Ask the Pharmacist
by Ron & Marla Chapleau

February 16, 2016


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Q) What do you think about using a cream to treat my pain? Is it safer?

A) Given the general apprehension about the potential side effects of the pills we use to treat pain, many patients are pursuing topical (this is the general term used in medicine for creams, gels, patches etc..) options in the hopes that they are safer and possibly even more effective. In general, this belief is a valid one.

While the active ingredients in these topicals do pass through the skin and enter our blood supply, the levels detected there are generally much lower compared to those taken by mouth as less than 10% of a cream is absorbed. As long as they are applied to unbroken skin and only to the localized areas where the pain is being felt (they are not really appropriate or convenient for application to large surface areas), for the average healthy person, these are considered very safe options.

By far the most popular option readily available on the market is the over the counter gel known as Voltaren. It's active ingredient is diclofenac which has been available in oral form for decades as a prescription drug. The Voltaren gels are considered to be very effective for treating arthritis and general muscle and joint pain arising from such injuries as sprains and strains. Unfortunately, there does not seem to be a lot of evidence to indicate they do much for lower back pain.

The risk of upset stomach is about the same as that of placebos (i.e. essentially almost no chance) which is a major advantage over its tablet counterparts which commonly cause stomach issues (including the potential for ulcers in some). While the gel form has less kidney and cardio-vascular risk than the tablets, that is not the same as saying they pose no risk to people who are already suffering from these types of disorders. Those people are still probably better off trying to treat their pain with acetaminophen (Tylenol) or touching base with their physician/ specialist first. Those with true allergies to Aspirin or other anti-inflammatories should avoid these gels in general.

Voltaren gels are available without a prescription in two strengths, 1.16% & 2.32%; the main difference being that the higher strength oneís pain relief lasts for a much longer period of time (12 hours vs 6) rather than being significantly stronger.

Some pharmacies (including Gordonís and Wardropís) have the ability to compound much higher strengths of topical diclofenac (up to 10%). The higher strengths tend to be far more effective due to their increased concentration and the addition of an ingredient known as DMSO which allows for greater penetration of the diclofenac into the joint/ muscle thereby allowing it to exert a more potent anti-inflammatory effect. These require a prescription which can be pursued at your next medical appointment, or possibly by your pharmacy with a fax to the physician depending on their comfort level with this.

 One last point about all diclofenac (Voltaren) creams is that it is unclear how safe it is to use if you are also consuming oral anti-inflammatories (such as Aleve, Advil and many others). While some health care practitioners are comfortable with the practice, others warn against the potential risks of additive side effects and the combination does not seem to work much better than either ingredient on its own.

There are also a bevy of topicals available to treat the pain of neuralgia. This is the burning, pin prick, tingling pain that arises from conditions that can damage nerves such as shingles, diabetes and chronic injuries. While there are a few good over the counter options, most of them such as Neuragen are prohibitively expensive.



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One option that is both effective and reasonably well priced are creams that contain the ingredient capsaicin. This comes from hot peppers and when applied to skin, it causes the nerve endings to release substance P (this is the chemical that begins the signal to the brain that tells you that you have hurt/ burned... yourself in a particular area). If it is applied repetitively, eventually the nerve endings become depleted of this substance P leading to a much reduced pain level. The downside of these topicals is that they need to be applied multiple times a day (4 times is best) and the area may hurt worse initially before gradually getting better over the first two weeks.

One cream known as Menthacin combines the capsaicin with menthol which helps to dampen or eliminate the initial burning sensation. Once again, compounding pharmacies can make creams with much higher strengths of capsaicin than is commercially available if you find that products like Menthacin and Zostrix only help so much but are well tolerated.

Compounding pharmacies are also capable of manufacturing a number of other topicals using ingredients such as lidocaine, amitriptyline, baclofen and many others to try and get these chronic nerve pains under control. Many also make very effective creams for the treatment of other painful conditions such as plantar fasciitis, back pain and just about any other you can imagine.

One very effective option that is used by many physiotherapy clinics to speed the treatment of injuries to ligaments, tendons and other so called soft tissues is phonophoresis. With this, ultrasound is used to help pass a drug (often hydrocortisone) that has been mixed into the standard gel used in ultrasounds in order to get it deeper into the affected muscles or other tissues. The procedure is very safe and can be an effective tool alongside the usual stretching and strengthening exercises these injuries require.

 In summary, if you are dealing with chronic pain, talk to a health care professional for options. There are many available topical options that are effective, safe and underutilized.


For more information about this or any other health related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination in Kincardine and Port Elgin Pharmasave.

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Tuesday, February 16, 2016