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5aturday, January 1, 2011 PA N TREA

¯
MENT ¯'

Is There a Role for Topical Opioids in Pain , A - >

Care? Visit Pain Treatment Topics

What to Know About
Topical medications have been used for
These UPDATES
ages and are delivered via a variety of
dosage formulations including creams,
ointments, gels, lotions, solutions, pastes,
and sprays. Agents applied topically
specifically for analgesia have traditionally -

included various NSAIDs, capsaicin, local Stay Up-To-Date on

anesthetics (eg, lidocaine), rubefacients or UPDATES
counterirritants (eg, menthol, camphor, Register here to receive a
others), and herbal products (eg, arnica, comfrey, and once-weekly notice of new
others). For unknown reasons, the topical application of postings.
opioids has been largely overlooked; yet, such formulations
might be a safe and effective alternative for the better care of .

Search Pam-Topics
many acute and chronic pain conditions.
UPDATES

For example, there are only 9 clinical trials currently Sorrh

registered involving topical opioids and all are studying effects
on painfuI acute wounds [see, ClinicaITriaIs.gov]. A recent
and otherwise good review of topical analgesics incorrectly UPDATES Postings
lists fentanyl and buprenorphine transdermal patches as Table of Contents
topical opioids; however, while these agents are applied V 2011 (137)
topically they are intended to enter the bloodstream and have
systemic rather than localized or peripheral effects [Moody December 2011 (3)
2010]. The Cochrane Collaboration has only recently planned
November 2011 (11)
a first-ever systematic review of the literature on topical
analgesics that also will include topical, peripherally-acting October 2011 (12)
opioids [Moore et al. 2010].
September 2011 (10)
Revising Traditional Perspectives
The traditional perspective is that opioid pain-relieving effects August 2011 (11)
take place systemically within the central nervous system.
July 2011 (13)
Beginning with animal experiments, the existence of
. . .

peripheral opioid receptors that could be affected by topicalIY June 2011 (12)
applied opioid agents were explored well over 20 years ago.
aµµiieu uµiviu eyelica vveie exµiuieu vveii uvei av yeeis ayu.
In limited human trials, largely published as case-study > May 2011 (14)
reports, topical opioids appeared to offer therapeutic options
with numerous advantages over oral opioids for acute or > April 2011 (12)
chronic cancer or noncancer pain conditions. It should be
¥ March 2011 (12)
noted, however, that topical formulations of opioids are
an "off-label" application in the U.S., as there currently are no y February 2011 (13)
FDA-approved, commercially available preparations.
However, compounding pharmacies can, and do, readily V January 2011 (14)
formulate topical mixtures containing prescribed opioids, The Impossibility of
often in combination with additional prescribed ingredients. Pain-Care
Being a
.

[See disclaimer below.]

Expert
Further research discovered that, anatomically, many types Cancer Survivors
of pain sites are essentially wounds containing inflammatory
Suffer Burden of
compounds spurring a proliferation of opioid receptors along
with increases in sensory nerve terminals. All 3 opioid Chronic Pain
receptor types (mu, delta, kappa) can be present and active ..

, ,

iluiyaio wiluvue
in peripheral tissues, and the function of these inflammatory
NSAIDs Raise
processes is to attract the body's natural endorphins for pain
relief. These endogenous opioid peptides are expressed by Cardiovascular
resident immune cells in inflamed peripheral tissues, resulting Risks
in analgesic effects. The peripheral opioid receptors can
modulate nerve impulses in a way similar to the action of Data Mining Fallacies
opioid receptors in or near the spinal cord, so exogenous in Pain Research
opioids such as morphine applied at pain sites have effects Revisited
akin to systemic opioids (administered orally or parentally)
that impact the central nervous system [Stein 1995; The Trouble with
Watterson et al. 2004]. Opioid Treatment
Agreements
A major and critical difference is that peripherally
acting
opioids allow analgesia without undesirable central side Study Finds Low Risk
effects, such as respiratory depression, dysphoria, sedation, of Rx-Opioid-Use
nausea, or addiction, and without the adverse effects of Problems
systemic or topical NSAIDs (eg, renal toxicity, gastric

opioid actions are particularly prominent in inflamed tissues to Obesity -

A
may be clinically advantageous, considering that many acute Myth?
or chronic pain conditions are associated with inflammation
(eg, trauma, postoperative pain, pain due to cancer or FDA Puts the Brakes
arthritis, and myofascial pain). Furthermore, the involvement on Acetaminophen
of immune cells in pain inhibition may provide new insights
into pain associated with a compromised immune system, as Study Finds Placebo
in cases of AIDS, other autoimmune disorders, and certain Works Great for
cancers [Stein 1995, Watterson et al. 2004]. IBS! Why?

Topical Opioid Successes Chronic Back Pain

Not all opioids are suitable for topical pain relief, according to Affects Memory,
Forest Tennant, MD, who has extensively used this modality
Concentration
in patients with chronic pain [2010A]. The opioids he most
commonly prescribes topically are morphine, Practitioners Iqnore
hydromorphone, and oxycodone, which penetrate gradually Osteoarthritis
through skin and act directly on opioid receptors without .

Guidelines
requiring further metabolism. He notes that some patients
requiring further metabolism. He notes that some patients
use methadone topically and find it effective. Certain Is There a Role for
opioids -

such as hydrocodone, codeine, and tramadol are -

Topical Opioids in
prodrugs, requiring hepatic conversion to active analgesic
Pain Care?
metabolites, and remain inert on the skin surface. Fentanyl is
extremely soluble and dissolves quickly through the skin Why Practitioners
making it an effective systemic agent but a poor choice for
Dislike Chronic Pain
topical use, and there has been no mention in the literature
thus far regarding the use of oxymorphone in topical Patients
formulations.
Top 10 "Hit Parade"
Postings for 2010
are some examples from the literature reporting
.

Following,
effective applications of topical opioids. Specific formulations
also are noted, to the extent that they were indicated in the
¥ 2010 (138)
reports.
¥ 2009 (70)
• In a conference poster presentation, Tennant reported a
raen enrime nf at n=†·imn+c with Innn-+mrrn in+rart·mble

pain who self-administered prescribed topical opioids "Hit Parade" of the

[2010B]. Patients ranged from 29 to 82 years of age, Most Popular UPDATES
with pain due to spine degeneration (61%),
neuropathies (24%), or arthritis (15%). They used one
'
of 3 formulations morphine (30 mg or 90 mg),
-

oxycodone (30 mg or 90 mg), or hydromorphone (8 mg SERIES: Making Sense of

or 24 mg) per ounce of base cream and they were -

Pain Research
issued up to 16 ounces/month during 6 months for PRN
("as needed") application. All patients reported using SERIES: Pain and the
their cream at least once daily, with many (67%) also Great Brain Robbery!
using it for breakthrough pain or flares. SERIES: Vitamin D for
Pain
The vast majority of patients (85%) reported effective
pain relief lasting up to 3 hours from single topical opioid SERIES: NSAID Safety
applications. A significant number (62%) used Concerns
inexpensive heat, vibrator, infrared, or ultrasound
devices over the application area to enhance absorption. SERIES: Editor's Notebook
Added benetits reported by 30% or more of patients
FYI: What to Know About
included: decreased use of oral opioids, fewer or less
These UPDATES
severe pain flares, and less stiffness. Smaller numbers
of patients also noted being more active, enjoying more Individual Articles...
sleep, appetite improvement, and/or better self-control
> Myth-Representations of
over pain.
• In an earlier report, Tennant [2010A] described case Opioids & Their Risks
reports of patients who used mixtures containing 1 to 2
> Chronic Pain in America
of the following opioid tablets per ounce of common cold
a National
.

cream; morphine 30 mg, hydromorphone 4 mg or 8 is Disqrace

mg, or oxycodone 30 mg. Patients were instructed in > Beware of Drug
crushing the tablets and formulating the mixture Interactions With Pain
themselves, and many found other creams, oils, lotions,
Meds
or gels that seemed to work better for them. [Note:
This home-compounding might have the disadvantage > Is Buprenorphine
of producing coarse mixtures without an even Effective for Chronic
distribution of active ingredient.]
Pain?
• In a much earlier report, appearing in The Lancet,
Tann=nk a+ =I 110021 rennel-arl nm SC n=+ian+e uri+I-r a IAtWmb \Ainela, ,¾ Far
 Tennant et al. [1993] repoÑed
on 26 patients with > What Works Best for
severely painful back conditions who used a mixture Acute Pain: Evidence
containing 120 mg morphine in 80 grams of a Review
moisturizing cream (Aquaphor). From 1 mg to 3 mg was
applied daily and treated with ultrasound to enhance > Common Treatments
penetration. Most patients (88%) noted up to 40% or Fall to Relieve Chronic
50% Iocalized pain relief for 4 or more hours, and 19% Pain
reported relief lasting longer than a day.
> Treating Back Pain
Using the same approach, Tennant's team also Reverses Brain
conducted a small, placebo-controlled, double-blind, Abnormalities
crossover study. As expected, average duration of pain
relief was significantly greater with the topical opioid > The Lanquape of Pain
than placebo cream. Pain-free, body-movement 24 Can Make a Big
hours after treatment was reported in 44% of the Difference
morphine cream applications compared with none of the
placebo applications. > Study: Massage Tops
- , . .. . .. -- n-. -- · II - .. --.- M-A- X-... I -...-... P3--l,
e ill d FUCWilL LULLUE LU LilU I¯UILUF, I"Idt'•ifldll J. Isey, viviv, e i i=uo Ivi -un=i -ves

practitioner in a headache clinic, reported using a topical Pain

mixture of morphine (60 mg immediate release),
> More About Chronic
dimethyl sulfoxide (DMSO), and aloe vera gel (as a
diluent) [Ney 2010]. He noted remarkable improvement Pain, Opioids, & Suicide
in his patients in terms of pain relief and, thereby, > Meditation Works
psychological well-being without systemic opioid
-

Through Brain to Soothe

adverse effects.
Pain
DMSO is a very interesting agent, discovered in 1866 as > When is Pain
a byproduct of paper manufacturing. Used as an
Relief "Meaningful"?
industrial solvent, it also has a high capacity to
penetrate skin and tissues. Going back at least 5
decades, sometimes controversial claims have been Links to Key Topic
made regarding health benefits of DMSO, including Categories
potent analgesic effects; however, it is only FDA-
approved to treat interstitial cystitis, a painful bladder IMPORTANT INFORMATION:
About These UPDATES
condition, and some states prohibit its use for other
abüse-ddaltLION
medical applications. Animal experiments had -

demonstrated properties of DMSO as an effective carrier acetaminophen

agent facilitating transport of topically applied opioids acupuncture acute pain
through the skin [Kolesnikov et al. 2000]. Indeed, a Alcohol analqesic
newer topical NSAID product, containing diclofenac Anouncements-
sodium (Pennsaid®), incorporates a 45.5°/o solution of Warnings anticonvulsant
DMSO, presumably as an inactive carrier agent; so, this antidepressant arthritis a
may portend future uses of DMSO in topical analgesic
back pain birth defects
products. [For further information on DMSO, click here.] black box warnina
Jacobsen [2010] described randomized, double-blind, buprenorphine cancer pain
placebo-controlled studies (but encompassing only a
total of 34 subjects) to assess the efficacy of a topical
cardiac chronic pain
complementary-
opioid mixture (10 mg morphine/8 gm amorphous
hydrogel) for treating painful ulcers (mostly sacral alternative med
pressure ulcers). Compared with placebo, the topical conferences copina skills
opioid produced significantly improved pain scores, with CRPS/RSD death depression
decreases of 2 to 3 points on a 0-10 pain scale. In other dietary supplements DMARD
research enrolling patients with painful oral mucositis, drug interactions EBPM
 r nses th mor hir es t or 2 0 n or ine Editor's Notebook elderly
chlorohydrate in 1000 mL of water) produced a ergonomics exercise FDA
significantly decreased duration and intensity of pain as fentanyl fibromyalqia foot
p_ain GI pain Guest Author
compared with a mixture of lidocaine,
Quidelines hand pain
diphenhydramine, and magnesium aluminum headache homeopathy
hydroxide. The morphine-rinse protocol consisted of 15 hyonosis IB_S interventional
mL taken every 3 hours PRN and held in the mouth for 2 orocedures knee pain
minutes before expectoration. lancuace matters laser therapy
• Waterson and colleagues [2004] reported the first legal issues liver failure
magnetic therapies Makinq
clinical use of topical opioids for severely inflamed skin
.

Sense of Pain Research

lesions in young children. The treatment produced good mariiuana massage
pain relief without side effects, and they also found medication Quide meditation
improved healing as an incidental but important benefit. methadone miciraine
The very low dose of topical morphine used -

0.2 morphine naloxone

mg/kg, or a 0.06% mixture in hydrogel -

was naitrexone neck pain

considered safe even if rapidly absorbed. They proposed neuropathy NSAID opioid
that the technique could also help management of other ,sy,,, noi' |Bg
painful skin lesions, including burns, ulcerated vascular
hemangiomas, or postoperative wounds.
overdose oxycodone
pain-and-the-brain
In an interesting experiment using an animal model,
. . .

.
pediatriCS PENS placebO
Tandon and colleagues [2010] recently reported that propo×yphene relaxation REMS
low-dose naloxone (LDN) administered topically in repetitive strain RF therapv
combination with morphine and ketamine (an NMDA shinales-PHN shockwave
antagonist) produced significant and synergistic therapy shoulder pain side
analgesic effects. [We have previously discussed effects somatization SUIClde
surciery Tai Chi TENS
analgesic benefits of centrally-acting low-dose naloxone
Tension Mvositis Syndrome
and naltrexone (here), and this observed peripheral treatment agreements UDT-
action could be of significance for developing topical Urine Druci Testinq
opioid formulations.] vertebroplasty vitamin D
. Other recent research in animals found that the women-men voga
combination of topically administered mu- and delta-
opioid receptor agonists had a synergistic analgesic
UPDATES/Website
effect [Schramm and Honda 2010], and topical
low-dose Information
combinations of lidocaine with either low-dose
inn i.--,
a-dditiveR=n-i E..
se p-roducir
----, sine vicia-a
greater-an-algesia P A I NTRE A TMENT
sign fican effects g
than each agent alone [Kolesnikov et al. 2000]. Of Pain Treatment Topics and
interest, topical buprenorphine was 5-fold more potent these UPDATES are
than topical morphine in this animal model, and the independently produced
lidocaine-buprenorphine combination had the greatest
and supported in part by
potency and longest duration of action.
educational grants from...
An impressive feature of the research to date is the diversity NBA
of topical opioids, plus combinations with other agents in
many cases, that may produce effective analgesia in a variety
of pain conditions. However, much of the evidence comes To become a website
from preclinical experiments in animals, and human-trial supporter: See Info
reports of topical opioids thus far have consisted of anecdotal Also see Disclaimer and
cases or small, largely underpowered, studies. website Policies. Contents
are copyrighted by Pain
Unresolved Questions Treatment Topics, ©2009-
Clearly, more research is warranted and there are still 2011.
questions needing more complete answers:
questions needing more complete answers:
> What is the most efficacious opioid and/or combination of Stay Up-To-Date on
ingredients and their dosages? UPDATES:
> What is the most advantageous carrier (eg, gel, cream, Reclister for e-Notifications
lotion, DMSO, etc.) and method of application? to receive a once-weekly
> Which pain conditions are most amenable to topical opioid e-mail announcing new
therapy? postlags.
> What degree and duration of analgesic effects might be
expected? Contributor Profile:
> In which circumstances could topical opioids completely Stewart B. Leavitt, MA,
replace the need for systemic opioids or other analgesics? PhD
> What is the potential, if any, for developing tolerance or Gail: Stew.Leavitt [at]
hyperalgesia during prolonged use of topical opioids? Pain-Topics.org

There also is the question of whether systemic infiltration of About Sources & URL
topically applied opioids is completely avoided. The extremelY Links:
low incidence of tolerance and side effects reported in animal Unless expressing
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systemic absorption [Watterson et al. 2004]. In early studies, opinion, UPDATES

Tennant et al. [1993] observed no detectable serum contributors must give
morphine in patients applying a topical morphine mixture resource references for
daily for back pain, but more recently Tennant [2010A] has the health or medical
suggested that some patients regularly using topical opioid information noted and,
preparations covering large areas may show low levels of the when relevant and
opioid in serum and/or urine. In one case, a woman topicalIY available, URL links must
applying the equivalent of 60 mg morphine/day had trace be provided. URL links
amounts of 5 ng/mL in serum and 60 ng/mL in urine. open in a new window,
and access was checked
In a very small sample of human subjects with chronic prior to posting; however,
arthritis (n=3), Wilken et al. [2005] reported good pain relief some may change and not
with the application of topical morphine; however, 24-hour function in the future,
urine collection did show the presence of systemic morphine· which is beyond our
They concluded that, while topical morphine is absorbed to control.
some extent systemically in the body, the degree of such
absorption could not be quantified. Others have reported that Certifications:
opioid actions are restricted to the area of appiication witnour We comply with the
central, systemic effects [Jacobsen 2010, Joris et al. 1987]· HONcode standard for
Therefore, it appears that, even when it is possible to detect trustworthy health
the presence of topically applied opioids in serum or uriner information. Verifv
this is not tantamount to their producing adverse reactions Certification.
due to centrally acting, systemic effects.

Many Benefits With Few, If Any, Risks

Despite the limited evidence especially a lack of a large,
-

well-designed clinical trials the application of topical opioids

-

for acute and chronic pain conditions of many types appears

to represent a therapeutic option with unrecognized potential. Web Mèdica Acreditada
Several promising benefits of topical opioids may be (WMA) Certified. Verifv
summarized as follows [adapted from Tennant 2010A]: Here.

1. They are relatively inexpensive; however, costs may

vary and the mixtures must be specially compounded.
2. Topical opioids have a favorable safety profile; side Subscribe To UPDATES Fi
oFForte iF am; are relatitiolti raro
 effects, if any, are relatively rare.
3.Pain control is possible in localized areas, at and near ,

the point of application, without adverse systemic

effects.
4. Patients are afforded greater self-control over pain -

relief, which can be psychologically beneficial.

5. At the least, patients may be able to reduce
consumption of systemic, oral or parenteral opioids. Bookmark & Share
6. Hepatic metabolism is not required, which can be UPDATES
important in patients with compromised liver function or SHRRE - I

genetic deficiencies in metabolic enzymes.

7. There is little, if any, potential for abuse and addiction.

The last point is important because the scant, if any, systemic

effects of topical opioids (including psychotropic effects) and
the extreme difficulty of extracting the opioid ingredient from
a topical formulation, make it enormously unlikely that these
ailaiyemico vuuulu um auumeu ui ilave oily aciece value --

vvieil
the possible exception of topical oral-rinse solutions. There
would appear to be no overdose potential in adults with
topical opioids.

Therefore, topical opioids also might be a safe and effective

analgesic alternative for patients with moderate-to-severe
acute or chronic pain who are at the highest risk of misusing
or abusing oral opioids, including those who are concurrently
abusing alcohol, benzodiazepines, or other drugs. And, with
concerns these days about opioid misuse, abuse, and
diversion, topical opioids would appear to be the
ultimate "abuse deterrent" (indeed, "abuse avoidant")
formulation for helping to minimize the problems.

The application of topical opioids is an area of pain medicine

amenable to creative pharmacotherapy unlike any other,
considering the many possible combinations of ingredients
that may be efficacious. The limited research suggests that, in
combination with select opioids, a variety other ingredients
might be added to topical formulations for greater pain relief,
such as NSAIDs, Iow-dose naloxone, ketamine, lidocaine, and
other ingredients; perhaps, even topical vitamin D. And, most
compounding pharmacies offer a selection of a topical
transdermal creams, gels, or other carrier mediums (possibly
incorporating DMSO).

Currently, the prescribing of topical opioids for various pain

conditions appears to be the purview of a select cadre of pain
specialists who are aware of their potential and wfIling to
experiment. Unfortunately, costs for these custom-
compounded preparations are rarely, if ever, covered by
healthcare insurance and this may be a barrier for many
patients. Yet, it is curious that discussions of topical opioids
have been largely overlooked or ignored by almost all
medical publications.
It also is perplexing that, by all indications, pharmaceutical
firms have not shown any interest in researching and
developing proprietary topical oplold preparations. And, in
lieu of such commercial support, why have government
agencles withheld research funding to aggressively pursue
this innovative approach for better pain care?

We encourage reader s to comment below and share their

own experiences with topical opioids.

Disclaimer: The above discussion is based on the evidence cited and is for
informational purposes. It is not intended to offer medical guidance for
treating specific health conditions. Furthermore, Pain Treatment Topics
does not endorse or promote the o/F-label application of any drugs. In all
cases, professional discretion is advised.

REFERENCES:
> Jacobsen J. Topical Opioids for Pain [Fast Facts and
Concepts #185]. EPERC [End of Life / Palliative Education
Resource Center], Medical College of Wisconsin. 2010
(update) [article available here]
> Joris JL, Dubner R, Hargreaves KM. Opioid Analgesia at
Peripheral Sites: A Target for Opioids Released During Stress
and Inflammation. Anesth Analgesia. 1987;66(12):1277-1281
[a bstract].
> Kolesnikov YA, Chereshnev I, Pasternak GW. Analgesic
Synergy Between Topical Lidocaine and Topical Opfolds. J
Pharmacol Exper Ther. 2000;295(2):546-551 [article here].
> Moody ML. Topical Medications in the Treatment of Pain.
Pain Med News. 2010(Dec);8(12):15-21 [article PDF here].
> Moore RA, Derry S, McQuay HJ. Topical Analgesics for
Acute and Chronic Pain in Adults (Protocol). Cochrane Library.
2010;7(art. no. CDOOS609) [access with subscription].

2010(Nov/Dec);10(9):10 [no abstract].

> Schramm CL, Honda CN. Co-administration of Delta- and
Mu-Oploid Receptor Agonists Promotes Peripheral Opfoid
Receptor Function. Pain. 2010;151(3):763-770 [abstract].
> Stein C. The Control of Pain in Peripheral Tissue by Opfolds.
New Eng J Med. 1995;332(25):1685-1690 [article PDF here].
> Tandon OP, Mehta AK, Halder S, et al. Peripheral
Interaction of Opfords and NMDA Receptors in Inflammatory
Pain in Rats. Indian J Physiol Pharmacol. 2010;54(1):21-31
[a bstract].
> Tennant F, Moll D, DePaulo V. Topical Morphine for
Peripheral Pain [letter]. The Lancet. 1993;342(8878):1047-
1048 [no abstract].
> Tennant F. Taking Advantage of the Peripheral Opfold
Receptor. Practical Pain Management. 2010A;10(3):28-30
[a bstract].
> Tennant F [2010B]. Use and Benefits of Topical Opfolds by
Intractable Pain Patients. Poster presented at 21st Annual
Intractacle Pain Patients. Poster presented at ¿1st Annual
Clinical Meeting of the American Academy of Pain
Management; september 21-24, 2010; Las Vegas, Nevada.
Poster #33 [no abstract].
> Watterson G, Howard R, Goldman A. Peripheral Opioids in
Inflammatory Pain. Arch Dis Child. 2004;S9:679-681 [article
here].
> Wilken M, Ineck .lR, Rule AM. Chronic Arthritis Pain
Management with Topical Morphine. Pain Pall Care.1

Pharmacother. 2005;19(4):39-44 [abstract].

Posted by SB. Leavitt, MA, PhD at 10:31 AM EB

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9 comments:

Anonymous said...
Would this be something the NIH might put on the -

agenda to study?
January 3, 2011 10:36 AM

SB. Leavitt, MA, PhD said...

It seems reasonable that topical oploids should be on the
research agendas of the NIH in the U.S., as well as
comparable research organizations in other countries. -

SBL
January 3, 2011 10:53 AM

Anonymous sald...
I have Aqua phor in the house and plan to crush up ,g,

15mg of oxycontin into it tonight. I fell today on my

knees and then all the way down. The hospital reset my
finger, but my arthritic knees will need some help at
bedtime, so this information was very timely for me.
Considering the constlpation I suffer with pain meds, I
would love to be able to move some of the dose out of
my mouth!
January 3, 2011 7:42 PM

SB. Leavitt, MA, PhD said...

By "Aquaphor" we assume you mean a "heallng
ointment" of some sort. Keep in mind that taking it upon
yourself to crush an oral medication for another type of
administration, without being instructed to do so by the
prescriber, at the least would be considered "drug
misuse." This is not what we intended with our blogpost
above on topical oplolds. SBL -

January 3, 2011 8:07 Pt1

Helen Mueller said...

Helen Mueller said...
Aquaphor was one of the carrier ointments mentioned.
Also mentioned was that some patients are doing this at
home. Nevertheless, once I return home (am far from
CA in a rural area of TN) I will, of course discuss this
option with my pain care provider, after all he was the
source of the medication! I would never abuse
medication, but must confess to other self experiments
in the past as part of my own treatment for diabetes.

As to the experiment crushing a pill to a fine

itself,
enough powder might be best done by a professional.
That said, my crude ointment did help in my emergency
situation and I strongly feel that steps taken to make
this option available to chronic pain patients would be in
the best interests of both doctors and patients. Helen
Janua v 4, 2011 11:07 AM

SB. Leavitt, MA, PhD said...

Your points (above) are well made, Helen. I hope our
healthcare practitioner readers take note. SBL
--

Janua v 4, 2011 11:15 AM

Anonymous said...
This would likely be the only place I would feel
comfortable posting this....I had an adult tonsillectomy &
I was prescribed Lortab ELIXIR for post-operative pain.
Unfortunately it contains alcohol & burned the hell out of
my fresh wounds & sutured areas of my throat, so badly,
I refused to take it. Then I recalled having HYCODAN
Elixir (contains only: hydrocodone 5mg/ml and
Homatropine 1mg/ml) which is marketed for non-
productive cough, hence the homatropine supposedly
helps "dry" up mucous, although Pharmacist said
Homatropine was added to reduce effects of
hydrocodone if excessive dosing occurred....??.
Anyhow, Hycodan worked excellently just allowing
it 'wash' over wounds. Plus there was NO Tylenol or
Ibuprofen in it like ALL other available hydrocodone
-

preparations, which can be vitally important if patient

unable to take NSAIDS or acetaminophen! Not 2 mention
liquid seemed to work faster being a liquid plus NO
painful burning and great cherry taste!
Feb ua y 1, 2011 5:05 AM

SB. Leavitt, MA, PhD said...

Thank you, for the tip (above). No doubt you were
getting both topical and systemic benefits of the
analgesic, since I assume you were swallowing the
solution. --SBL
 February 1, 2011 7:26 AM

Anonymous said...
I can't comment on anything other than my own
experience with Lidoderm patches and my beloved
NSAID gels Diclofenac in the US and Nuprofen from
-

France. They work wonders, as does Arnica for lesser

injuries.

When I first mentioned the ibuprofen formula to my

doctor in the US about 7 years ago, she had never heard
of anyone procuring it for less than $100 from a
compounding pharmacy. But in France, it was 5 euros at
any corner pharmacy... Pathetic that we are so far
behind. Pain patients would do well to start demanding
what is now commercially available here...demand =

wwiggigÿ guilwildlig III I.A wmpli.ullos. ju nwillillwili..

April 23, 2011 4:14 AM

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