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Topical Lidocaine Patch Relieves a Variety of Neuropathic Pain Conditions: An Open-Label Study
Abstract
Our goal was to perform a pilot study to assess the effectiveness and tolerability of a topical lidocaine patch (Lidoderm) for the treatment of peripheral neuropathic pain conditions other than postherpetic neuralgia.
This was an open-label prospective study.
Sixteen patients with refractory peripheral neuropathic pain conditions who had reported intolerable side effects or inadequate pain relief with antidepressant, anticonvulsant, antiarrhythmic, and opioid medications participated in this study. Diagnoses included postthoracotomy pain, stump neuroma pain, intercostal neuralgia, diabetic polyneuropathy, meralgia paresthetica, complex regional pain syndrome, radiculopathy, and postmastectomy pain.
A six-item Pain Relief Scale was used (0 = worse pain, 1 = no change, 2 = slight relief, 3 = moderate relief, 4 = a lot of relief, 5 = complete relief).
Moderate or better pain relief was reported by 13 of the 16 participants (81%). One patient stopped treatment after 4 days due to lack of relief. The remaining 15 patients had a mean duration of patch use of 6.2 weeks with continued relief. Only 1 patient reported a side effect, a mild skin irritation.
The Lidoderm patch provided clinically meaningful pain relief in most of these refractory neuropathic pain patients without side effects. Controlled trials need to be performed to confirm these preliminary findings.
... Although opioids are effective and safe in chronic cancer pain treatment, neuropathic pain (NP) is a common problem encountered in 40% of cancer patients [1][2][3]. A cancer patient with NP has abnormal sensitivity to either noxious (hyperalgesia) or innocuous (allodynia) stimuli at the site of pain resulting from cancer insults to the peripheral or central nervous systems [4,5]. ...
... As an aminoethylamide local anesthetic, lidocaine inhibits voltage-gated sodium channels on excitable membranes, preventing nerve impulses from being generated and conduction [7,8]. A topical lidocaine patch can relieve various neuropathic pain conditions after surgery [1,9]. Several neuropathic symptoms, such as numbness, tingling, and pain, can be reduced with a lidocaine patch [10]. ...
... The 5-item pain relief score was determined as follows. Pain relief was assessed using a category scale consisting of the following 5 scores: 0 = "no" pain relief; one = "slight" pain relief; two = "moderate" pain relief; three = "much" pain relief; and four = "complete" pain relief [1]. A modified version of the Brief Pain Inventory (BPI) [15] was used as an assessment tool for analgesic treatment quality. ...
Background
Limited efficacy has been observed when using opioids to treat neuropathic pain. Lidocaine patches reduce neuropathic pain in postherpetic neuralgia, but their benefits for cancer-related neuropathic pain remain unclear. This study aimed to investigate a treatment for cancer-related neuropathic pain.
Methods
We conducted a prospective, open-label, single-arm study to assess the efficacy and safety of lidocaine transdermal patches in patients experiencing localized, superficial, neuropathic cancer pain. Terminal cancer patients already receiving opioid treatment participated in the 3-day study. The primary endpoint was pain intensity evaluated by the numerical rating scale (NRS). The secondary endpoints were the pain relief score and the quality of analgesic treatment.
Results
The results showed a significant difference in the median NRS over 3 days (Kruskal–Wallis test, p < 0.0001). The median NRS pain intensity from Day 1 to Day 3 was 4.0 with 95% C.I. (3.3, 5.0), 3.0 (2.5, 3.5), and 2.6 (2.0, 3.0), respectively. The difference between the median NRS pain intensities of any 2 days was significant (Wilcoxon signed-rank test, p < 0.0001). The generalized estimating equation (GEE) estimation model showed significant differences between the NRS pain intensities on any 2 days. There was no significant difference in the pain relief score or the quality of analgesic treatment.
Conclusions
In this study, the 5% lidocaine transdermal patch reduced the NRS pain intensity in neuropathic cancer patients already receiving opioid treatment. Treatment of localized and superficial neuropathic pain caused by cancer was well tolerated and effective.
... 4 Other conservative measures involved weight loss, topical application of lidocaine, or medication with Gabapentin, chlorpromazine, or antidepressants. 5,7,25,26 If these conservative treatments do not resolve symptoms within 3 months, procedures such as a LFCN block using anesthetics and steroids or pulsed radiofrequency neuromodulation treatments have been considered to avoid surgery and its subsequent risks. 25 Ultrasound use has been reported on multiple occasions to prevent damage to the surrounding areas and take into account the different variations of the anatomic course of the nerve. ...
... The literature also contains varying results observed in neurolysis and neurectomy procedures. 26 The study by De Ruiter et al 30 showed not only a higher success rate for neurectomies, but also that most patients were not disturbed by the numbness (62.5%) after the procedure, and some patients (25%) were bothered only sometimes. The authors speculate that this is due to the relatively long follow-up period for the neurectomy patients (mean, 93 mo), in which time sensory axons from other nerves in close proximity emerged and reinnervated the anesthetic area to improve sensation. ...
... One way to mimic the results of a neurectomy (as well as diagnose MP) is to administer local injection of lidocaine to the affected area. 26 This may be insightful in allowing the patient to experience the results of a nerve resection. ...
Meralgia paresthetica is a non-life-threatening neurological disorder characterized by numbness, tingling, and burning pain over the anterolateral thigh due to impingement of the lateral femoral cutaneous nerve. This disorder has been seen in patients with diabetes mellitus and obesity, but has also been observed in patients after procedures such as posterior spine surgery, iliac crest bone grafts, lumbar disk surgery, hernia repair, appendectomies, and pelvic osteotomies that ultimately lead to compression or damage to the lateral femoral cutaneous nerve. Overall, permanent sequelae of meralgia paresthetica are rare, however, some cases do require intervention.
... Topical lidocaine has been used in patients with herpetic neuralgia, diabetic polyneuropathy, osteoarthritis, and MSK pain including low back pain. 58,59 Its use is contraindicated in patients with hypersensitivity to amide anesthetics, open wounds, and skin eczema. The most common adverse effects include skin erythema, edema, and occasional burning at the application site. ...
... The most common adverse effects include skin erythema, edema, and occasional burning at the application site. 58,59 The dosing regimens are 1 to 3 patches daily with a 12-hour free period with a maximum dose of three patches daily. 58 A 5% topical lidocaine plaster was found to be more effective than capsaicin, gabapentin, pregabalin, and placebo and with fewer adverse effects in patients with postherpetic neuralgia. ...
Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.
... According to the World Health Organization (WHO) guidelines, cancer pain treatment is effective and safe [1]. Neuropathic pain (NP) is a common problem encountered in 40% of cancer patients [2,3]. ...
... As in our study, we emphasized the precise selection of the patients in whom, in addition to the presence of neuropathic pain, the pain had to be well localized, super cial, and involve positive symptoms such as allodynia, raised pinprick threshold, and hyperalgesia. The severity of the pain was analyzed using a VAS, thus measuring Day 1 to Day 3. Neuropathic cancer pain cannot be treated according to the World Health Organization (WHO) recommendations because there is no evidence that such pain responds to drugs that are recommended for mild or moderate cancer pain (steps 1 and 2 of the WHO's pain relief ladder) [1]. The majority of our patients who were treated with lidocaine patches often found them practical for reducing mild and moderate neuropathic pain assessed by VAS pain intensity. ...
PurposeLimited efficacy has been observed when using morphine to treat neuropathic pain. Lidocaine patches reduce neuropathic pain in post-herpetic neuralgia, but their benefits for cancer-related neuropathic pain remain unclear. This study aimed to demonstrate a useful treatment for cancer-related neuropathic pain. The primary endpoint was pain intensity evaluated by the visual analog scale (VAS). The secondary endpoints were the pain relief score and the quality of analgesic treatment. Methods
We assessed the efficacy and safety of lidocaine patches in patients experiencing neuropathic cancer pain. Terminal cancer patients with opioid treatment resistance participated in the 3-day study. ResultsThe results showed a statistically significant difference in the median VAS over three days (Kruskal-Wallis test, P<0.0001). The median VAS pain intensity from Day 1 to Day 3 was 4.0 with 95% C.I. (3.3, 5.0), 3.0 (2.5, 3.5) and 2.5 (2.0, 3.0), respectively. The difference between the median VAS pain intensities of any two days was statistically significant (Wilcoxon signed-rank test, P < 0.0001). There was no statistically significant difference in the pain relief score or the quality of analgesic treatment. ConclusionIn this study, the 5% lidocaine transdermal patch reduced the VAS pain intensity in neuropathic cancer patients with morphine resistance. The transdermal patch is generally useful and well-tolerated.
... Although topical lidocaine is FDA-approved for the treatment of post-herpetic neuralgia, the evidence for its use in neuropathic pain is of relatively low quality, A Cochrane review found no large randomized trials of topical lidocaine for neuropathic pain [114••]. A 332-patient open-label trial showed improved mean pain intensity and quality of life scores when compared with placebo, as did an open-label prospective study in a series of 16 patients with various types of neuropathic pain [115,116]. An enriched enrollment crossover study found patients strongly preferred lidocaine patches compared with placebo in the treatment of post-herpetic neuralgia, and two trials of lidocaine gel in post-herpetic neuralgia found increased pain relief compared with placebo [117][118][119]. ...
... Compared with systemic analgesics, topical lidocaine presents a milder side effect profile. Because of its limited systemic absorption, the majority of adverse effects are localized to the site of patch placement and generally consist of skin irritation, including erythema and pruritus [116,122]. Topical lidocaine may be a valid first-line option in patients who cannot tolerate standard systemic first-line analgesics, a population that includes many elderly patients [67]. ...
Purpose of Review
Sickle cell disease (SCD) remains among the most common and severe monogenic disorders present in the world today. Although sickle cell pain has been traditionally characterized as nociceptive, a significant portion of sickle cell patients has reported neuropathic pain symptoms. Our review article will discuss clinical aspects of SCD-related neuropathic pain, epidemiology of neuropathic pain among individuals with SCD, pain mechanisms, and current and future potential pharmacological interventions.
Recent Findings
Neuropathic pain in SCD is a complicated condition that often has a lifelong and significant negative impact on life; therefore, improved pain management is considered a significant and unmet need. Neuropathic pain mechanisms are heterogeneous, and the difficulty in determining their individual contribution to specific pain types may contribute to poor treatment outcomes in this population.
Summary
Our review article outlines several pharmacological modalities which may be employed to treat neuropathic pain in SCD patients.
... [2][3][4][5][6][7] Some of the available treatment options for intercostal neuralgia are medical management, nerve blocks, cryoablation, and radiofrequency ablation (RFA). [8][9][10][11] Despite these options, intercostal neuralgia remains difficult to treat, and no single treatment modality or combination of modalities has been shown to consistently provide adequate pain relief. We present 2 cases of intercostal neuralgia, both resistant to conservative treatment, that were effectively treated using thermal RFA. ...
... As noted earlier, treatment options for patients suffering from intercostal neuralgia include medical management, nerve blocks, and cryoablation. [8][9][10][11] However, none of these modalities has been shown to provide consistent pain relief. We described 2 cases of intercostal neuralgia resistant to conservative management that were effectively treated by RFA. ...
Background:
Intercostal neuralgia is a complex and difficult-to-treat condition. We present 2 cases that demonstrate the safe and effective use of thermal radiofrequency ablation (RFA) to achieve significant pain relief.
Case reports:
Our first patient was a 62-year-old female who developed chronic chest pain following lumpectomy for breast cancer and failed conservative management. Two intercostal diagnostic nerve blocks were performed with good results. One block provided pain relief for 3 weeks, and the other provided pain relief for 5 weeks. These blocks were followed by RFA that provided excellent improvement in her pain for >1 year. Our second patient was a 67-year-old female with a history of esophageal carcinoma and non-small cell lung cancer. She developed chronic chest pain following surgery and treatment. Conservative management was implemented at first without significant improvement in pain. The patient received intercostal diagnostic blocks that significantly improved her pain. She then underwent RFA for the same nerves and had resolution of her pain at 2-month follow-up.
Conclusion:
Our cases suggest that thermal RFA can be safely used to treat patients suffering from intercostal neuralgia. This unique treatment has significant implications for chronic pain physicians and warrants additional studies to elucidate its effectiveness, safety profile, and scope of use.
... It can be of somatic origin (bone fractures, muscle spasms, osteoarthritis, and postoperative pain) or visceral (peptic ulcer, cancer, liver cirrhosis, and ischemia). Neuropathic pain can affect central nerves, such as from spinal injuries, Parkinson's disease, multiple sclerosis or transverse myelitis, or peripherally, such as with carpal tunnel syndrome, or local pain of a traumatic nature, nutritional deficiencies, and acute herpes zoster [6]. Nociplastic pain can have various causes, such as fibromyalgia, irritable bowel syndrome, or bladder pain [7]. ...
Transdermal delivery is a non-invasive route, used as an alternative to the oral route, to administer drugs through the skin surface. One of the fields in which they are particularly used is that of pain therapy. In this treatment, transdermal patches, particularly those containing opioids, are used to complement or replace orally administered drugs. First-generation patches are constituted by reservoir systems, where the drug is dissolved in a solvent and gelled with a polymer. In contrast, the active principle is incorporated into the polymer adhesive in more recent matrix patches. In this review, the main papers related to the production and employment of transdermal patches containing the two most used opioids, i.e., fentanyl and buprenorphine, have been critically analyzed. From the analysis of the literature, it is possible to deduce that the type of drug and the amount of drug present in the patch must be chosen not according to the origin of the pain but to the age of the patient, the area where the patch is applied, and the frequency at which the patch is replaced.
... Tais formulações são amplamente usadas como anestésicos tópicos em pequenos processos cirúrgicos e no tratamento da neuralgia pós-herpética (NPH), principalmente em idosos os quais são mais susceptíveis as reações adversas sistêmicas. 11,12 Vários trabalhos descrevem a eficácia do uso tópico de adesivos de lidocaína 5% no tratamento da NPH. O mecanismo de ação proposto para a lidocaína consiste na redução da geração e condução dos impulsos periféricos da dor através do bloqueio dos canais de Na + dos nociceptores lesados situados diretamente abaixo do sítio de aplicação. ...
Despite the use of local anesthetics (LAs) having the primary purpose of producing nerve blockages by the inhibition of Na+ channels, the literature has shown that these agents may have additional pharmacological actions, also affecting the potassium and calcium channels and acting on intracellular mechanisms. Besides causing anesthesia, the LAs may act directly on other receptors and their signaling pathways which are involved in processes of inflammation, platelet activation, nociception, peripheral pain and arrhythmias, among others, increasingly seeking better clinical efficacy and safety, in addition to new and potentially useful properties for the LAs. Therefore, the aim of this study is to search the scientific literature and review the pharmacology and the additional potentially desirable effects of the LAs used in medical clinic.
... 73 La lidocaina topica si è anche dimostrata efficace nel trattamento di un'ampia gamma di condizioni di dolore neuropatico sebbene sia approvata solo per la nevralgia posterpetica in alcuni Paesi. [74][75][76][77] L'efficacia e la sicurezza del cerotto cutaneo di lidocaina 700 mg sono state studiate e confrontate con quelle della pregabalina in pazienti con nevralgia posterpetica. 78,79 Una maggiore proporzione di pazienti con nevralgia post-erpetica ha risposto al trattamento con il cerotto cutaneo di lidocaina 700 mg rispetto a quello con pregabalina (63.0% ...
Chronic pain is a major health concern, albeit underestimated in times of a pandemic. With about a third of pain patients without a diagnosis and delayed referral to pain therapy specialists, the current management of chronic pain requires significant re-evaluation. The COVID-19 pandemic has, on the one hand, made the gaps in health systems more evident and, on the other, acted as a catalyst for a profound transformation in pain care. Following an in-depth context analysis, the Science of Relief 2.0 Event brought together clinicians operating in pain therapy centers throughout Italy with the aim of identifying concrete solutions and sharing proposals to optimize the organization of chronic pain management and treatment through working groups and educational sessions. This document illustrates the salient points of the event and discusses its implications for clinical practice. Copyright © 2021 Natale MR, Degirolamo C, Perversi F, Varrassi G. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0 which allows anyone to copy, distribute, and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.
... We envision that this fast-acting/sustained release patch will set the foundation for future MN research towards next generation patches, able to treat diverse disease conditions per single application at low manufacturing cost. The ultimate goal of our collaborative research is to apply this unique delivery capability for the management of pain, considering the current limitations of existing pain-relieving patch technologies, such as general Mylan generic lidocaine patches, 43 and the lack of effective transdermal modalities for post-operative settings. 44 Such postoperative pain control will be realized using a single patch, providing fast and slow tunable delivery of the corresponding anesthetic drugs. ...
Transdermal microneedle (MN) drug delivery patches, comprising water-soluble polymers, have played an essential role in diverse biomedical applications, but with limited development towards fast deep release or sustained delivery applications. The effectiveness of such MN delivery patches strongly depends on the materials from which they are constructed. Herein, we present a dual-action combinatorial programmable MN patch, comprising of fast and sustained-release MN zones, with tunable release kinetics towards delivering a wide range of therapeutics over different timeframes in single application. We demonstrate the fine tuning of MN materials; the patches can be tailored to deliver a first payload faster and deeper within minutes, while simultaneously delivering a second payload over long times ranging from weeks to months. The active and rapid burst release relies on embedding biodegradable Mg microparticle 'engines' in dissolvable MNs while the sustained release is attributed to biocompatible polymers that allow prolonged release in a controllable tunable manner. In addition, the patches are characterized and optimized for their design, materials and mechanical properties. These studies indicate that such programmable dual-action versatile MN platform is expected to improve therapeutic efficacy and patient compliance, achieving powerful benefits by single patch application at low manufacturing cost.
... LP was approved, by the United States Food and Drug Administration in 1999, for the relief of pain of postherpetic neuralgia. Multiple studies showed that the LP 5% may be effective in alleviating neuropathic pain in patients with postmastectomy syndrome, diabetic polyneuropathy and complex regional pain syndrome [29]. The superiority of LP over CDB in serratus plane on the intensity of numbness at third postoperative week could be explained by the synergistic analgesic effect of LP with pre-emptive SAPB. ...
Objectives
The study compared the effect of pre-emptive serratus plane block, with postoperative continuous drug delivery: into the serratus plane (bupivacaine 0.125% CDB), or around the wound (lidocaine 5% patches LP) on acute nociceptive and neuropathic pain after mastectomy.
Methods
This randomized-controlled blinded study was conducted on 43 women scheduled for mastectomy for breast cancer, under standard general anaesthesia and pre-emptive serratus plane block. Patients were randomly assigned to 2 groups according to postoperative analgesia: Group (S) received a 6 ml hourly doses of bupivacaine (0.125%) for 24 hrs using an epidural catheter inserted into the serratus plane and Group (L) received 2 LP around the wound for 12 hrs/24 hrs. IV morphine (3 mg) was given to patients with visual analogue scale >3 and repeated at 10 min intervals if needed.
Measurements
Primary outcome was visual analogue scale (VAS) for nociceptive pain at rest and arm movement for 24 hrs postoperatively. Secondary outcomes included incidence, characters and severity of acute neuropathic pain, using DN4 questionnaire and Neuropathic Pain Scale (NPS) for 4 weeks. Hypothesia to touch and temperature, mechanical allodynia and hyperalgesia were assessed between T2-T6 compared to the other side for 4 weeks. Patient satisfaction was measured by satisfaction score.
Results
There was no significant difference between the two groups regarding VAS at rest and movement, incidence, duration and sites of neuropathic pain and its effect on sleep, mood and work. The intensity of numbness measured by NPS was significantly less in Group L than Group S in the third postoperative week (P ≤ 0.05). Patients ‘satisfaction with postoperative pain relief was higher in Group L (P ≤ 0.05).
Conclusion
LP are as effective in reducing acute nociceptive pain as continuous bupivacaine delivery into the serratus plane. They are superior in reducing numbness and favoured by patients postmastectomy.
... En cuanto al tratamiento con parches de lidocaína o la aplicación de dimetilsulfóxido al 50 %, se aprecia un criterio dispar entre los expertos, que no alcanzan el consenso en su recomendación. En el primer caso, tal situación se puede justificar por la falta de estudios concluyentes sobre el anestésico local (39,40), mientras que en el segundo caso, la falta de un refrendo posterior al estudio clásico que avaló su uso (41) parece explicar la escasa experiencia clínica de los panelistas consultados con dicho agente. Respecto al parche de capsaicina al 8 %, aunque el 65 % de los expertos lo considera una opción terapéutica válida para el alivio del dolor en el SDRC (Fig. 2), en sentido estricto no se alcanza la mayoría requerida para avalar su recomendación clínica por consenso experto. ...
Objective: To propose consensus from a panel of state level that integrates clinical experience and the most current evidence, recommendations on the clinical use of topical treatments for the management of peripheral neuropathic pain (PNP).Methods: We propose, based on a literature review on topi-cal therapeutic options in PNP, a series of professional standards and clinical recommendations for improving the use of these topical agents. We used the modi ed Delphi method in two rounds to contrast the views of a national panel of 52 renowned experts, selected by a “snowball” strategy among the group of anesthesiologists pain units (94 %) and other specialists (neurol-ogist and trauma). We evaluated 61 clinical recommendations grouped into 6 areas: a) PNP systemic versus topical treatment (11 items); b) postsurgical neuropathic pain, post-traumatic and painful stumps (12 items); c) post-herpetic neuralgia, intercostal and trigeminal (9 items); d) PNP entrapment (8 items); e) CRPS (11 items); and f) diabetic neuropathy (DN) and other polyneu-ropathy (HIV, alcohol, toxicity, etc.) (10 items). We used a Lik-ert-type ordinal scale of 9 points (disagree/agree) to evaluate each recommendation. After the rst round of the survey, infor-mation was provided requested to reconsider the vote on items not agree.
... 16 Additively, lidocaine patch was found to be effective for subacute and chronic low back pain, post herpetic neuralgia and other neuropathic pain syndromes. [17][18][19] However, topical lidocaine was not effective for decreasing pain of perineal region after vaginal delivery. 20 Although lidocaine prior to cannulation did not alter success rate in our study, it was shown to increase the visibility of veins and success rate in another study using lidocaine containing creams. ...
Background: Lidocaine is a well-known medium-acting local anesthetic with a short onset time. It is a valuable drug for managing both acute and chronic pains and is being used as a popular agent for pain control in the emergency department (ED). In this systematic review, we intended to define the effectiveness of lidocaine in pain management of the patients referring to ED. Methods: The preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement was utilized for this Systematic Review (SR). We searched the databases of PubMed, Scopus, ProQuest, and Medline (Ovid) from 1990 to August 2017 for Randomized Controlled Trials (RCTs) in which the study population was referred to the emergency department and received lidocaine. Full-texts of the studies that were published in English were reviewed for inclusion. Both authors individualistically evaluated all studies. Seven articles were eligible for the meta-analysis based on their common outcomes. Results: The total number of subjects was 671. The studies were categorized based on the type of drug and administration route. Mean pain, regardless of the drug administration method, in the placebo group was 0.69 units higher than the lidocaine group. Considering the administration route, mean pain in the placebo group was 0.35 units higher than the lidocaine group when administered topically, and it was lower in the subcutaneous method than the topical method by 1.41 units. Conclusion: Infiltration of lidocaine decreases pain of different procedures in the ED whereas the effect of topical lidocaine is controversial issue.
... Capsaicin (selective excitation of C-polymodal nociceptors) has also been used to treat itch and surface hypersensitivity in MP [60]. Topical lidocaine has also been employed in resistant neuropathic pain of MP with good effect [61]. ...
... This raises the peripheral ectopic discharge threshold and reduces the pain transduction. Topical lidocaine has been demonstrated to be effective in the treatment of neuropathic pain conditions, including DNP (54)(55)(56)(57). A network meta-analysis compared 5% lidocaine-medicated plaster for the relief of DPN with other relevant drugs, including amitriptyline (30, 75 and 125 mg/day), pregabalin (300 and 600 mg/day), capsaicin (0.075% cream, four times a day), gabapentin (≤900 and 1,200 mg/day) and placebo. ...
... Sodium channel blocking agents were effective in reducing spontaneous and evoked pain in CRPS [47,48]. Patch with 5 % lidocaine have also shown clinically significant pain relief under the supplication site [49]. ...
The main purpose was to highlight the problem of hyperalgesia and allodynia. Main anatomic structures, which participate in nociception were mentioned in this article, with pathologic and pathophysiologic changes, that can be caused by hyperalgesia and allodynia. Main methods of diagnostics and assessment of mentioned symptoms were represented along with the modern approaches to treatment and prevention.
... [47] Beside the short course oral NSAIDs, local lidocaine patch provides clinically meaningful pain relief in most of these refractory neuropathic pain patients without side effects. [48] Methylcobalamin, antidepressant (amitriptylin, Fluoxetin), Anticovulsant (carbamazepine, gabapentine, pregabaline) have been used with variable outcome. ...
Meralgia paraesthetica (MP) is a clinical syndrome produced by entrapment mono-neuropathy of lateral femoral cutaneous nerve (LFCN). It classically presents as numbness, paresthesia or dysesthesia of anterolateral aspect of thigh but sometime it may mimic conditions like lumbar radiculopathy, femoro-acetabular impingement, trochanteric bursitis, etc. Since it has wide spectrum of clinical presentation, it should be the diagnosis of exclusion when causes of anterolateral thigh pain is not explained by other known causes. The aim of this review is to provide an overview of this clinical condition with the emphasis on various clinical presentations and anatomical variations of the lateral femoral cutaneous nerve. Different methods of diagnosis and treatment are also explored and discussed in this paper.
... Despite this, neuropathic pain patients achieve pain relief from topical lidocaine [259,[261][262][263][264][265][266][267]. Lidocaine patches also produce analgesia in patients with painful diabetic neuropathy [268], Complex regional pain syndrome (CRPS) [269] and non-neuropathic conditions such as osteoarthritis and low-back pain [261,[270][271][272][273]. Systemic side effects are extremely rare and topical lidocaine is therefore recommended as a first-line therapy for all children and youths with localized peripheral neuropathic pain or CRPS and definitely before consideration of IVLT. ...
Pediatric acute and chronic pain experiences involve the interaction of physiological, psychological, behavioural, developmental, pharmacological and situational factors. In the acute perioperative pain setting preventative multimodal analgesia is required to provide comfort and minimise the potential for “wind-up” and central sensitisation. When pain is recurrent, ongoing or chronic some children embark on a downward spiral of decreased physical, psychological and social functioning. The multidisciplinary team management approach is a well-established standard of care for children with complex chronic pain. Intravenous lidocaine has peripheral and central mediated analgesic, anti-inflammatory and anti-hyperalgesic properties. Intravenous lidocaine infusion therapy (IVLT) has been shown to be effective in the management of acute and chronic pain in adults. This chapter will present the rational for IVLT in pediatric pain management with emphasis on preventative multimodal therapy in acute pain and the multidisciplinary treatment approach in chronic pain. Large multi-centre randomised controlled trials are required to provide the evidence-base to confirm that IVLT is indeed an effective and safe treatment option in acute preventative multimodal analgesia and as an adjunct in the multidisciplinary care of chronic pain in the pediatric population.
... It is convenient to use as there is no systemic absorption and thereby the side effects are reduced. Lidocane patches has shown pain relief in refractory neuropathic pain such as post thoracotomy pain, stump neuroma pain, intercostal neuralgia, diabetic polyneuropathy, meralgiaparesthetica, complex regional pain syndrome, radiculopathy, and post mastectomy pain [20,21]. ...
... • Medicated-patches The medicated-patches containing local anesthetic (lidocaine) [2][3][4] or antiinflammatory (NSAIDs) are used to manage patients with select pain condition (acute and chronic). A topical patch containing diclofenac epolamine, available in more than 40 countries worldwide, was approved for use in Europe since 1993 (2007 in USA), and the available postmarketing surveillance data offers good safety data [5][6][7]. ...
The variety and multiple dimensions of pain (acute/chronic, mild/moderate/severe, nociceptive/neuropathic) requires different pharmacologic and non-pharmacologic treatments in certain patients. A lot of topical formulation, from various therapeutic classes have been proposed in order to decrease systemic exposure and to reduce the risks of adverse events. Topical as well as transdermal drug delivery systems are proposed as medicated plasters with: anesthetics (lidocaine), analgesic or nonsteroidal anti-inflamatory drugs (NSAIDs), alone or co-formulated. Capsaicin, salicylates, menthol and camphor represent the counterirritant class of topical analgesics used as patch active compounds. These compounds produce their analgesic effect by activating and desensitizing epidermal nociceptors. The most used topical treatment in order to decrease pain is the application of cold and heat patches - by acting directly on the affected tissue. In many cases there is a limited number of studies providing insufficient information to clinicians in order to evaluate the benefits of these products. This paper reviews the use and efficacy of available self-adhesing occlusive medicated plaster (pain patches) that might represent an alternative option for the management of patient pain, specially in the case of musculoskeletal and neuropathic disorders.
... The chronic and acute pain, which accompanies the cardiothoracic surgery, is pretty significant but still underappreciated, with an established level of functional and physiologic impact, and unknown economic and social costs. It is likely that an invasive pre-operative analgesic medication, aside from its more immediate advantages with respect to pulmonary and comfort function, will result in decrement in longer-term pain (40). When it manifests itself, such long-term pain should be pursued aggressively and early using an analgesic plan tailored for the specific features of that pain .■ ...
... A number of randomized controlled trials with focus on PPDN and PHN [39,[48][49][50] have shown lidocainemedicated plasters to be effective in the treatment of their associated neuropathic pain and accompanying allodynia and with fewer adverse events than pregabalin [51]. Its absence of systemic absorption and therefore adverse systemic effects has made the lidocaine-medicated plaster a popular choice both for the clinician and the patients alike, and it is recommended as first-line treatment in several guidelines [52]. ...
Chronic neuropathic pain (NeP) is common. Traditional pharmacological treatments can demonstrate surprisingly little efficacy for reducing pain scores or improving function, and their use is often limited by side effects. Research into chronic pain pathophysiology has expanded in recent years and only by understanding these underlying mechanisms will we be best placed to develop new and novel drug therapies. In this review article, we will highlight some of the more recent pharmacological agents that have established themselves in the pain physicians’ armamentarium and continue to gain popularity as the evidence base grows together with some of the supporting evidences for their use. It is anticipated that this article will act to bring to the forefront of the pain physicians’ mind some of the alternative therapies for the management of chronic NeP that are often thought of as tertiary- or even quaternary-line in many established guidelines.
Background:
Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted, and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons.
Methods:
Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data was analyzed using Fisher's Exact and ANOVA tests. A similar approach was used for pudendal cryoanalgesia.
Results:
Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia to pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute post-operative pain. One study compared cryoanalgesia to local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia to epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using CT-imaging with positive outcomes for the patient with pain of pudendal nerve origin.
Conclusions:
Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.
Background: Pain and sensory disturbance in the distribution of the lateral femoral cutaneous nerve in the ventrolateral portion of the thigh is called meralgia paresthetica (MP). The incidence of MP has risen along with the increasing prevalence of obesity and diabetes mellitus and was recently estimated at 32 new cases per 100 000 persons per year. In this review, we provide an overview of current standards and developments in the diagnosis and treatment of MP.
Methods: This review is based on publications retrieved by a selective literature search, with special attention to meta-analyses, systematic reviews, randomized and controlled trials (RCTs), and prospective observational studies.
Results: The diagnosis is mainly based on typical symptoms combined with a positive response to an infiltration procedure. In atypical cases, electrophysiological testing, neurosonography, and magnetic resonance imaging can be helpful in establishing the diagnosis. The literature search did not reveal any studies of high quality. Four prospective observational studies with small case numbers and partly inconsistent results are available. In a meta-analysis of 149 cases, pain relief was described after infiltration in 85% of cases and after surgery in 80%, with 1-38 months of follow-up. In another meta-analysis of 670 cases, there was pain relief after infiltration in 22% of cases, after surgical decompression in 63%, and after neurectomy in 85%. Hardly any data are available on more recent treatment options, such as radiofrequency therapy, spinal cord stimulation, or peripheral nerve stimulation.
Conclusion: The state of the evidence is limited in both quantity and quality, corresponding to evidence level 2a for surgical and non-surgical methods. Advances in imaging and neurophysiological testing have made the diagnosis easier to establish. When intervention is needed, good success rates have been achieved with surgery (decompression, neurectomy), and variable success rates with infiltration.
The crosslinked sodium alginate/mucilage/Aloe vera/glycerin was optimized by different ratios of each factor to be an absorption wound dressing base for infected wound healing. Mucilage was extracted from seeds of Ocimum americanum. The Box-Behnken design (BBD) in response surface methodology (RSM) was used to construct an optimal wound dressing base with the target ranges of mechanical and physical properties of each formulation. The independent variables selected were sodium alginate (X1: 0.25-0.75 g), mucilage (X2: 0.00-0.30 g), Aloe vera (X3: 0.00-0.30 g), and glycerin (X4: 0.00-1.00 g). The dependent variables were tensile strength (Y1: low value), elongation at break (Y2: high value), Young's modulus (Y3: high value), swelling ratio (Y4: high value), erosion (Y5: low value), and moisture uptake (Y6: high value). The results showed that the wound dressing base with the most desirable response consists of sodium alginate (59.90 % w/w), mucilage (23.96 % w/w), and glycerin (16.14 % w/w) without Aloe vera gel powder (0.00 % w/w).
The effective management of peripheral nerves in amputation surgery is critical to optimizing patient outcomes. Nerve-related pain after amputation is common, maybe a source of dissatisfaction and functional impairment, and should be considered in all amputees presenting with pain and dysfunction. While traction neurectomy or transposition has long been the standard of care, both regenerative peripheral nerve interface (RPNI) and targeted muscle reinnervation (TMR) have emerged as promising techniques to improve neuroma-related and phantom pain. A multi-disciplinary and multi-modal approach is essential for the optimal management of amputees both acutely and in the delayed or chronic setting.
Significance:
Diabetes is a major source of neuropathy and neuropathic pain that is set to continue growing in prevalence. Diabetic peripheral neuropathy (DPN) and pain associated with diabetes are not adequately managed by current treatment regimens. Perhaps the greatest difficulty in treating DPN is the complex pathophysiology, which involves aspects of metabolic disruption and neurotrophic deficits, along with neuroimmune interactions. There is therefore an urgent need to pursue novel therapeutic options targeting the key cellular and molecular players. Recent Advances: To that end, cellular targeting becomes an increasingly compelling drug delivery option as our knowledge of neuroimmune interactions continues to mount. These nanomedicine-based approaches afford a potentially unparalleled specificity and longevity of drug targeting, using novel or established compounds, all while minimizing off-target effects.
Critical issues:
DPN therapeutics directly targeted at the nervous system make up the bulk of currently available treatment options. However, there are significant opportunities based on targeting of non-neuronal cells and neuroimmune interactions in DPN.
Future directions:
Nanomedicine-based agents represent an exciting opportunity for the treatment of DPN with the goals of improving the efficacy and safety profile of analgesia, as well as restoring peripheral neuroregenerative capacity.
Introduction:
The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.
Areas covered:
The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological treatment options used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.
Expert opinion:
The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed closely by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life and, in turn, affect their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain are paving the way to new therapeutic strategies.
Adults with congenital heart disease often have complex medical issues requiring individualised multidisciplinary care for optimising outcomes and quality of life. Chronic pain is an example. We report a rare case of intercostal neuralgia seemingly caused by irritation from a prosthetic valve in a right ventricle to pulmonary artery conduit in a patient with tetralogy of Fallot. Intercostal neuralgia is a painful disorder linked to nerve irritation or injury from trauma, infection or pressure. Although chronic postsurgical pain after cardiac surgery is prevalent, rarely the aetiology relates to valve irritation on a single intercostal nerve. After failing pharmacological therapy for 8 months, the neuralgia completely resolved after an ultrasound-guided neurolytic block with long-term effectiveness and improvement in patient satisfaction.
Post-mastectomy pain syndrome is a constellation of symptoms that affect patients for longer than 6 months after treatment for breast cancer. It is believed to be of neuropathic etiology with many contributing variables. Epidemiology, diagnosis, and treatment are discussed. By understanding the nature of the syndrome, physicians are better equipped to identify and provide comprehensive management strategies.
Objectives
The ophthalmic branch of the trigeminal nerve is one of the most frequently involved sites of postherpetic neuralgia (PHN). A single‐center randomized controlled study was conducted to evaluate the efficacy of local methylcobalamin injection for subacute ophthalmic herpetic neuralgia (SOHN).
Methods
One hundred and five patients with a pain score of 4 or greater were randomized to receive a combination of methylcobalamin and lidocaine via local injection (LM, N=35), intramuscular methylcobalamin and local lidocaine injection (IM, N=35), and oral methylcobalamin tablet and lidocaine local injection (OM, N=35) for four weeks. Multilevel mixed modeling was employed to examine treatment responses.
Results
Pain scores were reduced in all groups but this reduction was significantly greater in patients who received local methylcobalamin (6.7 at baseline vs 2.8 at endpoint) when compared with systemic administration (intramuscular 6.8 vs 4.9, oral 6.7 vs 5.1). Clinically relevant reduction of pain (>30%) was seen in 91% of patients in the local methylcobalamin group, a significantly greater proportion than in the systemic groups (66% intramuscular, 57% oral). Analgesic use reduced significantly in the local group (94% at baseline vs 6% at endpoint) but not in systemic groups (intramuscular 97% vs 86%, oral 94% vs 80%). Health‐related Quality of Life was higher in the local group than in the systemic groups. In mixed modelling, increased age was associated with a lower response to methylcobalamin.
Conclusions
This study indicates that the local injection of methylcobalamin produces significant pain relief from SOHN and is superior to the systemic administration.
Microneedle patch devices have been widely utilized for transdermal drug delivery in pain management, but is challenged by accurate control of drug release and subsequent diffusion to human body. The recent emerging wearable electronics that could be integrated with microneedle devices offer a facile approach to address such a challenge. Here a 3D‐printed microheater integrated drug‐encapsulated microneedle patch system for drug delivery is presented. The ink solution comprised polydimethylsiloxane (PDMS) and multiwalled carbon nanotubes (MWCNTs) with a mass concentration of up to 45% (≈10 times higher of existing ones) is prepared and used to print crack‐free stretchable microheaters on substrates with a broad range of materials and geometric curves. The adhesion strength of the printed microheater on the microneedle patch in elevated temperatures is measured to evaluate their integration performance. Assessments of encapsulated drug release into rat's skin are confirmed by examining degradation of microneedles, skin morphologies, and released fluorescent signals. Results and demonstrations established here creates a new opportunity for developing sensor controlled smart microneedle patch systems by integrating with wearable electronics, potentially useful in clinical and biomedical research. This work shows a manufacturing route to print an electronic circuit on a curved substrate with a broad variety of materials using an ink‐solution based 3D printing technique, and demonstrates that the microheater printed on a microneedle patch enhances the delivery of its encapsulated drug molecules into skin, which is potentially useful for effective pain management.
The United States is currently in the midst of an opioid epidemic that has led to previously unforeseen opioid misuse, abuse, and death. A major emphasis is being placed on reducing the exposure patients have to opioids, whenever possible, in an effort to hopefully reduce the risk of dependency, addiction, and overdose. However, opioid alternatives must be chosen carefully to ensure efficacy, safety, and availability for patients within the community. Non-opioid medications and modalities can reliably be used to treat not only opioid naive patients, keeping them opioid naive if possible, but also patients with opioid use disorders. Unfortunately, robust randomized controlled trials comparing non-opioid alternatives to opioids are lacking. Therefore, this review provides recommendations for best practices regarding improving pain management via the use of novel alternatives in the emergency department, medical wards and outpatient setting.
Serratus anterior plane block has been used for pain management during the acute period of conditions affecting the thorax, such as post-thoracotomy recovery, rib fracture, and breast surgery recovery. Here, we report the use of serratus anterior plane block in post-traumatic chronic pain treatment. We describe a case of post-traumatic chronic intercostal neuralgia, in which successful pain relief was achieved via repeated injections of local anesthetic and steroid combinations in the serratus anterior plane under ultrasonographic guidance. This novel technique is easy to administer, reliable, and warrants further investigation with regard to its use for rehabilitation of patients who are suffering from post-traumatic chronic neuropathies of the chest wall.
Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, poses a challenge to treating clinicians. Multiple pain pathways are thought to be involved in driving the condition. Medication management should focus on targeting these various pathways to improve efficacy. Unfortunately, strong evidence is lacking for the majority of medication treatment options. Corticosteroids are supported early in the acute phase of the disease. Although gabapentin and pregabalin lack strong evidence, they are commonly prescribed because of their tolerability and safety profile. Chronic opioid therapy should be used cautiously secondary to addiction risk and long-term tolerance.This chapter focuses on the available oral and topical pharmacotherapy options in the treatment of CRPS. The mechanism of action, available evidence, dosages, and side effects/complications are discussed for each class of medication.
Background:
The management of neuropathic pain and pain related to bone vaso-occlusive crises in sickle-cell disease remains challenging in children. Lidocaine 5% patches are recommended in adults for neuropathic pain treatment, but they are not recommended in children. The purpose of this study was to assess the efficacy and tolerance of lidocaine 5% patches in pediatric inpatients.
Methods:
This prospective multicenter single-arm phase II aimed to assess the use of lidocaine 5% patches in 6 to 21 years old pediatric patients suffering from neuropathic pain or superficial bone vaso-occlusive crises. Patches were applied on the painful area for 12 hours a day. The primary endpoint was the proportion of inpatients with significant pain relief defined as a decrease of at least two points on the Visual Analogue pain Scale measured at 12 hours after patch placement (12h-VAS) during at least two consecutive days.
Results:
The 12h-VAS score decreased by at least two points (≥2p-decrease) during two consecutive days in 48.6% of patients (95%CI [33.8%;-[). Only 7.7% of patients experienced grade 1 or grade 2 toxicities.
Conclusion:
Although lidocaine 5% patches decreased pain's intensity in nearly half of enrolled patients with an excellent tolerance, the efficacy endpoint was not reached. Further studies should consider a more refined selection of the experimental population to assess lidocaine 5% patches efficacy in the pediatric population. This article is protected by copyright. All rights reserved.
The goal of our review was to emphasize important aspects that physicians should take into consideration when prescribing topical analgesics as part of chronic neuropathic pain treatment. We discuss the dermatopharmacokinetics and microstructural components of the skin, differences between topical and transdermal drug delivery, and topical medication effects on peripheral neuropathy and central sensitization. Even though the US FDA approved topical analgesics are 8%-capsaicin and 5%-lidocaine patches for treating postherpetic neuralgia, there are many other studies conducted on the efficacy of topical ketamine cream, clonidine gel, topical gabapentin, topical baclofen and topical phenytoin for peripheral neuropathic pain, either alone or in combination with other formulations. Furthermore, we discuss new compounded topical analgesics that are becoming more popular and that are showing promising results in the management of chronic peripheral neuropathies. However, more studies are needed for elucidation of the role of topical analgesics and their effects, especially when combined with other treatments.
This chapter presents a review and discussion of evidence on the use of invasive and noninvasive neuromodulatory methods in difficult-to-treat chronic pain syndromes, such as Complex Regional Pain Syndrome (CRPS), Phantom-limb pain, Central post-stroke pain, Facial neuropathic pain, Fibromyalgia, Headaches, and others. For each syndrome, a brief overview of clinical symptoms and conventional treatment approaches is presented, followed by research and clinical findings on effects of noninvasive neuromodulatory methods, including repetitive transcranial magnetic stimulation (rTMS), transcranial Direct Current Stimulation (tDCS), Cranial Electrical Stimulation (CES), or Motor Imagery, as well as major invasive neuromodulatory techniques, such as Deep Brain Stimulation (DBS), Motor Cortex Stimulation (MCS), or Spinal Cord Stimulation (SCS).
Overall, the evidence up to date suggests that both invasive and noninvasive neuromodulatory approaches have a promising clinical potential and a specific role in pain management. While invasive neuromodulation has been reserved for carefully selected patients who do not respond to noninvasive pharmacological and nonpharmacological treatments, noninvasive neuromodulation holds a promising clinical potential for wider spectrum of chronic pain patients and can be explored as an add-on therapy in conjunction with various types of treatments.
The future exploratory work on neuromodulation in pain management should navigate the development of the method-specific and patient-population-specific stimulation protocols and parameters, patient-tailored adjustments for specific cases, as well as the development of evidence-based guidelines for specific neuromodulatory techniques, in order to facilitate the implementation of neuromodulation to the clinical practice of pain management.
Background and objectivesSearch strategyDefinitionsClinical examination and psychophysiological measuresLaboratory tests
Context:
Despite recent advances in the understanding of the chronic pain concept, its diagnosis and management remains a daily challenge for clinicians and patients. Based on the published literature, this review discusses and tries to organize the current knowledge and the up-to-date clinical experience about the efficacy and safety of the use of intravenous lidocaine in treatment and prevention of chronic pain.
Evidence acquisition:
To prepare this narrative review, we performed an in depth literature review using the PubMed searching engine. We extracted all relevant articles published in English, up to April 2016.
Results:
Lidocaine, administered as transdermal patch or intravenous lidocaine, is a safe and effective modality in the treatment of post-herpetic neuralgia (PHN), complex regional pain syndrome, as well and for prevention of chronic pain. It may be effective in the management of neuropathic pain syndromes, chronic pain, post-operative pain, and refractory cancer pain.
Conclusions:
Intravenous lidocaine and lidocaine patch are effective and safe for the treatment of several chronic or neuropathic pain syndromes. The use of lidocaine during surgery could prevent the development of some chronic post-surgical pain syndromes.
Topical analgesics differ from systemic analgesics by exhibiting analgesia without significant systemic absorption as compared to systemic analgesics, which require systemic absorption for their analgesic activity. Topical analgesics are frequently confused with transdermal agents; however, they differ from transdermal analgesics (e.g., transdermal fentanyl patch) because systemic absorption of a transdermal agent is required for clinical benefit. There is a variety of mechanism of actions of specific topical analgesics. Topical analgesics have been studied in acute pain as well as in various types of chronic pain including both non-neuropathic and neuropathic pain types. The results of many of these studies are described in this chapter. New data that suggest that topical analgesics which were assumed almost by definition, to act peripherally, may affect central pain processing are also discussed.
Adolescents and children are frequently affected by chronic pain conditions that can lead to disability and distress. The best approach to evaluation and treatment of these conditions involves use of the biopsychosocial model, which includes use of medication management. Chronic pain conditions are treated pharmacologically with a number of different medication classes via several routes of administration as drug delivery systems have progressed. These include anti-inflammatory drugs, muscle relaxants, antiepileptic medicines, antidepressants, opioids, and local anesthetics. Most are prescribed without regulatory body approval to treat specific pain syndromes as data to support their use are sparse. Medical decision making is guided by experience, empiric evidence, extrapolation from adult studies, and matching medication classes with the theorized mechanism of the pain condition. It is not recommended that nonpain practitioners prescribe opioid medications for treatment of chronic pain conditions, and pain management practitioners should seek to minimize their use. The appropriate and commonly used medications for pain conditions are presented in this narrative review.
Analgesic medications compounded for topical use are gaining popularity for the management of chronic pain. The advantages of topical pain medications include reduction of systemic adverse effects, improved patient acceptance, few drug interactions, ease of dose determination, avoidance of first-pass metabolism, and direct access to the target site. Compounded topical medications typically use a mixture of 3 or more single medications to achieve multiple complementary effects at lower doses of each individual medication. Herein, we review the mechanisms, adverse effects, and evidence for some of the most commonly used medications in topical compounds for pain management. Because more topical medications are used for chronic pain, dermatologists can expect an increase in irritant and allergic contact dermatitis related to these medications.
Post-herpetic neuralgia (PHN) is a common and often intractable neuropathic pain syndrome predominantly affecting the elderly. Topical local anesthetics have shown promise in both uncontrolled and controlled studies. Thirty-five subjects with established PHN affecting the torso or extremities completed a four-session, random order, double-blind, vehicle-controlled study of the analgesic effects of topically applied 5% lidocaine in the form of a non-woven polyethylene adhesive patch. All subjects had allodynia on examination. Up to 3 patches, covering a maximum of 420 cm2, were applied to cover the area of greatest pain as fully as possible. Lidocaine containing patches were applied in two of the four 12-h-long sessions, in one session vehicle patches were applied, and one session was a no-treatment observation session. Lidocaine containing patches significantly reduced pain intensity at all time points 30 min to 12 h compared to no-treatment observation, and at all time points 4--12 h compared to vehicle patches. Lidocaine patches were superior to both no-treatment observation and vehicle patches in averaged category pain relief scores. The highest blood lidocaine level measured was 0.1 micrograms/ml, indicating minimal systemic absorption of lidocaine. Patch application was without systemic side effect and well tolerated when applied on allodynic skin for 12 h. This study demonstrates that topical 5% lidocaine in patch form is easy to use and relieves post-herpetic neuralgia.
This study compared the efficacy of topical lidocaine patches versus vehicle (placebo) patches applied directly to the painful skin of subjects with postherpetic neuralgia (PHN) utilizing an 'enriched enrollment' study design. All subjects had been successfully treated with topical lidocaine patches on a regular basis for at least 1 month prior to study enrollment. Subjects were enrolled in a randomized, two-treatment period, vehicle-controlled, cross-over study. The primary efficacy variable was 'time to exit'; subjects were allowed to exit either treatment period if their pain relief score decreased by 2 or more categories on a 6-item Pain Relief Scale for any 2 consecutive days. The median time to exit with the lidocaine patch phase was greater than 14 days, whereas the vehicle patch exit time was 3.8 days (P < 0.001). At study completion, 25/32 (78.1%) of subjects preferred the lidocaine patch treatment phase as compared with 3/32 (9.4%) the placebo patch phase (P < 0.001). No statistical difference was noted between the active and placebo treatments with regards to side effects. Thus, topical lidocaine patch provides significantly more pain relief for PHN than does a vehicle patch. Topical lidocaine patch is a novel therapy for PHN that is effective, does not cause systemic side effects, and is simple to use.
The analgesic effects of single and repeated applications of a eutectic mixture of local anaesthetics (EMLA) cream on both spontaneous and evoked pains were evaluated in 11 patients with post-herpetic neuralgia (PHN). Detection thresholds, pain thresholds and the responses to suprathreshold mechanical and thermal stimuli were quantitatively determined at baseline, 30 min after the first application and after a series of daily applications over six consecutive days (duration of application: 5 h/day). In the acute situation, EMLA produced an overall anaesthetic effect without significantly reducing spontaneous ongoing pain and mechanical allodynia. Repeated applications significantly reduced paroxysmal pain and both the dynamic and static subtypes of mechanical hyperalgesia. The effects on spontaneous ongoing pain were more variable. They were inversely correlated to the magnitude of the thermal deficit at baseline, and were significant only in patients with dynamic mechano-allodynia. Pathophysiological implications of these results are discussed.