| One-Minute Clinician

Topical Opioids can Reduce Systemic Exposure

Dr. Aljassem: In reviewing the literature with topical opioids, like many things that are kind of outside the box, a lot of it is not standardized. But what we do know is that they are effective in reducing pain and they are minimally absorbed systemically so they do have a high benefit with low risk ratio. I believe that they are applicable for wounds that are malignant, for wounds that have active inflammation, and wounds that are permeable-type membrane. The wounds that are not so successful are usually when they don’t have that granulation tissue opioid receptors.

Dr. Hall: In our clinical practice, we’ve seen a significant reduction in systemic opiate exposure. Once we’ve start someone on a topical opiate, specifically morphine, we’ve been able to reduce their systemic opiate for the treatment of pain with some great success. The information that we have in terms of appropriate dosing or dose titration is still very limited and I think preliminary, but in terms of safety we understand that we’re going to consider the same contraindications and adverse effects that you’d get with systemic opiates. But predominantly they’re going to be less severe with most of the hydrophilic opiates not penetrating the wound and so you get very little systemic absorption and that’s been shown in various publications. However, your more lipophilic molecules, like fentanyl or methadone, you do have to worry about a significant amount of systemic absorption that could potentially occur. For primary care, I think it’s a bit of a challenge right now to incorporate this into your armamentarium of agents predominantly because there’s no commercially available topical opiate that we can use, and so we’re relegated to using compounding pharmacies or your local pharmacy to make these agents. I think in a hospital setting, it’s a little bit easier. You have an inpatient pharmacy that can provide some of these services.

Dr. Aljassem: In looking to the future for topical opioids, I think about our aging baby boomers and that whole next generation of wounds and debility and morbidity that’s going to exponentially grow. I think having a product like this can be very beneficial when you consider that in nursing homes and long-term care facilities, they’re always dealing with wound care. The traditional-type wound care agents that we have now are questionable. I think this is a unique opportunity to address a pretty horrific problem when you’re debilitated and sick and the systemic traditional things are not working to relieve that pain. Bringing a solution directly to the point of insult, I think is going to be a real game changer.

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