A lot of attention surrounds the abuse and addiction rates of prescription oral pain medications. Although a suitable choice for acute pain following traumatic injury or surgery, they may not be the best option for chronic pain. Topical pain medication has the potential to treat chronic pain with fewer side effects. Chronic pain is defined as a disease state that is ongoing, usually lasting longer than 6 months. This type of pain has no anticipated end-date and requires a more comprehensive approach. It’s often a complicated search to find lasting relief, requiring multiple forms of treatment. In this article, we will cover topical pain medication along with the different types of pain they address.

Topical pain aids come in many forms such as patches, creams, gels, lotions, foams or liquids and are applied to the skin. They are available in both prescription and non-prescription strengths. These dosage forms may target pain more precisely by applying to the specific site of pain. Oral medications travel through the digestive system and then through the bloodstream to the site of pain. This delivery system may take longer to work and comes with a long list of side effects. Side effects include constipation, dizziness, lightheadedness, nausea, vomiting, and possible abuse and addiction. Applying a medication to the site of pain can often provide quicker and more complete pain relief with reduced side effects.

When evaluating OTC treatments, you’ll usually see the terms anesthetic or analgesic. Anesthetics work by numbing pain and analgesics work by decreasing pain and/or reducing inflammation. Examples of anesthetics include menthol, methyl salicylate, and camphor. Different types of analgesics include acetaminophen, aspirin, ibuprofen and a variety of opioids, such as hydrocodone and oxycodone.

Patches

Patches come in different sizes and adhere to the specific site of pain. They can cover large areas such as the lower back or smaller areas such as the neck, arms or legs. They come in both prescription and non-prescription strengths. The various types of pain patches, each with different ingredients and each works a bit differently.

Non-Prescription Patches

These patches are best used for minor to moderate aches and pains caused by overexertion or arthritis. They are often used on joints, back, and neck.

Name	Ingredients	How it Works
Aspercreme	Lidocaine 4%	Anesthetizing agent, numbs nerve endings
ThermaCare	Heat discs made of activated charcoal, iron powder, sodium chloride, sodium thiosulfate, and water.	Air activates the heated discs, providing relief through heating the affected area.
Salonpas	Camphor, menthol, methyl salicylate (NSAID)	Topical analgesic
Salonpas-Hot	Capsaicin (an active component of chili, cayenne, and jalapeno peppers)	Decreases pain transmission

Prescription Patches

Prescription patches such as Lidoderm® contain a higher concentration of lidocaine. As mentioned above, this agent works by numbing nerve endings. This option is often used to treat pain associated with post-herpetic neuralgia from shingles and diabetic peripheral neuropathy.

Non-Prescription Creams, Gels, Foams, and Liquids

Cream, gel, foam and liquid pain relief products offer an alternative to patches. These forms typically include the same or similar ingredients as the patches. The active ingredients will work the same in any form. The option you choose is completely based on personal preference.

Custom-Compounded Topical Pain Medication

One of the most versatile treatment options is a compounded topical pain medication. Available by prescription, these medications are custom made for a patient’s specific type of pain. They are often made with 2-5 different types of medications to target each type of pain present. This customization is essential for those who experience a combination of pain types (neuropathic, central and peripheral). We discuss these in detail below. Your doctor or pharmacist can help you identify your type of pain. From there, the doctor, pharmacist, and patient work together to design a custom medication.

Pain Types

The type of pain you have determines what the doctor and pharmacist recommend for delivery and ingredients. It’s even possible to have more than one type of pain, necessitating the use of multiple medications. Below we describe the different types of pain. You should discuss your symptoms with your doctor to determine which type you have.

Peripheral/Nociceptive Pain

This type of pain, also known as nociceptive, is most common and caused by some type of injury or inflammation in your body. This triggers the nociceptors to send a signal to your central nervous system and brain indicating there is pain. Examples include arthritis, broken bones, and cuts.

Central/Non-nociceptive Pain

This type of pain, also known as non-nociceptive, is often due to an error in processing pain signals coming to the brain. Examples of this pain include fibromyalgia, irritable bowel syndrome, tension headache, or idiopathic low back pain.

Neuropathic Pain

This type of pain results when there is damage to nerves or abnormal nerve function. This results in pain signals sent regardless of pain stimuli. Common characteristics can be a burning, tingling, shock-like, or shooting pain. Examples of this pain include diabetic neuropathies and post-herpetic neuralgias from the shingles virus.

Topical pain medications can be very effective for all pain types and offer the following advantages:

Localized to the specific site of pain
Can be compounded with multiple different medications that work in different ways
Likely fewer drug interactions due to lower absorption into the bloodstream
Less toxicity

Additionally, topical compounds can reduce the amount of new opioid prescriptions. They can also be used in conjunction with opioids to reduce the number of opioids needed to reduce pain.

Below are classes of medications which are good for the types of pain discussed above:

Medication	Type	Pain Type	Best for acute or chronic pain?	Over the Counter (OTC) or Prescription
Lidocaine	Anesthetic	Neuropathic	Acute/Chronic	OTC
Capsaicin	Decrease pain impulse transmission	Neuropathic	Chronic	OTC
Bupivacaine	Anesthetic	Neuropathic	Acute/Chronic	Prescription
Cyclobenzaprine	Muscle Relaxant	Peripheral	Acute/Chronic	Prescription
Tetracaine	Anesthetic	Neuropathic	Acute/Chronic	Prescription
Clonidine	Pain impulse inhibitor	Neuropathic	Chronic	Prescription
Ketoprofen	Analgesic/NSAID	Peripheral/Neuropathic	Acute/Chronic	Prescription
Diclofenac	Analgesic/NSAID	Peripheral/Neuropathic	Acute/Chronic	Prescription
Baclofen	Antispastic	Peripheral/Neuropathic	Chronic	Prescription
Flurbiprofen	Analgesic/NSAID	Peripheral/Neuropathic	Acute/Chronic	Prescription
Amitriptyline	Pain impulse inhibitor	Central/Neuropathic	Chronic	Prescription
Carbamazepine	Pain impulse inhibitor	Central Neuropathic	Chronic	Prescription
Doxepin	Pain impulse inhibitor	Central/Neuropathic	Chronic	Prescription
Gabapentin	Pain impulse inhibitor	Central/Neuropathic	Chronic	Prescription

An Important Note About Topical Pain Medication

Topical pain medications absorb into the bloodstream. If you have risks related to taking these ingredients orally, they may also have risks using them topically. The most common example is NSAIDs (such as aspirin or ibuprofen), which can have adverse effects for those taking blood thinners or those who have heart disease. You should discuss these risks with your doctor or pharmacist.

Your Next Steps

Once you establish what type(s) of pain you have, it’s time to find the method of pain relief that will work for you. Keep in mind that you may need to use multiple options and healthcare disciplines. This may include a physician, pharmacist, massage therapist, acupuncturist, yogi, etc. Remember, the list of options you have is long and relief is possible.

If you have questions about topical pain relief, please give one of our pharmacists a call at (207) 899-0886. We’re happy to help you in any way we can.

Additional Resources

NSAID Prescribing Precautions, American Family Physician

Topical Treatment of Neuropathic Pain Using Compounded Medications, The Clinical Journal of Pain

Pain Management Compounding, Professional Compounding Centers of America (PCCA)

About the Author

Stephen Drapeau, RPh, JD

Stephen has over 20 years of experience working in various pharmacy settings, including compounding, retail and specialty pharmacy and is a third generation independent pharmacist. He welcomes the opportunity to use these accumulated experiences to provide patients and practitioners with the most comprehensive pharmaceutical based support. Stephen has also practiced as an attorney in both Maine and Massachusetts and has used his experience in both areas to serve as a consultant in medication malpractice cases and worked with District Attorney offices as a consultant in medication-induced OUI cases. These experiences have created a firm belief that through counseling and education, individuals are empowered with greater knowledge on the effects of prescription medications. Stephen is one of the managing partners of Coastal Pharmacy & Wellness.

An Alternative to Oral Pain Medication: Using Topical Medication to Address Chronic Pain