Duby JJ. Multimodal Analgesia and Opioid Use in Critically Ill Trauma Patients. J Am Coll Surg. 2019 May 1;228(5):769-775.e1.
6. Understanding the Basics of Pharmaceutical Compounding [Internet]. [cited 2023 Jul 8]. Available from: https://pharmanewsintel.com/features/understanding-the-basics-of-pharmaceutical-compounding
7. Kopsky DJ, Bhaskar AK, Zonneveldt HJ, Keppel Hesselink JM. Topical loperamide for the treatment of localized neuropathic pain: a case report and literature review. 2019 [cited 2023 Jul 8]; Available from: http://doi.org/10.2147/JPR.S196927
Specialist Pharmacy produces custom-made medications across a wide range of treatment areas such as bioidentical hormones, pain management, dermatology, haircare, sports medicine, and veterinary medications.