Conway McLean, DPM, Journal columnist

Pain is both a symptom and a disease, affecting about 50 million US citizens. It may manifest in many ways and treatment is often complex, benefitting from an individualized approach to management. The consequences of pain can impair an individual’s health and well-being, potentially leading to physical, social, economic, and emotional changes. World-wide, the problem affects approximately 1 in 5 adults, with nearly 1 in 10 adults diagnosed with chronic pain each year.

Traditional approaches to chronic pain management have relied on the usual oral medications, most of which have been in use for decades. The opioid crisis, resulting in nearly 80 thousand deaths in 2019, developed because the drug companies promoted these substances for the use of many different chronic pain syndromes, claiming it was perfectly safe with minimal risk of addiction or other complications. We now know this is not the case.

It would seem all drugs, when injected or taken by mouth, have the potential to cause problems. The potential side effects listed on your average drug commercial is extensive and intimidating. But many Americans rely on the old standards, medications once considered ground-breaking discoveries, now taken for granted. Acetylsalicylic acid, the chemical name for plain old aspirin, is now ingested primarily for its ability to alter the clotting process, referred to (inappropriately) as a blood thinner. When taken regularly for pain, stomach ulcers are a frequent complication of use.

Acetaminophen, more commonly called by the brand name Tylenol, is used in a great variety of products, from cough medicine to many pain relievers. Generally considered a very safe drug, the biggest problem is ingesting more than recommended. Because it is used in so many different commercial preparations, many Americans take in far more than they are aware of. Because acetaminophen is metabolized (broken down) by the liver, liver toxicity is a possible consequence.

But there are numerous methods of pain relief not requiring oral consumption of a drug. There’s a very different approach, which has been available for years, but is under-utilized. The technique is called compounding, in which various medicines are mixed into a specialized cream that is applied topically. With compounding, each patient receives a custom formulation, allowing the prescribing physician to meet the unique needs of each patient individually.

The cream used in each pharmaceutical compounding is vitally important, with research yielding significant improvements in their ability to transport the medications into the tissues. Because of this unique method of delivery, drug interactions aren’t seen, allowing us to combine all manner of different medications, each with its own action and distinct benefit. This ability enables us to treat one problem in multiple ways.

There are other significant differences between compounded drugs and the typical prescription, picked up from your neighborhood pharmacy. Compounded drugs are not evaluated by the FDA, and cannot be formulated by your standard druggist, only by a compounding pharmacist. Thus, the benefits and the safety of a compounded drug depends greatly on the expertise of the individual who is compounding. If they do their “due diligence,” these are generally much safer than most oral medications. Much less of the drug ever makes into the circulation. By applying it topically, the drugs applied are acting primarily locally. The less of a drug carried in the circulation, the safer it is.

Another difference is the lack of insurance coverage for compounded pharmaceuticals, with most plans denying coverage or carrying restrictions making their use impractical. Why this is the case is unclear but may be tied to the variability in their preparation. If the compounding pharmacist is inaccurate or imprecise, the resulting cream won’t work as desired.

These can be expensive, depending on many factors, including the pharmacy, the size of the region experiencing pain, the drugs used to formulate the prescription. But many common compounded creams are no more than 25 to 30 dollars per month. At least with these compounded concoctions, stopping the cream doesn’t require any tapering. As you may have gathered, the most challenging part is having access to a good compounding pharmacist.

Compounded medications are an excellent option when the oral route is not feasible, a common challenge in the geriatric or pediatric population. When the FDA-approved medication is manufactured with a material to which someone is allergic, once again, compounding is a popular and successful choice. Or when there are special dietary restrictions, it is frequently utilized.

The most common compounded medications are those prescribed for pain management. Various drugs can be used in one cream, from local anesthetics to anti-inflammatories, all to treat a single painful structure, but in different ways. Other regular uses of compounding include hormone replacement therapy and for a host of dermatologic conditions where it naturally has advantages.

Along with its use in many skin diseases, these are also beneficial in the treatment of neuropathy pain. One might conclude compounded medications serve an important role in modern medicine. Surprisingly, they do not, largely because they bypass the traditional, insurance-based prescribing process. Many physicians are hesitant to recommend a choice which requires the patient to pay out-of-pocket, which these so often do. And yet, depending on the prescription, compounding need not be excessive.

Through the tailored actions of a specific combination of ingredients, we can achieve better therapeutic effects. And due to the absence of systemic effects or concerns of toxicity, compounding has clear advantages in the treatment of chronic pain, like a painful arthritic joint or perhaps an extremity injured by long ago trauma. The concurrent and safe use of many medications, in one cream, to treat a single problem; sounds like it could be a recipe for successful pain management.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care and lower extremity biomechanics.