As a pain management practitioner, you see patients with a wide variety of pain forms, intensities, lengths, locations, etc. caused by so many simple or intricate factors.

You have a large therapeutic arsenal to treat them. But does it meet all your patients’ therapeutic needs?

I am sure many of the patients respond well to the treatments you prescribe for them.

Yet studies show ⁽¹⁾ that about 43% of chronic pain sufferers are noncompliant with medications prescribed. Some of the reasons for that may be:

• Complex treatment plans that may be difficult, inconvenient and confusing to follow.
• Side effects of the medications, such as – stomach irritation, ulcers, bleeding, nausea and vomiting, blurred vision, dizziness and drowsiness, etc.
• Concern for Addiction – particularly with opioids –a known epidemic in the US
• Increased work absenteeism and decreased work performance related to the treatment plan and/or the medications’ side effects
• Cost – the more complex the treatment, the less cost-effective and more expensive

As a caring, compassionate, and successful pain management doctor, your main goal is to improve the clinical outcome for your patients by increasing their compliance.

One demonstrated way to accomplish this is through personalized care. A critical component of personalized care consists of the ability to create a customized compounded formulation that best meets the patient’s unique medication needs based on their specific situation.

There are many studied and tested transdermal active pharmaceutical ingredients (API’s) ^{(2), (3), (4)} used in pain management formulations. There are algorithms ^{(5), (6), (7), (8), (9)} created by pain management organizations that explain the API selection and combination criteria, the recommended strength(s) for each API, and the various dosage forms.

Here is how to create/write a compounded pain formulation.

Select the API(s) and strength from classes of drugs often used in pain control such as:

• NSAIDS – Diclofenac Sodium, Ketoprofen, Ibuprofen, Piroxicam, Indomethacin, Flurbiprofen and Meloxicam
• Neuropathic agents:
• Antidepressants – Amitriptyline, Imipramine
• Anticonvulsants – Gabapentin, Topiramate, Lamotrigine, Carbamazepine
• Anesthetics – Lidocaine, Bupivacaine, Tetracaine, Ketamine
• Others – Clonidine, Tizanidine, Capsaicin
• Antispasmodics (Muscle Relaxants) – Baclofen, Magnesium, Cyclobenzaprine, Guaifenesin

Select the dosage form (the base/vehicle) – penetrating cream, liposomal cream, gel, lotion, ointment or a combination of bases.

Indicate the directions, quantity, # of refills

Example of a neuropathic pain formulation:

Diclofenac 6%/ Gabapentin 5%/ DMSO 5%/ Lidocaine 5%

Penetrating cream 240g

Sig.: Apply 1-2g to affected area QID UD

Refills: #5

Once you understand how compounding can help you help your patients in pain, you can prescribe as many unique formulations as needed for each of your unique cases.

It will take some learning and some practice to implement compounding for the benefit of your patients, but it will be well worth it. The key step you must take is to find the right compounding pharmacy that best meets your practice’s needs. The selected pharmacy will be your long-term partner in helping find and suggest creative solutions for your difficult to treat cases and your reliable resource for advice when you need it.

Let HALDEY Pharmaceutical Compounding be that pharmacy for your practice. Call us today for an evaluation.

References:

1. Pain Physician.2014 Jan-Feb;17(1):81-94. Medication compliance in patients with chronic pain.

Kipping K1, Maier C, Bussemas HH, Schwarzer A.

2.  Algorithm for Chronic Pain (by Mode of Action) Jones M. Chronic Neuropathic Pain: Pharmacological Interventions in the New Millenium – A Theory of Efficacy. International Journal of Pharmaceutical Compounding. Jan/Feb 2000; 4(1): 6-15.
3.  Jones M. Clinical Nuggets and Pearls: Chronic Neuropathic Pain and Opioid Tolerance. International Journal of Pharmaceutical Compounding. Jan/Feb 2002; 6(1): 4-6.
4.  Pud D, Eisenberg E, Spitzer A, Adler R, Fried G, Yarnitsky D. The NMDA receptor antagonist amantadine reduces surgical neuropathic pain in cancer patients: a double blind, randomized, placebo controlled trial. Pain. 1998 Apr;75(2-3):349-54.
5.  Bennett GJ. Update on the neurophysiology of pain transmission and modulation: focus on the NMDA-receptor. J Pain Symptom Manage. 2000 Jan;19(1 Suppl):S2-6.
6.  Sawynok J. Topical analgesics in neuropathic pain. Curr Pharm Des. 2005;11(23):2995-3004.
7.  de Leon-Casasola OA. Multimodal approaches to the management of neuropathic pain: the role of topical analgesia. J Pain Symptom Manage. 2007 Mar;33(3):356-64.
8.  Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005 Dec 5;118(3):289-305. Epub 2005 Oct 6.
9.  Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist. 2004;9(5):571- 91.