MEDICATION CHOICESPain management and pharmaceutical compoundingTreatment of pain is often at the forefront of both healthcare professional and patient’s minds. How might compunding medication aid in treatment? Pain is an unpleasant bodily sensation that causes mild-to-severe physical and emotional distress, usually deriving from an injury or illness. Pain can be classed as one of the most common reasons patients seek healthcare worldwide, and is a significant contributor to healthcare costs. It is difficult to define the epidemiology of pain, because of the subjective nature of the symptoms, and the lack of consensus for specific diagnosis and conditions. It is, therefore, hard to talk about evidence for the true incidence of most pain conditions.1 Pain can vary from acute, intermittent, or chronic, depending on its duration and severity. Acute pain is generally a shorter duration, lasting up to six months, and is resolved when the bodily distress is healed by itself. Examples of acute pain can range from a broken arm, cosmetic procedures, or healing from a surgery. Pain that comes and goes is called intermittent pain, and an example of this is toothache. On the other hand, chronic pain lasts longer than six months and can vary from patient to patient. Some chronic pains can be a result of nerve damage pain, lower back pain, or even from cancer treatment. Due to the long-lasting duration, chronic pain produces anxiety and emotional distress, interferes with functional capacity, and hinders the ability to participate in family and social events. It is hard to diagnose chronic pain due to its complexity and, in some cases, it is misdiagnosed.Therefore, the optimal management of pain, either acute, intermittent, or chronic, is imperative for a patient’s wellbeing.2 A good pain management treatment plan will provide the patient with the pain relief they need, while also offering them the ability to regain their range of motion and mobility as quickly as possible without injury.Current pain management treatments Current pain management treatments primarily aim to reduce or eliminate pain with minimal side effects through pharmacological and non-pharmacological therapy.Pharmacological therapy is done by administering a range of analgesic drugs, and can be divided into:Non-opioid analgesicsOpioid analgesicsAdjuvant analgesicsNon-opioid analgesics include paracetamol and non-steroidal anti-inflammatory drugs. Opioid analgesics can be divided into those used for mild-to-moderate pain (such as codeine phosphate), and those used for moderate-to-severe pain (such as morphine or oxycodone hydrochloride). Adjuvant analgesics include drugs such as antidepressants, antiepileptics, benzodiazepines and other muscle relaxants, bone-modulating drugs, corticosteroids, topical capsaicin, lidocaine, and rubefacients.3 Non-pharmacological therapy is the management of pain without medications. This method utilises ways to alter thoughts and focus concentration to better manage and reduce pain. Methods of nonpharmacological pain therapy include neurostimulation, hypnosis, comfort therapy, education and psychological interventions, and physical therapies.4Pharmaceutical compounding can offer better results Throughout the years of pain management research, we can see that the art of compounding medication and personalising dosage forms for an individual patient can potentially become an optimal solution for patients. Pharmaceutical compounding is the creation and dispensing of tailormade medications, and can be used as a pharmacological approach to benefit patients suffering with pain. Compounding allows the pharmacist to work with the patient and the prescriber, to customise pain medication to meet the patient’s specific needs.5 Pharmaceutical compounding offers a much wider choice of pain-relieving ingredients than mass produced, single-dose medicines, and the ability to target pain in a multitude of ways. A prescriber working closely with a pharmacist can prescribe a range of active ingredients, each of which may target a specific mechanism in the body. As a result, compounding usually results in smaller concentrations of each medication, and more overall targeted pain management.While single-ingredient analgesics are preferred to allow for independent titration of each drug, fixed-dose compounded analgesics may be considered for those with stable chronic pain. Sometimes analgesic preparations that contain multiple analgesics, such as aspirin or paracetamol with an opioid component, reduce the scope for effective titration of the individual components in the management of pain of varying intensity. 3 In some instances, chronic pain sufferers are likely to be placed on a variety of medications to help address the symptoms associated with their condition. With compounding, multiple medications can be combined into a single dose of a specially prepared compound either as a capsule or topical treatment, providing greater convenience for the patient, and therefore improving overall compliance.Many patients experience stomach irritation or other unpleasant side effects from taking pain medication. Some patients have difficulty taking the medication in its commercially available form, and this is where compounding provides patients access to personalised medication, which can lead to less displeasing side effects and a more palatable formulation.Compounding also allows patients to choose how the medicine is delivered and absorbed into their body. This is particularly useful if you have difficulty taking or swallowing capsules and need an alternative solution, such as topical preparations, customflavoured troches that dissolve buccally or sublingually, sublingual drops, rapid dissolve sublingual tablets, nasal spray, or a suppository. Such dosage forms may bypass the gastrointestinal tract, providing optimal results with less gastrointestinal irritation, reducing pain, and overall removing another source of aggravation.7 Patients, particularly those who suffer from allergies, can also benefit from compounded pain medications. As well as active ingredients, medications can also contain inactive ingredients such as binders, fillers, and dyes. Some people are allergic to these ingredients, which can make a medical treatment potentially fatal. Commonly used allergens include peanut oil derivatives, gelatine, corn, dairy, wheat, coconut, and potatoes. If there are allergens in a prescription medication, a compounding pharmacist can reformulate the drug, removing the non-essential ingredients to which a patient is allergic.Lastly, a considerable number of patients with long-term pain management treatment may have the issue of their drug becoming discontinued. This often occurs not because the drug is unsafe or ineffective, but simply because it is no longer cost-effective for large pharma companies to manufacture. Compounding pharmacies can recreate the exact formulation of the original drug, and deliver it in the precise dose required by the prescriber for a truly personalised pain management option.6 Compounded pain medication Compounded analgesics can be created by compounding pharmacies and customised to patients’ specifications, to help develop an effective pain management treatment plan. The compounded formulations can include ingredients such as amantadine, amitriptyline, benzocaine, baclofen, clonidine, diclofenac, lidocaine, ketoprofen, and tetracaine, to name a few. These can be formulated to deliver a concentrated analgesic at the site of application. Low-dose and/or multi-drug formulations can be prescribed to reach multiple pain pathways optimising and targeting pain relief for patients.Either combined or alone, active pain medications can be compounded into a topical cream, gel, or ointment, which can offer tailored, effective pain management, whilst also providing the opportunity to reduce adverse side effects, increase efficacy, reduce opioid use, and improve patient compliance.8 Furthermore, expert compounding pharmacists can compound low-dose naltrexone primarily used to help reduce pain and inflammation, in any strength ranging from 0.5mg to 6mg in different formulations. Capsules tend to be the preferred formulation; however, other formulations can be compounded such as buccal lozenges, topical creams, and sublingual drops (depending on patient preference with swallowing difficulties or allergies/intolerances). 9Summary Regardless of advanced research and scientific development, many patients are still taking pain medication, which may not provide optimal results. Compounding pain medication can help reduce these cases and create a unique medication specific for the individual. Each compounded analgesic medication is patient specific, and the ingredients can also be altered for dietary requirements such as lactose or glucose intolerance, or allergies to dyes found in the commercial drugs. Compounding opens a new avenue for prescribers who in the past were not able to prescribe medication due to the various reasons discussed above. Since traditional compounding practice might be the only viable option to meet individualised patient needs, more healthcare professionals should be encouraged to publish case reports and participate in small or large investigational studies to further the data we can gather on compounded pain medications. Having all experiences gathered and shared may benefit the growing, yet important, practice of compounding personalising the treatment of pain.7 References
  1. Henschke N et al, The epidemiology and economic consequences of pain, Mayo Clinic Proceedings, 90(1): pp39–47, 2015.
  2. Katz N, Proceedings from the Roundtable on “The Role of Coxibs in Successful Pain Management”, The Impact of Pain Management on Quality of Life, Journal of Pain and Symptom Management, 24, 2002.
  3. Visit: www.bnf.nice.org.uk/treatmentsummary/pain-chronic.html
  4. Pak SC et al, Nonpharmacological interventions for pain management in paramedicine and the emergency setting: A review of the literature, Evidence-based Complementary and Alternative Medicine, 2015.
  5. Visit: www.uk.fagron.com/en-gb/pharmaceutical-compounding
  6. Visit: www.wellnesspharmacy.net/pain/
  7. Visit: www.researchgate.net/ publication/322862247_Pain_Systematic_Review_of_Pharmacy_Compounding_of_ Pain_Medication
  8. Visit: www.specialist-pharmacy.com/ prescribers/pain-management/
  9. Visit: www.japractice.co.uk/2022/02/ low-dose-naltrexone-ldn-a-boost-forpatients-struggling-with-chronic-painautoimmune-disease-adrenal-fatigue-andlong-covid/14150
Paaven Patel is Operations and Quality Assurance Pharmacist at Specialist Pharmacy, a compounding pharmacy, producing custommade medications across a wide range of treatment areas such as bioidentical hormones, pain management, dermatology, and haircare.
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