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Talk with the Doc: Safer methods of pain control

Conway McLean, DPM, Journal columnist

As the average human’s lifespan has increased, the problems of longevity have become more prevalent, with chronic pain being one. Many consider recurrent aches and pains as part of life (until it happens to them), originating from such disparate conditions as osteoarthritis, nerve pain, and chronic overuse injuries from poor biomechanics. Pain is a daily concern for many Americans as it affects more of us than diabetes, heart disease and cancer combined.

While acute and chronic pain can have similar effects on both the physical and mental well-being of an individual, their origins and treatment should be different. The opioid crisis was the result of an increased demand for the treatment of chronic pain, as well as “inaccurate” information from the drug companies about the safety of this class of pharmaceuticals. Clearly, these drugs are not a healthy option for the long-term treatment of lasting, enduring pain.

Older livers mean slower liver function, as well as reduced kidney activity. Drugs consumed by mouth can have unintended actions in this scenario. Adverse consequences are far more common in this age group. In the senior population, other conditions and illnesses are often present, adding to the likelihood of complications. Many of these individuals regularly take an anti-inflammatory drug, like ibuprofen, but this class of drug has well-recognized dangers, especially to the G-I system, as well as to the heart. The side effects of these medications are a frequent reason for hospitalization and death.

The treatment of this all-too-common condition, chronic pain, is a source of great concern. The result has been a dependence on pharmaceuticals for pain relief. Too many Americans have fallen victim to the problems associated with chronic drug use. In the minds of many in health care, we have too few options for pain relief, although there is another route of administration both safer and more direct, one rarely considered and grossly underutilized.

The topical application of medicine has a long and successful history. This method has numerous advantages, such as concentrating the substance at the site of the pain. With this technique, there are dramatically lower levels of the drug in the bloodstream and so less side effects Topical methods of pain relief are especially helpful in patients who are already taking numerous medications since the minimal amounts of the drug absorbed into the blood are unlikely to result in a drug-to-drug interaction. Another advantage is for those who don’t want to take something internally. Then there are those who seek to avoid getting an injection.

Topical approaches to pain management are supported by many studies, both in the lab and on animals and people. Although it has a long history of use, topical therapies are underutilized in the opinion of many experts. Some of the current uses include for the treatment of an inflamed tendon or ligament, for a variety of skin disorders, as well as in wound healing. One of the benefits is the medications employed by topicals are almost all generic, which results in drastically reduced costs.

Many people experience pain due to a prior surgery or injury, a condition that is often difficult to treat. This is a perfect situation for topical pain relief. Numerous examples are in use, although most people only think of the common over-the-counter products. Although these have their benefits, they are not particularly effective against more significant types of pain. One under-utilized approach involves the application of a cream derived from a pepper plant, resulting in reduced levels of the pain messenger chemical. Although initial application can produce a burning sensation, continued use leads to lessened chronic pain.

Another topical method of pain relief is rarely used, mostly for economic reasons. Compounding is the delivery of a drug by mixing it into some kind of “vehicle”, basically some cream or ointment. This technique has numerous advantages, but is almost never covered by private insurance or by Medicare. It involves formulation with a prescription medication (usually) so naturally some considerable expense is associated. Compounding is generally a safer method of drug delivery since blood levels with this practice are less than 5% compared to when taken orally.

Compounding allows for numerous medications to be combined, each having their own specific function. An opioid can be used in a compounding formulation to great effect, with drastically lessened concerns associated with the use of these drugs. Numerous pharmaceuticals with known complications can be used safely when applied topically. For example, lidocaine can be applied to the skin to numb some painful structure, but has the added benefit of causing smaller blood vessels to relax, a positive effect when applied to a chronic wound. This allows greater blood flow to the tissues which aids in healing. Various drugs can be added to the mix, each with different goals, such as accelerating healing, reducing inflammation, or killing surface bacteria.

Although in use for hundreds of years, an exciting group of products are the CBD creams. These administer a substance known as an endocannabinoid. This is a class of signaling molecules, produced by the body, which has many different functions. They are especially important in our body’s pain control system and function to reduce many types of pain. The same basic material can also be found in a hemp plant. When processed correctly, the substance obtained can relieve pain and reduce inflammation when applied to the surface, yet has few if any side effects.

Because of the lack of negative consequences, and their ability to act only locally, not systemically, topicals need to be considered more often. Unfortunately, because they are not covered by insurances, compounded medications are offered rarely, and used even less. And yet, as our population ages, we need to look at possible alternatives for treating pain in both our active and our aging populations. Topical medications should be in the armamentarium of every physician treating problems of the bones, nerves, joints and muscles.

Many drugs exist for the relief of chronic pain, from old fashioned aspirin to opioids, but some viable options aren’t taken internally. To reduce the number of drug complications occurring, topical approaches need to be considered. From novel forms of laser light to precise forms of electro-magnetic radiation, from compounding to natural plant extracts, numerous options exist for pain control. Our health and well-being, as a society, will benefit by utilizing the many topical approaches to pain management.

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