Compounding for Pain
Oct 20, 2015
By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
I have a very valuable garden Gnome beside my TV. As he will probably now be with me the rest of my days, I figure he should stay inside. No rain, snow, sleet or hail for this precious sculpture in Gnome form. Strangely, when I look at him I get a hankering for Kung Pow goose bites. You see Winnipegosis had their 30th Annual Ducks Unlimited Dinner on the weekend, and as usual it was a great time. If I hadn't gone, I wouldn't have known that Kung Pow goose existed, let alone how good it was. And it took the Winnipegosis DU dinner to show me I get a little too competitive when bidding on garden Gnomes.
I don't think there is a cure for garden Gnome auction pain. I think you just have to learn to live with your decision. However, pain in general has to be one of the most common symptoms that people have when they come to the pharmacy. There are many, many commercially available over the counter and prescription pain killers out there. Sometimes, though, the commercial products aren't right for a patient. Sometimes, after discussing the situation with the patient and their doctor, the best product is determined to be a compound we make especially for them.
Our most popular compounded pain killer is diclofenac PLO gel. Diclofenac is a pain killer and anti-inflammatory. It is used in arthritis, sports injuries and many other different painful conditions. One of the problems with diclofenac in pill form is that it can be hard on the stomach and can even lead to ulcers. Things change when we make diclofenac in to a topical gel. As it avoids the stomach, it is far less likely to cause stomach problems like ulcers. Patients also like it because they can rub it directly onto their sore joints.
There are different types of pain. Neuropathic pain is when there is no actual tissue damage, but the pain nerves send pain signals to the brain anyway. A common type of neuropathic pain is the pain some people experience after shingles. This nerve pain after shingles is called post herpetic neuralgia (PHN). Like other types of nerve pain, PHN can be very difficult to treat. Whereas the pain from a broken bone will usually respond well to an opioid pain killer like morphine, sometimes nerve pain like PHN does not. Often we have to look for more unusual pain killers. One of those is ketamine. Ketamine is an NMDA receptor antagonist. The NMDA receptor can be involved in nerve pain. Most pain killers like morphine don't help when it comes to NMDA receptor related pain, but NMDA receptor antagonists like ketamine can help. Because of this property, sometimes our ketamine containing gels can help treat PHN pain when other medications fail.
Sometimes the doctor wants a fast acting pain killer that doesn't last very long. One reason might be when a patient has a painful procedure done every day. For example, sometimes changing dressings on a wound can be very painful. Ideally you want a pain killer that can be given just before the dressing is changed, and is out of the system shortly after the dressing change is done. One way to do this is give the medication under the tongue. We have taken the potent opioid pain killer fentanyl and compounded into a good tasting liquid. This sublingual fentanyl can be given under the tongue before the dressing change. Medications given under the tongue are absorbed very quickly. So the pain killer is only on board during the painful dressing change and is eliminated quickly and gone when the patient doesn't need it.
What do you do when a hospitalized patient can't take their pain killer by mouth? Sometimes the answer is easy. If the patient's pain killer is morphine, morphine is available as an injection, so we just switch from the tablet to the injection. We had a patient whose pain killer was gabapentin. There is no commercially available gabapentin injection. After discussing the problem with the patient's doctor, we came up with a solution. We made a gabapentin suppository. I am happy to report the gabapentin suppository did a good job of pain control.
I have always been impressed how the Ducks Unlimited volunteers are able to skillfully separate me from my money while still making me happy about my donation. My Gnome pain started the usual way. I was bidding in the live auction. The very friendly Auctioneer, Kim Crandall, made a gentle suggestion that maybe my wife wouldn't let me bid up the Gnome anymore. So then I had to have him. And I got the winning bid and it felt great! But Gnome pain is a slow starting symptom. It's not until you get home that your wife and children start harassing you for the silly way you threw too much money at a Gnome. I think my Gnome pain will be with me for a while. But I may get the last laugh after all . Now that Gnomey has a place of honor beside the TV, I think it is time to redecorate the living room. I wonder if they make any Gnome themed wall paper?
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The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.