Other Uses Of Topical Analgesics

Based upon the results of a number of small studies, mostly case reports, topical analgesics of various types including opioids may be very helpful in reducing the pain associated with pressure ulcers or dressing changes.80 [I], 81[II], 82[II], 83[III], 84[II], 85 Patients undergoing any surgical procedure might benefit from the use of a topical analgesic to treat postoperative pain and reduce the need for systemic analgesics. Controlled studies have demon strated the benefit of EMLA cream in the reduction of pain associated with circumcision and venepuncture, as well as for the pain associated with breast cancer surgery.4 [III], 86[II] Newly approved by the FDA for "local dermal analgesia'' for superficial venous access and dermatolo-gical procedures is the lidocaine/tetracaine topical patch (SyneraTM). Several studies have suggested that either ketamine or morphine may be used topically for muco-

sitis-associated pain following chemotherapy or radiation therapy in patients with head and neck carcinomas.87[II],

88[V] There is also a recent report of two children with epidermolysis bullosa who were treated successfully with topical opioids.89[V] A rather interesting recent report suggests that the analgesic effect of menthol, an ingredient common to many over-the-counter analgesic preparations, may exert part of its analgesic effect through the activation of kappa opioid receptors.90 Burn pain has been reported to be treated effectively with a topical loperamide preparation.91[V] Two randomized controlled studies - one involving postoperative pain (diclofenac patch) and one involving wound pain treatment (capsi cum plaster topically applied at acupuncture sites) - have also been published recently.92[II], 93[II]

In a single case report, a patient with a condition known as "central neuropathic itch'' has been treated apparently successfully with the lidocaine 5 percent patch.94[V] Several studies recently presented at professional association meetings are also worthy of mention. At the 2004 Joint Meeting of the American Pain Society/ Canadian Pain Society, two new studies of new topical analgesic preparations were reported. The results of an enriched enrollment study in which an open-label initial study led to the randomization of responders in a placebo-controlled study of the use of either a 4 percent amitriptyline/2 percent ketamine cream, 2 percent amitriptyline/1 percent ketamine cream or placebo for patients with PHN demonstrated that after three weeks of treatment the average daily pain intensity was lowest in patients receiving the higher concentration combination cream compared to the lower concentration combination or placebo (p = 0.026 high concentration cream versus placebo). Plasma levels of either drug were detected in fewer than 10 percent of those patients receiving active treatment.95[II] An open-label study of the use of a 0.25 percent capsaicin topical agent in a lidocaine-containing vehicle in 25 patients with painful diabetic polyneuro-pathy and seven patients with PHN demonstrated pain relief in the majority of patients who were studied.96[III]

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