Complaints about pain are a common reason that patients seek medical care, although many initially opt for self-treatment with OTC analgesics.1 Pain is a complex symptom that affects every person differently, so therapy should be tailored to each patient’s needs.

Because pain is multifaceted, it may affect several facets of quality of life, including cognitive, emotional, and physical functions. The pharmacy shelves are lined with a host of transdermal analgesic patches, yet the selection of an appropriate product may be overwhelming for many patients. Pharmacists can guide patients seeking advice on topical nonprescription analgesic transdermal patches as well as direct them to seek counsel from their primary health care providers when warranted, especially if further evaluation is needed, the patient is experiencing severe pain, or self-treatment is not appropriate.

FAST FACTS
Results from a 2017 publication show that 50 million Americans, or 20.4% of the population, suffer from chronic pain, a higher percentage than in any other country.2-4 Pain affects more Americans than cancer, cardiovascular disease, and diabetes combined.5 Musculoskeletal pain is the most frequent type of pain for which patients elect to use nonprescription analgesics for self-treatment.1

Topical analgesics reportedly account for about $647 million in nonprescription sales.1 Research indicates that topical analgesics can provide patients with fewer risks of drug drug interactions (DDIs), long-term symptom relief, and reduced dependence on systemic analgesics.6

In general, many episodes of pain or musculoskeletal injuries are amenable to self-treatment with the various topical nonprescription analgesics on the market, when used in conjunction with nonpharmacological measures such as cold and heat therapy and the RICE (rest, ice, compressions, and elevation) method. Nonprescription topical analgesics represent an important therapeutic option for treating joint and muscle pain and are indicated for treatment of mild to moderate musculoskeletal pain, including back and joint pain. They can be used in conjunction with oral analgesics when appropriate or as monotherapy. Topical nonprescription analgesics are classified as counterirritants and typically contain 1 or more of the following ingredients: camphor, capsaicin, menthol, methyl nicotinate, methyl salicylate, and trolamine salicylate. The anesthetic lidocaine is also available in OTC products marketed for nerve pain.1

Topical analgesics may offer specific advantages over oral nonprescription analgesics in that they do not require high serum concentrations of the active agent and therefore are linked to fewer adverse effects (AEs).6 Nonprescription topical analgesic products may also increase patient compliance, because they allow for improved accessibility and can be easily obtained and self-administered.

The CDC guideline for treating chronic pain without opioids recommends that clinicians consider alternative first-line topical agents when appropriate, because they are thought to be safer than systemic medications.7 The guideline states that clinicians consider alternative first-line agents such as lidocaine for neuropathic pain, topical capsaicin for musculoskeletal and neuropathic pain, and topical nonsteroidal anti-inflammatory drugs (NSAIDs) for localized osteoarthritis, because they are considered safer than systemic medications.7 Topical analgesics may aid in decreasing the possibility of systemic AEs and drug interactions as well as provide localized pain relief.8,9 Health care providers are continually learning about the advantages of using topical analgesics, and most providers would typically recommend them as a first line of therapy.6

Results of a survey show that 100% of pain management physicians would recommend nonprescription topical analgesics to patients, and an estimated 81.5% of respondents said they were not concerned with the safety and tolerability of nonprescription topical analgesics and that they were an excellent first-line therapy in relieving acute joint and muscle pain.6 When counseling patients, pharmacists should be mindful that certain populations may benefit from the use of topical analgesics8,9:
  • Individuals with more than 1 chronic condition or older patients who are at greater risk for DDIs, thus limiting the potential for DDIs
  • Individuals with cardiovascular and gastrointestinal risk factors that may restrict the use of oral NSAIDs
  • Individuals with hepatic or renal dysfunction, where the metabolism or clearance of oral medications is affected
During counseling, patients should be advised to adhere to the following recommendations from the FDA to ensure the safe use of topical analgesics10:
  • Avoid bandaging the area tightly after applying the product.
  • Do not apply topical analgesics to wounds or broken, damaged, or irritated skin.
  • Immediately discontinue using the product if swelling or blistering of the skin occurs.
  • Keep the topical analgesic away from eyes and mucous membranes, such as the skin inside the mouth and nose.
  • Never apply local heat, such as heating pads, hot water in bags or bottles, or lamps, as doing so can increase the risk of serious burns after using topical analgesics.
 
Yvette C. Terrie, BSPharm, RPh, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

REFERENCES
  1. Olenak J. Musculoskeletal injuries and disorders. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 19th ed. Washington, DC: American Pharmacists Association; 2018.
  2. Khazan O. America experiences more pain than other countries. The Atlantic. December 20, 2017. theatlantic.com/health/archive/2017/12/america-experiences-more-pain-than-other-countries/548822/. Accessed July 9, 2019.
  3. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. 2011.
  4. Dalhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. doi: 10.15585/mmwr.mm6736a2.
  5. US Department of Health & Human Services. Pain management. National Institutes of Health website. report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57. Updated July 30, 2018. Accessed July 9, 2019.
  6. Zampogna G. Pain specialist's awareness of topical analgesic and their use in pain control survey results. J Anesth Surg. 2016;3(3):1-5. doi.org/10.15436/2377-1364.16.034.
  7. CDC. Treating chronic pain without opioids. CDC website. cdc.gov/drugoverdose/training/nonopioid/508c/index.html. Accessed July 9, 2019.
  8. Ciccone TG. Patients get long term benefits from topical analgesics. Practical Pain Management website. practicalpainmanagement.com/meeting-summary/patients-get-long-term-benefits-topical-analgesics. Accessed July 8, 2019.
  9. D'Arcy Y. Targeted topical analgesics for acute pain. Pain Medicine News. January 7, 2015. painmedicinenews.com/Review-Articles/Article/12-14/Targeted-Topical-Analgesics-For-Acute-Pain/28992/ses=ogst. Accessed July 8, 2019.
  10. FDA. FDA drug safety communication: rare cases of serious burns with the use of over the counter topical muscle and joint pain relievers. FDA website. www.fda.gov/Drugs/DrugSafety/ucm318858.htm. Updated February 11, 2016. Accessed July 8, 2019.