The Transdermal Approach to Pain Management

By Geoffrey Godfrey MSN, FNP-BC and Melissa McFarland MSN, FNP-BC

You’ve probably have heard the term “compounding” and may have wondered if it was something that could help with your pain. So what is it? Simply put, compounding is the creation of a small amount of a particular pharmaceutical product to fit the unique needs of an individual patient.Oral medications for pain management can be broken down into three classes of drugs: non-steroidal antiinflammatory (NSAIDS) medications such as ibuprofen; opioids such as Percocet or Morphine; and a wide variety of medications often used to treat other conditions and are well known to reduce pain including antidepressants,
anticonvulsants, antihypertensives and local anesthetics. But with the application of topically administered drugs in the form of a cream, lotion, gel, patch or aerosol, you are able to apply the medication directly to the painful site, and not have to wait for the drug to go through the digestive system for it to take affect.

Topical compounds date as far back as 4,000 BCE when herbs were often ground finely, added to oils and then applied to the skin in order to provide healing and relief for various conditions. You may be familiar with lidoderm, Fentanylpatches or Voltarengel. These are considered to be transdermal medications and you may have even used one of these in the past.

12As technology has advanced, the transdermal approach to pain control has become the preferred therapy for many who suffer with pain. Current grinding and milling machinery allows medications to be refined as small as 4 microns in diameter, which allows the medication(s) to pass through the skin to subsurface tissues to a greater degree than possible in the past.

Other advantages of topically applied medication include the lack of dangerous interactions with medications you may be taking orally, the increased ability and effectiveness in treating various painful conditions and the lower risks of potentially dangerous side effects.

Have you ever wondered why your physician asks you to describe the quality of your pain — exactly how it feels? They are trying to target the specific type of pain you are experiencing, because when healthcare practitioners address the issue with the most precise and targeted form of therapy, the more successful the therapy and the more pain free you will become. With compounding transdermal medications, the practitioner can customize a product to specifically treat your pain that can safely be combined with other pain medications to far greater effect. When customizing transdermal medications, your physician may ask you what medications you are allergic to and will avoid using them in their transdermal form.

In 2009, Dr. Diane Barton of the Mayo Clinic used a combination of Baclofen, Amitriptyline and Ketamine in a topical cream for treating patients with “Chemotherapy Induced Peripheral Neuropathy,” a painful side effect of some cancer treatments. She saw remarkable results with her research. She found she was able to safely reduce the pain in her patients with virtually no side effects.

Now imagine using a cream with most of your oral medications such as gabapentin/Neurontin for the nerve stabilizing effects, without feeling tired or out of sorts. Or perhaps adding an anti-inflammatory, which will never cause you to experience an upset stomach or other stomach problems. A practitioner may add a muscle relaxant over the same area to obtain additional relief. Ketamine is used in a number of transdermal formulations for its N-methyl-D-aspartate (NMDA) receptor blocking function. NMDA blockers are a recent and welcome addition to our list of powerful pain reducing medications.Ketamine is a powerful pain fighter and many practitioners know it from its widespread use in anesthesia. used on the skin, it appears not to work throughout the body and only provides pain control at the site where it is applied. Current research shows the blockers of Glutamate and substance “P” are additional pain reducing medications. If practitioners are able to successfully control your pain and inflammation outside of your central nervous system, then your use of other pain medications will be reduced and your pain improves allowing you to return to your normal activities and your normal life.

The risks of transdermal medications are extremely low, with the most reported side effect being a mild rash or irritation at the application site. If a rash should develop it is most often due to a foreign substance such as a fragranced lotion or environmental irritant such as dirt. When these substances or irritants are driven into the skin with the medications, a rash may form. Washing the area thoroughly prior to applying the transdermal product and before any subsequent applications can easily reduce this risk.

Can you imagine pain relief without constipation, fatigue or tolerance? Imagine a return to previous levels of activity and happiness without taking so many medications orally.