A Forward

I recently heard the news from the West Coast, where someone ended their life with assisted suicide. I find it ironic that so many fight for the right to assist suicide, which I understand having watched my dad die as he did, yet nobody mentions fighting for effective pain relief.  Must we endure the Dr. Kavorkian issue all over again? How unnecessary!

I remember the P. Connor's quote: "Despite the recent advances in knowledge, pain control in the terminally ill remains a disgrace. What is needed is not a stunning whole new understanding of pain pharmacology, but the rational and consistent application of what we already know. History will judge us harshly if we fail to meet even this modest goal." I think that was written in 1987!!! How far have we come?


Success Story #1

This was a 42 year old woman with stage IV breast cancer with metastases to bone.

Assessment revealed pain in six sites:
The sternum, the lower ribs from sternum to vertebrae, the lumbar spine, the lower buttocks, the knees, and the anterior aspect of the lower legs.

She had been treated with opioids, which relieved the pain a little, but they made her feel very sleepy and ‘spaced out’ and the relief only lasted an hour, so she had discontinued taking them.  She was also taking a NSAID twice daily, which she reported as having helped for about two weeks, but then became ineffective, so she discontinued taking that, too.

Assessment revealed pain, which was described variously as:
“Deep ache, like toothache, stabbing, very sensitive to light touch, worse on movement and sometimes pulling and tightening.”

These descriptions suggests soft tissue pain, bone pain, muscle spasm and neuropathic pain. Most of her unrelieved pain was neuropathic and muscle spasm, which were severe at times and none of the above medications would relieve those types of pain.

The following medications were compounded in an anhydrous gel by a Compounding Pharmacist:
Clonidine 0.2 %
Amitriptyline 5%
Gabapentin 6%
Baclofen 5%
Ketoprofen 5% -10%


The gel was applied as a thin film to the site(s) of pain. Then, 0.2mls – 0.4mls was applied at spinal level to the corresponding dorsal horn of each dermatome involved. The gel was applied 3 times daily routinely, plus two hourly in between if necessary. Once the pain was under control, the gel was reduced to once or twice daily.

She was reassessed after using the gel for at least a week. She reported that the intensity of pain in all sites had reduced significantly. (She quoted 85% reduction). She reported that she had only been applying the gel twice daily, so she was advised to apply at least three times daily until the pain was under control. She was reassessed after another week. Pain was almost completely gone in all sites.  Certain activities appeared to trigger the pain in one site, so she was instructed to apply the gel prior to carrying out that activity, which was highly effective.

One of the advantages to this approach is that once the neuropathic pain is under control, the need for opioids decreases. This has been a consistent finding.


Success Stories #2-5

Five patients with multiple myeloma, one man and four women, ages ranging between 42 and 57 years – mean age 52 years who developed chemo induced neuropathic pain in the hands, legs and feet were referred for Pain Consult.

Each patient had an Initial Pain Assessment carried out using the Carling Algorithm. The data collected then formed the basis for analysis, report and plan of care. All had been treated with opioids, which did little or nothing to relieve the pain. Some discontinued because of nasty side effects.  Three of them had been taking Neurontin, but had discontinued because of side effects – mostly somnolence. Two had tried Cymbalta, which helped one of them a little, but the other one discontinued taking it because it upset her stomach.

The following medications were compounded in an anhydrous gel by a Compounding Pharmacist

Clonidine 0.1% - 0.2%
Nortriptyline 3% - 5%
Gabapentin 3% - 6%
Baclofen 2% - 5%
Ketoprofen 5% - 10%


All five patients used the above combination in varying strengths:

The gel was applied as a thin film to the site(s) of pain. Then, 0.2mls – 0.4mls was applied at spinal level to the corresponding dorsal horn of each dermatome involved. The gel was applied 3 times daily routinely, plus two hourly in between if necessary. Once the pain was under control, the gel was reduced to once or twice daily.

They were each reassessed after a week and, if the pain was not completely controlled, then Ketamine 5-10% was added. All achieved complete to excellent pain control.

One advantage of this method was that pain relief was achieved very quickly – some immediately, some within hours and some within days, but all achieved pain relief.
A second feature of this approach was that without exception, once the neuropathic pain was brought under control, the need for oral opioids decreased. This too was a consistent finding.