With the current opioid crisis continues to escalate in Canada, it is refreshing to read the new findings on the use of topical NSAIDs (non-steroidal anti-inflammatory drugs) for acute musculosketetal pain.  The Canadian Agency for Drugs and Technology in Health (CADTH) recently released a rapid review report on Topical NSAIDs. The report was designed to find and evaluate evidence comparing topical NSAIDs with opioids in the management of acute musculoskeletal pain. While the report has concluded there is no data available for such a comparison, their findings support that topical NSAIDs are at least more effective than placebo.

This has important implications! There are currently many topical analgesics available for sales without a prescription in Canada. Examples include RubA535, Bengay and Lakota Rub. Many of these products have not demonstrated their efficacy as an analgesic product. As such, they are rarely recommended. With topical NSAIDs shown to be more effective than placebo, it means that there is a valid place for recommending their use in pain management.

Currently the approach to managing acute pain is to start with non-opioids such as acetaminophen and oral NSAIDs. If these options are inadequate, contraindicated or dose escalation is not feasible (e.g. due to renal impairment), the next step is to try combining with a mild opioid.   With the release of this rapid report, we now have another option to consider – recommend topical NSAID either as another option or in addition to non-opioid options before resorting to opioids.  For some individuals, it may be the best option to offer before they venture into the dangerous world of opioid prescription.

Currently, the only topical NSAID available in Canada is diclofenac. Commercially, it is sold as Voltaren Emugel (diclofenac 1.16%) available an over-the-counter item, or as Pennsaid solution (diclofenac 1.5%) available as a prescription medication. Some specialty pharmacies may be able to compound other strengths and different topical NSAIDS to cater to specific needs of the patients.

Topical NSAIDs are not without their concerns. While they are relatively safe, free of systemic side effects such as gastrointestinal ulcers  or nephrotoxicity, there are some challenges related to their administration:

  • As with any topical preparation, the exact dose is not given in a tablet or a capsule, the patient must apply a reasonable amount based on the size of the painful area. So there is some judgement involved to determine how much to apply.  This also makes it difficult for pain assessment – that is if pain is still inadequately controlled, it is due to inadequate or insufficient application?
    • For Pennsaid solution, the recommended dosage is 40 drops to affected knee QID. Who has the patience to squirt out 40 drops? 
    • For Voltaren Emugel, the amount is not specified but implied that the large painful area may require larger dose.
  • The topical preparation needs to be applied frequently – at least three or four times daily. Some patients may find it difficult to incorporate this regimen in their lifestyles
  • A deep rub may be needed to ensure the medication can reach  the problem area.  For some individuals with chronic neck or back pain, they may require assistance to administer the preparation.

So these nuisances can be a “pain” but they are nonetheless easy to overcome with education and motivation.   Currently, the greatest challenge is that these medications are not covered by Ontario Drug Benefits Program.

Earlier last year, Eric Hoskin – our Provincial Minister of Health and Long Term Care, has been instrumental to bring out the following strategies to address the opioid crisis in Ontario:

  • Naloxone (an antidote for opioid overdose) is now available without a prescription and free of charge in the community.
  • Suboxone (a medication to treat opioid dependence) is now available as a general benefit in the Ontario Drug Benefit formulary. This means all physicians have the ability to treat opioid dependence and prescribe Suboxone if needed.
  • Fentanyl Patch 4 Patch program was rolled out in Oct 2016 to minimize risk of Fentanyl Patch diversion in the community.
  • A new pain guideline is currently being drafted at McMaster University. Click here  to review or share your comments.

Maybe Eric Hoskin can exercise his power to push for coverage of topical NSAIDs in our Ontario Drug Benefit Formulary. After all, these topical NSAIDs can be another non-opioid option offered in the setting of acute musculoskeletal pain. The benefits of such a measure can be immense if it means diverting another individual to potential opioid addiction.

 

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