Are Painkillers Through The Skin As Effective As Pills

Today's post from dailyrx.com (see link below) discusses whether topical creams and gels are as good as or better than analgesics in pill form. Many people find taking pills every day a difficult task and the rise in topical gel preparations provides a good alternative. The problem with topical gels and creams is that people have less trust in them than in a pill and have a tendency to over do the application, possibly leading to more of the drug being absorbed than is necessary. People living with neuropathy have long known about certain creams and patches which are meant to help with neuropathic symptoms but they too are not without controversy. Capsaicin cream and high strength patches can be painful and even cause burning and although many people have gained benefit from them, equally as many haven't. Because most people have symptoms in their feet and legs (or hands and arms), the topical creams can be applied at the source of the pain but the source of peripheral neuropathy pain can actually be elsewhere (in the spine or brain for instance); it's just the symptoms manifest themselves most commonly at the ends of nerve pathways (feet and hands). It's always advisable to get the best medical advice possible and ask to be monitored as to how these creams are working but with advances in preparations, they may well turn out to be effective alternatives to popping pills in the future.

Creams Versus Pills for Pain
Author Info: Charles E. Argoff, MD, of the Department of Neurology at Albany Medical College, Reviewed by: Joseph V. Madia, MD By:Laura Dobberstein March 2013


Pain relievers applied to the skin can be just as effective as those taken orally
(dailyRx News) Gel and cream pain relievers are gaining in popularity. This method of pain relief has fewer side effects than their pill counterparts and may work just as well.

A recent review looked at the use of pain relievers absorbed through the skin to manage pain.

The review found that the pain relieving medications diclofenac and ibuprofen were effective in treating muscle, tendon and ligaments and joint conditions like osteoarthritis when absorbed through the skin.

The medication lidocaine also effectively treated nerve-related pain when applied to the skin.
"Ask your doctor if topical analgesics are best."

Charles E. Argoff, MD, of the Department of Neurology at Albany Medical College, searched existing databases for studies on topical analgesics (pain relievers absorbed through the skin). Dr. Argoff identified a total of 65 studies that associated long-term, short-term and neuropathic pain with topical analgesics.

Neuropathic pain is a type of pain caused by nerve damage and often seen in patients with trauma, diabetes and amputations.

The most common drugs included in the studies were nonsteroidal anti-inflammatory drugs (NSAIDs) including diclofenac, ibuprofen, ketoprofen, piroxicam and indomethacin. The next most common drugs were lidocaine, capsaicin, amitriptyline, glyceryl trinitrate, opioids, menthol, pimecrolimus and phenytoin.

Eighteen of the studies used the pain relievers for short-term soft tissue injuries, 17 studies involved neuropathic pain and six involved pain induced for the purpose of the experiment only. Five of the studies used the pain relievers for long-term joint related conditions, five involved skin or leg ulcers and two used the medication for chronic knee pain.

Dr. Argoff concluded ibuprofen relieved chronic knee pain and short-term soft tissue injuries pain just as effectively when applied to the skin as when ingested.

The use of diclofenac topically to treat joint pain was shown in a study of temporomandibular joint disorder, a painful condition of the jaw. The study showed diclofenac applied to the skin worked just as well as when taken orally.

Lidocaine was the only drug in the studies that effectively relieved neuropathic pain.

No other drugs included in the review showed strong evidence of relief when used topically.

Pain relievers applied through the skin had fewer side effects, such as stomach and heart irritation, than orally administered pain relievers.

Dr. Argoff recommended the further study of NSAIDs and lidocaine for short-term and long-term pain relief.

The study was published in Mayo Clinic Proceedings.

Financial support for the study was provided by Mallinckrodt Inc., a company that manufactures pharmaceuticals and other health-related items.

Dr. Argoff is associated with over a dozen pharmaceutical companies and health research groups.

http://www.dailyrx.com/pain-relievers-applied-skin-can-be-just-effective-those-taken-orally

Treating The Patient As An Individual Essential For Neuropathy Treatment Success

Today's post from practicalpainmanagement.com (see link below) is written mainly for the benefit of pain professionals who are currently scratching their heads at the difficulties and complexities posed by pain treatment anno 2017. The message is that the best way of treating pain is by treating the individual and tailoring courses of treatment to that individual. Blindly following model pain behaviours has failed and results in wasted opportunities but at the moment, the medical community has little else to offer (hence the ridiculously vague, pain-testing modules). Everybody in the medical community accepts that individualised treatment has to be the answer but turning the theory into practice is mind-numbingly complex in terms of how that should be done. Nobody understands this better than the neuropathy patient who knows that his/her symptoms are unique to him/herself but is forced to follow outdated treatment models based on failing drug therapies. It strikes me that time is the problem. The average doctor or neurologist frankly does not have the time to develop individual treatment courses based on a holistic overview, for every patient. Yet this is the only answer that will bring quicker results and result in the patient swallowing less harmful medications along the way. In the end, the patient is going to have to be respected enough to form a partnership with the doctor to develop the best possible treatment outcomes. Definitely worth a read.

Distinguishing Neuropathic, Non-Neuropathic, and Mixed Pain By Charles E. Argoff, MD Last updated on: February 14, 2017 First published on: February 10, 2017
 
Given the complexity of chronic pain management, clinicians are challenged to move toward more rigorous assessment and individualized treatment to improve quality of life for all patients.

In the pain management community, we are all too familiar with the statistic estimating that there are 100 million adults suffering from chronic pain in the United States.1 However, with all of the recent negative attention on pain management, insufficient energy and attention have been focused on perhaps one of the more daunting aspects of chronic pain—the actual assessment and treatment of the person in pain. Therefore, it is reasonable to acknowledge that managing chronic pain in today’s healthcare system, as we come to understand more and more the complexity of pain, is challenging, but also quite rewarding.

It has become increasingly clear that chronic pain does not refer to one disorder or underlying mechanism and cannot be assessed or treated with a one-size-fits-all approach. Advances in our understanding have led to new, more effective patient assessment and treatment strategies.2,3 We expect that practitioner adoption of these types of tools may better guide and inform optimal chronic pain management, leading to better quality of life for patients. However, considerably more work needs to be done to implement truly individualized approaches to patient care with regard to pain management.

Among the most difficult aspects of treating a person in pain is identifying the type(s) and mechanism(s) of pain. Our patients often present to us experiencing more than 1 type of chronic pain, with more than 1 mechanism underlying their complaints. Assessing which mechanisms of pain a person is experiencing—in other words, assessing a patient’s pain profile—is not simple, but it is vital.

There are at least 2 important components of assessing the pain complaint(s):
 
Intensity, quality, and change over time
Differentiation among the mechanisms of ongoing pain, including those resulting in neuropathic and/or non-neuropathic pain.

To most accurately and effectively identify and understand the type of pain a person is experiencing, a multidimensional assessment covering both these components is imperative.

However, differentiation among pain types, as well as the root causes of the pain, can be difficult to ascertain using in-office tests. It is unlikely that functional magnetic resonance imaging (fMRI), or other similar tests, in the absence of detailed history-taking, would be sufficient to fully assess pain appropriately. Although there are many tests available, they seldom result in a specific diagnosis of a patient’s pain and may provide confounding results.

New resources are being developed to assist in the assessment of pain, including screening tools, such as the painDETECT questionnaire,4 which has been validated to detect neuropathic components of lower back pain. In the absence of specific tests, however, practitioners can still assess a patient by asking how he/she would describe the way the pain feels. For example, asking if there is any of the following symptoms: numbness, burning, tingling, or feelings of electric shock, which can provide useful insights. Notably, distinguishing between neuropathic and nonneuropathic pain types, and understanding if a person has features of both, can better allow for a more tailored treatment.

The Best Pain Management Comes From a Thorough Pain Assessment

When conducting a pain assessment, the evaluation should be as in-depth as possible to plan the most appropriate management course. When a patient with an established pain diagnosis(es) presents for chronic pain treatment, it is important to begin by assessing the patient’s functional impairment, expectations, and psychosocial needs, as well as to evaluate for any medical red flags, such as the risk of medication misuse or abuse.

Questions to consider asking include:
 
Has the patient been treated for cancer, or is he/she being treated for some potentially unrelated condition that may contribute to the pain?
What other medical/interventional/non-medical treatment is the patient receiving?
What treatments have been unsuccessful in the past?
What is the intensity and duration of the pain?
Is the patient experiencing distress or impairments associated with chronic pain?

When considering the responses to determine a course of treatment, be mindful that multimodal therapy may be required for optimal care. Since there are various potential origins for the pain that present with similar symptom profiles and distinct mechanisms that drive pain, devising a personalized treatment may be hard to come by, but still must be our ultimate goal.

Ideally, the selection of appropriate medication to address chronic pain complaints should follow the same principle as choosing an antibiotic treatment regimen, although the complexity of chronic pain and our current knowledge do not allow for this approach in all instances. For example, there are dozens of antibiotics that can be prescribed to treat a bacterial infection. Rather than a trial-and-error approach, treatment for a bacterial infection is specifically tailored to the illness based on the culture of the bacteria and the specific manifestation of the disease. Selecting the appropriate pain medication should be treated in the same manner, whenever possible.

Consider Pain Mechanisms in Prescribing Medications

Besides analgesia and depending on severity, chronic pain can be managed in many ways, including appropriate physical therapy, cognitive-behavioral approaches, neurostimulation, acupuncture, functional medicine, and other noninvasive approaches, nonanalgesic medications, and other modalities.

Medications may include commonly used analgesics, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs); for more severe pain, opioids may be more effective. So-called adjuvant analgesics (eg, anticonvulsants or antidepressants) may also be considered.

However, there may be individual differences in response to these drugs, depending on the patient’s neuropathic and non-neuropathic pain profile. Nociceptive pain, a type of non-neuropathic pain, is generally more responsive to anti-inflammatory agents and classical opioids, while neuropathic pain may be less responsive to traditional pain management. In some cases, pharmacologic agents that address more than 1 type of pain may be more effective for some patients, and many newer medicines are designed to target both types of pain in a single pill.

As we continue to gain insight into pain mechanisms and subtypes and begin to develop increasingly sophisticated evaluation tools, the need for both a thorough assessment and individualized treatment has become more evident. Preferably, pain management will begin with a rigorous evaluation, using the latest available tools, followed by evidence-based, individualized treatment with multimodal therapy where appropriate. Bringing these crucial pieces together to improve management of chronic pain will ultimately help improve patients’ lives, which is, of course, our end goal.

View Sources

https://www.practicalpainmanagement.com/pain/distinguishing-neuropathic-non-neuropathic-mixed-pain

Sometimes No News About Nerve Pain Treatment Is Just As Bad As Fake News!

I have to say that today's post from sciencedaily.com (see link below), which is widely repeated across the internet at the moment, is problematic for me. When you see the words: 'moderate evidence' and 'probably' and 'Unfortunately, more research is still needed', littering an article, you know that what you're reading is more of the same and nothing new. So, we have a report from the esteemed, Agency for Healthcare Research and Quality (AHRQ) which broadly supports the continued use of the anti-depressants and anti-seizure drugs to treat nerve pain we all know and are generally disappointed by but offers no new evidence, or new alternatives, just more vague estimations that these drugs are probably better than nothing. Frankly it's not good enough. People are going to read this in the way that people do and come to the conclusion that pregabalin, duloxetine, gabapentin, amongst others; with botox and capsaicin thrown in for good measure, are all okay for nerve pain. Now, forty years of stagnation in pain control for nerve pain, suggests the opposite. The side effects are so often worse than the symptoms themselves that yet more suffering is heaped upon innocent patients who believe what they read here. Of course, these days, no article of this sort is ever complete without the statutory warning about the evils of opioids (as if sensible opioid users don't already feel guilty enough about taking the only thing that really reduces their pain!). If you look carefully at this story and maybe read some of the other versions that are currently sweeping the neuropathy net, you'll see that while this is not a 'fake news' story, it is a non-news story - we've heard these conclusions for decades - why are they getting so much publicity?

Which drugs effectively treat diabetic nerve pain?
American Academy of Neurology (AAN) Date: March 24, 2017

A federal health agency has found certain antidepressants and anti-seizure drugs are among medications that effectively treat diabetic nerve pain. The research is being published simultaneously in the March 24, 2017, online issue of Neurology®, the medical journal of the American Academy of Neurology (AAN) and in a more comprehensive report by the Agency for Healthcare Research and Quality (AHRQ).


AHRQ is the lead federal agency charged with improving patient safety and the quality of America's health care system.

The Centers for Disease Control and Prevention (CDC) says more than 9 percent of the U.S. population has diabetes and an estimated 50 percent of people with diabetes have some form of diabetic peripheral neuropathy, nerve damage caused by high levels of blood sugar, although not all have symptoms. Symptoms can include nerve pain, numbness and tingling in the legs and feet. The longer someone has diabetes, the greater the risk of developing neuropathy, especially for those who have problems controlling blood sugar. Severe neuropathy may eventually lead to the need to consider amputation.

"Providing pain relief for neuropathy is crucial to managing this complicated disease," said Julie Waldfogel, PharmD, of The Johns Hopkins Hospital in Baltimore, Md., and author of the systematic review. "Unfortunately, more research is still needed, as the current treatments have substantial risk of side effects, and few studies have been done on the long-term effects of these drugs."

A systematic review is an analysis of the results of multiple, carefully designed studies available on a topic.

For this systematic review, researchers looked for studies and other systematic reviews conducted after the American Academy of Neurology's 2011 guideline "Treatment of Painful Diabetic Neuropathy." A total of 106 studies were included in the review.

Researchers found moderate evidence that the antidepressants duloxetine and venlaxine, which act as serotonin-norepinephrine reuptake inhibitors, were effective in reducing neuropathy-related pain.

They also found weak evidence that botulinum toxin, the anti-seizure drugs pregabalin and oxcarbazepine, as well as drugs classified as tricyclic antidepressants and atypical opioids were probably effective in reducing pain.

Waldfogel noted that the long-term use of opioids is not recommended for chronic pain due to lack of evidence of long-term benefit and the risk of abuse, misuse and overdose.

Researchers noted that while pregabalin works in the same way as gabapentin -- both are often used interchangeably in clinical care -- this review found gabapentin was not more effective than placebo. This is contrary to the 2011 AAN guideline, which found gabapentin to be probably effective.

The seizure drug valproate and capsaicin cream, which were considered probably effective in the 2011 AAN guideline, were ineffective in this meta-analysis.

"We hope our findings are helpful to doctors and people with diabetes who are searching for the most effective way to control pain from neuropathy," said Waldfogel. "Unfortunately, there was not enough evidence available to determine if these treatments had an impact on quality of life. Future studies are needed to assess this."

There were other limitations. One was that all studies were short-term, less than six months, and all studies on effective drugs had more than 9 percent of participants drop out due to adverse effects. Longer-term outcomes should be evaluated in future studies so that side effects and continued effectiveness of the drugs can be assessed.

Story Source:

Materials provided by American Academy of Neurology (AAN). Note: Content may be edited for style and length.

Journal Reference:
Julie M. Waldfogel, Suzanne Amato Nesbit, Sydney M. Dy, Ritu Sharma, Allen Zhang, Lisa M. Wilson, Wendy L. Bennett, Hsin-Chieh Yeh, Yohalakshmi Chelladurai, Dorianne Feldman, Karen A. Robinson. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. Neurology, 2017; 10.1212/WNL.0000000000003882 DOI: 10.1212/WNL.0000000000003882
 
https://www.sciencedaily.com/releases/2017/03/170324192328.htm

IMMUNE CELLS PROPOSED AS HIV HIDE OUT DONT LAST IN PRIMATE MODEL

Where does HIV hide? Antiretroviral drugs can usually control the virus, but can't completely eliminate it. So any strategy to eradicate HIV from the body has to take into account not only the main group of immune cells the virus targets, called CD4 or helper T cells, but other infected cells as well.

New research from Yerkes National Primate Research Center, Emory University, sheds light on the question of which cells support viral replication and persistence, and the answers have implications for future efforts to eliminate HIV from the body in human patients.

The results were published Oct. 30 in the journal PLOS Pathogens.

"Our results have implications for efforts to cure HIV," says lead author Mirko Paiardini, PhD, assistant professor of pathology and laboratory medicine at Emory University School of Medicine and Yerkes National Primate Research Center. "Our findings suggest that therapeutic strategies aimed at stimulating infected macrophages may facilitate viral elimination."

Researchers at Yerkes looked at what happens when rhesus macaques have CD4 T cells removed from their immune systems before infection by HIV's cousin SIV. They found that another type of immune cell, called macrophages, then becomes heavily infected by SIV. Infected cells are present in lymph nodes, intestine and brain as well as in the blood.

However, the macrophages live shorter than expected based on previous research studies, which calls into question the idea that the macrophages could serve as a long-term hideout when someone is infected by HIV but receiving antiretroviral drugs.

"Among HIV researchers, there has been a lot of debate about the contribution of macrophages to the HIV reservoir," Paiardini says. "We show that in the absence of CD4 T cells, macrophages can be heavily infected by SIV, which supports a role for macrophages in viral infection. However, when infected at high levels, macrophages become short-lived cells in vivo, with an average lifespan of 1.3 days. Thus, if validated in the setting of HIV infection in humans, our data support a model in which macrophages do not constitute the long-lived reservoir (in order of weeks) that has been proposed."

The researchers also found evidence that in macaques with depleted CD4 T cells, SIV is infecting microglial cells in the brain, otherwise rarely seen.

The Safety Of Medical Marijuana As A Pain Killer

Today's post from webmd.com (see link below) is a recent one looking at the safety of medical marijuana, which if we're honest as neuropathy patients, is what concerns us most. Most people these days have researched enough to realise that the moral, legal and addictive qualities of medical marijuana are not so important; what they're interested in is whether it works as a pain killer for neuropathic symptoms and it quite clearly does for most users. This article assumes that and looks at a study of the drug's safety in comparison with other drugs used to treat neuropathy including opioids. It comes to the conclusion that medical marijuana is a useful addition to the doctor's tool chest when it comes to neuropathy medication. Worth a read.

Medical Marijuana Seems Safe for Chronic Pain
And the drug modestly reduced people's pain scores
By Dennis Thompson HealthDay Reporter WebMD News from HealthDay
WEDNESDAY, Oct. 7, 2015 (HealthDay News)

 Medical marijuana appears mostly safe for treating chronic pain, at least among people with some experience using the drug, a new study suggests.

People who used pot to ease their pain didn't have an increased risk of serious side effects, compared to people with pain who didn't use marijuana, a Canadian research team found.

But, medical marijuana users were more likely to have less-serious side effects, the study authors said. These side effects included headache, nausea, sleepiness and dizziness, the research revealed.

"In terms of a side effect profile, we felt the drug had a reasonably good safety profile, if you compare those effects to other medications," said study lead author Dr. Mark Ware. He is director of clinical research for the Alan Edwards Pain Management Unit at McGill University Health Center in Montreal.

Although this study focused on the safety of medical marijuana, Ware reported that participants also appeared to experience some pain relief through their use of the drug. The researchers also saw improvements in mood and quality of life in the marijuana users.

Findings from the study were reported online recently in the Journal of Pain.

The trial is the first and largest study of the long-term safety of medical marijuana use by patients in chronic pain, Ware said.

The researchers followed 215 adult patients with chronic pain who used medical pot for one year. The researchers compared the marijuana users to a control group of 216 chronic pain patients who didn't use medical marijuana. The study involved seven pain treatment centers across Canada.

The people using pot were given leaf marijuana containing 12.5 percent THC from hospital pharmacies, Ware said. THC is the chemical in marijuana that causes intoxication. People could use pot however they liked -- smoking it, eating it in food, or inhaling it from a vaporizing device.

There was no difference in serious side effects between the two groups, the researchers found.

Marijuana users did have a 73 percent increased risk of minor side effects, the study found.

Mitch Earleywine, chair of NORML, a marijuana legalization advocacy group, said many of these side effects could be reduced by changing the way the pot is used.

"Essentially, people who used vaporized cannabis would have no more adverse events than controls," said Earleywine, who's also a professor of psychology at the State University of New York at Albany.

Ware said he hopes the study will provide valuable information for patients considering medical marijuana for pain treatment.

"This is a paper they should bring to the attention of their physician or health care provider," Ware said. "Anybody who is interested in using cannabis to treat pain should know this information, as it can influence the decision-making process considerably."

Since the study focused on people familiar with marijuana, however, it might not be as useful for patients who've never tried pot before, he added.

"For somebody reading this who's never tried it, the effects they experience might be different," Ware said.

Paul Armentano, deputy director of NORML, said the study provides further evidence that the use of marijuana doesn't deserve to be criminalized.

"These findings, and others like it, are in direct conflict with cannabis' present schedule I status under federal law, a classification that fails to acknowledge the substance's clinical efficacy and acceptable safety profile," he said.

Dr. Jonathann Kuo, an interventional pain management specialist at North Shore University Hospital in Manhasset, N.Y., said medical marijuana has the potential to be a valuable alternative for doctors who specialize in chronic pain management.

"We frequently find that opioids [such as OxyContin, Percocet, Vicodin] are not a good long-term solution for chronic pain," Kuo said. "We'd like to see some more of these long-term safety profiles of medical cannabis, and studies like these are important steps forward in that direction."

However, Kuo said larger follow-up studies looking at pot's safety and effectiveness are needed.

"I'd like to see more definitive studies before prescribing this to my patients in the future," he said.
 
SOURCES: Mark Ware, M.B.B.S., director, clinical research, Alan Edwards Pain Management Unit, McGill University Health Center, Montreal; Jonathann Kuo, M.D., interventional pain management specialist and attending physician, North Shore University Hospital, Manhasset, and Long Island Jewish Medical Center, New Hyde Park, N.Y.; Mitch Earleywine, Ph.D., professor, psychology, State University of New York at Albany, and chair, NORML; Paul Armentano, deputy director, NORML; Sept. 16, 2015, Journal of Pain, online

http://www.webmd.com/pain-management/news/20151007/medical-marijuana-seems-safe-for-chronic-pain-patients-study-finds