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TOP THIS
Excerpted from Bottom Line's Daily Health News, June 30, 2005

I've talked a lot in recent months about options for muscle pain
relief -- substitutes for nonsteroidal anti-inflammatory drugs
(NSAIDs) and other pain pills... supplements that can help ease joint pain... and even exercise and massage regimens. What about topical creams and lotions?

Topical Advantages

To learn about topical pain relief options, I spoke with Norman J.
Marcus, MD, founder of the Norman Marcus Pain Institute in New York
City, past president of the American Academy of Pain Medicine and
author of Freedom from Pain (Fireside). He told me that topical
treatments offer significant pain relief with few of the side effects
of oral medications, thanks to the fact that topical treatments
generally are not absorbed into the bloodstream at the level that
ingestibles are.

Specifically, topical medications...

  • Are not absorbed through the gut, and so avoid stomach bleeding from aspirin, for example.
  • Are absorbed through the skin, so less medication enters into the bloodstream. This means lower cardiovascular risk and less chance of painkiller addiction.
  • Have fewer possible drug interactions due to less medicine in the bloodstream. This is especially advantageous to older people, who are more prone to side effects, often have a variety of medical conditions and take multiple medications (which can lead to multiple drug interactions). Older people don't clear medicines from the bloodstream as quickly and efficiently, which can gradually cause a dangerous accumulation of drugs in the body.
  • Relief comes faster than with a pill. Topical medications directly
    affect pain receptors in the skin and can offer virtually immediate relief for what moments earlier seemed to be intractable pain.

Topical painkillers and other medications come in a variety of forms,
including cream, lotion, ointment, gel, spray and solution. They vary
in strength, with the more potent ones available by prescription
only. Dr. Marcus outlined a number of topical options, from local
anesthetics to specially compounded products.

Local Anesthetics

This is a good place to start with topical medicines. Milder
alternatives for minor pain and injuries are available
over-the-counter (OTC), while stronger remedies require a
prescription from your physician.

  • OTC anesthetics. These are used to relieve pain and itching caused by minor cuts and scratches, sunburn and other minor burns, insect bites or stings and poison ivy, oak or sumac. Examples include Solarcaine and Dermoplast (benzocaine preparations).
  • Lidocaine. Lidocaine (Lidoderm) is prescribed for the relief of
    pain caused by nerve damage, such as diabetic neuropathy and shingles. It works by blocking the signals at the nerve endings in the skin.

Capsaicin, Eucalyptus and More

Other OTC options include capsaicin made from the oil extract of
cayenne peppers, and eucalyptus oil from the bark of the tree of the same name. Capsaicin works by depleting the nerves of a pain-inducing chemical called substance P. It is recommended for arthritic pain and nerve pain due to diabetes or shingles. Although capsaicin offers pain relief that accumulates with regular use, many people cannot tolerate the initial intense burning sensation upon application.

Natural substances such as eucalyptus, wintergreen and menthol
produce intense hot or cold sensations that temporarily offset pain.
They are found in conventional OTC products such as Ben-Gay and Icy Hot, and in many natural preparations at your local health-food
store. These are often combined with the capsaicin in "icy/hot"
preparations. Some people find it difficult to tolerate their strong
scent.

Corticosteroids

These drugs work by reducing inflammation. By staunching the release of inflammatory substances from skin cells, they decrease swelling, discomfort, itching and redness. Corticosteroids are used to treat eczema, dermatitis, insect bites and stings and poison ivy, oak and sumac. Most require a prescription, although a few -- a low-dose preparation of hydrocortisone such as Cortaid, for example -- are available OTC.

Other corticosteroids available in cream or ointment form include
aclometasone (Aclovate), clocortolone (Cloderm) and desonide
(DesOwen). Topical corticosteroids must be used for limited periods
only, since they increase skin sensitivity and chronic use can cause
thinning of the skin. Additionally, corticosteroids are passed into
circulation and thus do have potentially dangerous systemic effects
over time.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical NSAID creams and gels are an excellent option for those who are worried about the growing number of side effects and safety concerns being chalked up to NSAID pills. OTC products such as Aspercreme and Sportscreme provide pain relief and reduce
inflammation of arthritic joints. You also can get ibuprofen cream
from a compounding pharmacy. (More about compounding pharmacies below.)

According to the Archives of Internal Medicine (October 11, 2004), a new prescription topical NSAID under review by the FDA shows promise. In one study, topical Pennsaid (diclofenac 1.5%) was significantly more effective than a placebo in reducing pain, increasing physical functioning and improving overall well being in people with osteoarthritis in the knee. The most common side effect was minor skin irritation, which occurred in 68 out of 164 patients. Pennsaid is already approved for use in Canada and Europe.

Compounded Products

Don't be limited by what you can buy off the shelf, advises Dr.
Marcus. If you find that standard remedies don't work for you, ask
your physician about getting a custom-made medication from a
compounding pharmacy. One pain reliever that Dr. Marcus has
compounded for his patients is ketamine, which he finds elicits a
great response topically. (Read more about compounding pharmacies in Daily Health News, July 15, 2004.)

Ketamine is an NMDA (N-methyl-D-aspartate, a nerve receptor)
antagonist, which blunts the transmission of pain signals along one
of the nerve pathways. It was originally developed as a surgical
anesthetic and is used in conjunction with other anesthetics. Taken
orally, these drugs have side effects similar to opioids, including
sedation, dizziness, nausea, constipation and dry mouth, as well as
hallucinations and psychotic episodes. However, spare amounts applied topically relieve pain while virtually eliminating the risk of these effects.

Dr. Marcus notes that muscular pain is very common, but highly
underestimated and highly underdiagnosed. The topical application of ketamine provides virtually instant relief of muscular pain. Caution: Prolonged application may result in delusion or hallucinations -- so apply with extreme discretion.

Topical pain relievers are something to consider given the FDA's
recent announcement that all NSAIDs -- even OTC ones -- carry
stomach, cardiovascular and skin risks. And, because topicals place
less burden on your system, they are an option to consider in general for pain. Of course, Dr. Marcus is quick to point out that the answer doesn't always lie in a drug. Measures such as stretching and flexing the muscles and controlling stress levels are often just as important in stimulating the body's own healing mechanisms.