Why Do Doctors Prescribe Topical Analgesics? Do Guidelines Support Them?

| | Evidence Based Medicine

Analgesics Article Graphic for Dr C 5-2-2016

Topical analgesics are creams, sprays and patches designed to provide pain relief on contact. The pain is usually related to arthritis, tendonitis, contusions, muscle strains and sometimes neuropathic pain. They are available both over the counter and by prescription. The more common over the counter analgesics include such brands as Bengay, Biofreeze, IcyHot, Aspercreme, Flexall, Tiger Balm and Vicks Vapor Rub. Some common prescription analgesics include Terocin, Voltaren, and Lidoderm.

The prescribing topical analgesics, both over-the-counter and prescription, as well as branded and custom compound medications, continues to be a common practice by treating providers. Insurance carriers continue to scrutinize their use. This is primarily because many of these topicals do not meet commonly used treatment guidelines, such as Official Disability Guidelines (ODG). In addition, many of these topicals are very expensive.

What are some reasons for topicals? Some patients have symptoms that are not considered severe enough to necessitate oral medications. These patients can often benefit from a topical analgesic. If the pain is localized, patients may want to avoid the systemic risks of an oral medication.

There are some patients that do not tolerate oral medications due to gastrointestinal conditions or difficulty swallowing. In some instances, oral pain medications don’t mix well with other medications patients take for other conditions. There may also be liver or kidney conditions that make taking certain oral medications unsafe.

Topical medications are sometimes prescribed as an adjunct to oral pain medications to decrease the need for stronger oral medication. Unfortunately, some medical providers prescribe topical analgesics because they want to take advantage of a significant profit margin. Please refer to UR nation article “My Thoughts on Physician Dispensing“.

Do guidelines support prescribed topicals? Some prescribed topicals are supported by guidelines. ODG and California Medical Treatment Utilization Schedule (CA MTUS) support the use of the prescribed topical non-steroidal anti-inflammatory diclofenac (Voltaren) in several forms, including a gel and patch. Lidoderm patch is also supported.

Do guidelines support over-the-counter topicals? Biofreeze, capsaicin .025% and topical salicylates such as BenGay are very common and generally supported by guidelines.

Can these supported topicals be used for any medical condition? The guidelines outline specific indications for when the topicals are recommended. For example, Voltaren Gel 1 percent is indicated for soft tissue injuries such as sprain/strains and topical treatment of osteoarthritis of the ankle, elbow, foot, hand, knee and wrist.

Lidocaine in the form of Lidoderm patch is recommended for neuropathic pain. Lidocaine is not recommended for trigger points, myofascial pain or osteoarthritis.

Are there specific topicals that are not supported by guidelines? ODG and CA MTUS do not support any compounded product that contains at least one drug (or drug class) that is not recommended. These guidelines also clearly state that any topicals that include Baclofen, other muscle relaxants, gabapentin, antiepilepsy drugs, ketamine and capsaicin .0375% are not recommended.

Custom compounding and dispensing of combinations of medicines that have never been studied is not recommended. The same would apply to branded topicals. If these topicals contain one or more ingredients that are not supported by guidelines for a specific indication, they are not recommended.

As topical analgesics grow in popularity we will continue to monitor them and any changes they have on treating injured workers. It does serve to remember that guidelines are just that, guidelines. Exceptions need to be evaluated on a case-by-case basis.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.