Chronic pain conditions cause a tremendous burden on patients and the health care system alike. Few treatments have demonstrated enduring efficacy for chronic pain syndromes, and these patients often expend inordinate amounts of time and effort navigating a system ill-prepared to meet their needs. This shortcoming may have been a driver behind the opioid crisis, and certainly leads to difficulty at the bedside.
Poised at the forefront of evidence-based nonopioid pain management, however, are a slew of multimodal analgesic options. Ranging from regional anesthesia maneuvers to parenteral painkillers, effective techniques and treatments aimed at providing rapid pain relief while retaining a wide safety window are slowly supplanting the wastebasket application of opioids. The emergency medicine literature has exploded over the past few years with pragmatic pain research, and training institutions are often measured with a yardstick made of alternative analgesic techniques.
Unfortunately, our latest and greatest interventions often stop at the ED's doors. Incorporating cutting-edge therapies can work wonders during a patient's emergency visit, but ongoing outpatient treatment falls short because the tools available within the ED are typically difficult or impossible to obtain in the primary care and home environments. Certainly, intravenous ketamine infusions, sphenopalatine ganglion blocks, or haloperidol shots are rarely in the analgesic armamentarium of the primary care physician, and continuation of therapy is a true concern when these techniques are employed in the ED.
I've written about the potential value of zydis antipsychotic formulations previously (“Neuroleptic and Psychotropic Drugs for Abdominal Pain.” EMN. 2019;41:15; http://bit.ly/EMN-Pescatore), but our specialty has perhaps ignored an incredible resource and tremendous ally in the fight to provide judicious nonopioid pain relief: compounding pharmacies.
Compounding pharmacies have had some bad press lately. A number of patients in New Jersey died after fungal species contaminated epidural steroids made by a New England pharmacy, and a handful of unscrupulous New Jersey physicians went to jail after investigators uncovered a multimillion-dollar scheme in which the doctors would write prescriptions for medically unnecessary (and ineffective) compounded topical pain creams.
I remember a nurse-turned-pharma rep showing me while I was a resident a booklet of ready-made prescriptions for pain potions chock-full of ketamine, cyclobenzaprine, baclofen, and a half-dozen other purported analgesics. The impetus to prescribe these poultices is strong (they're topical, can't be abused), but the data are pretty clear that they don't work. Military researchers in a recent randomized trial compared various analgesic creams and found no benefit (but massive cost) over placebo. (Ann Intern Med. 2019;170:309.)
Fungi and fraud aside, the value of compounding pharmacies rests in their ability to continue the medications we routinely use in the ED, specifically intranasal lidocaine and oral ketamine.
Intranasal lidocaine is commonly used in EDs to treat primary headache disorders. Employed in an effort to obtain sphenopalatine blockade (though likely unsuccessful, as I discussed in October: EMN. 2019;41:20; http://bit.ly/2oqWIvN), intranasal lidocaine is an effective analgesic in its own right, leading to rapid relief even when traditional neuroleptic therapy fails or among craniofacial pain syndromes not amenable to typical ED headache treatments. (J Res Med Sci. 2014;19:331; http://bit.ly/315vVTa.)
Critics have rightly argued that the benefit is effaced by its inability to be provided for home use, but incorporation of a compounding pharmacy's skillset enables prescription and continuation. Lidocaine can easily be compounded in concentrations ranging from 1% to 8%, with instructions to spray twice into each nostril at the start of a headache up to four times a day. My practice is to write for a 4% concentration and a 30 mL bottle. Cost, in my experience, has been wildly variable (one patient reported it cost her $4; another happily paid $75 to continue the relief the ED brought her), but may, as always, be a limiting factor.
Ketamine for Home Use
Ketamine has repeatedly proven to be an effective and important nonopioid analgesic in the ED. Few hospitals have yet to incorporate its use into emergency pain management, but sub-dissociative ketamine has even found uptake in statewide EMS protocols aimed at striking a balance between safety and efficacy. As infusions end and patients are discharged from emergency departments, the question of enduring analgesia is reasonable. Inability to provide continued similar pain relief may present a significant barrier to use when we often compare efficacy with prescription opioids.
Ketamine can be prescribed safely for home use. At doses of 0.5 mg/kg, the analgesic effect of ketamine in its oral form is comparable with the 0.3 mg/kg IV commonly used. Typically, I prescribe 20-30 mg of the troche form, and a local compounding pharmacy that I have worked closely with can quickly provide a patient with 15-30 troches for home use.
I counsel the patient on proper and careful methods: place against the buccal mucosa, allowing it to absorb over 30 minutes to an hour, never use more than prescribed, and avoid concomitant sedative or opioid use. The delayed absorption and low dosing significantly attenuate any dissociation or euphoria, harnessing analgesic benefit without recreational effects.
Obviously, the risks of this abusable medication must be weighed and considered, but it is an excellent option when patients have responded well to ketamine infusion in the ED and are candidates for ongoing pain management. As with intranasal lidocaine, the cost varies and should always be examined. The lozenges are quite bitter, but a pro tip is to ask the pharmacy to provide flavoring (I've heard good reviews about grape).
Emergency physicians are presented daily with pain management puzzles, and we've led the way in hospital-based analgesia. Limited as we've been by our ability to continue effective medication in the outpatient environment, working alongside compounding pharmacies and collaborating with pharmacist colleagues to provide safe and obtainable options for home treatment is a way to capitalize on our progress and continue to do what's best for our patients.
Dr. Pescatoreis the director of emergency medicine research for the Crozer-Keystone Health System in Chester, PA. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.