Topical Anesthetics

Topical Anesthetics

PEP Topic 
Acute Pain
Description 

The topical use of anesthetics consists of applying an anesthetic agent, such as lidocaine, to the skin. In cancer care, topical anesthetics are used to reduce the acute pain of diagnostic procedures, such as biopsy, and postoperative incisions. Topical anesthetics have been examined in chronic pain as well.

 

Effectiveness Not Established

Research Evidence Summaries

Cheville, A.L., Sloan, J.A., Northfelt, D.W., Jillella, A.P., Wong, G.Y., Bearden III, J.D., . . . Loprinzi, C.L. (2009). Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: A phase III double-blind crossover study (N01CB). Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 17(4), 451–460.

doi: 10.1007/s00520-008-0542-x
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Study Purpose:

To investigate the efficacy of one or more lidocaine patches in reducing incisional pain

Intervention Characteristics/Basic Study Process:

In the initial four-week treatment phase, patients received either lidocaine patches or placebo to apply to postsurgical incisional sites. After four weeks, the lidocaine group received placebo and vice versa. Pain was rated at baseline and at four and eight weeks.

 

Sample Characteristics:

  • The sample was composed of 28 patients. 
  • Mean patient age was 61.9 years.
  • Nineteen patients (68%) were female. Nine patients (32%) were male.
  • Eligible patients
    • Had experienced pain for one month or longer, and the pain rating was equal to or greater than 4.
    • Had pain with neuropathic features (e.g., burning, paresthesias, allodynia), pain involving an area that could be covered by three patches or fewer, pain related to a surgical site associated with cancer treatment.
    • Were at least 18 years old and had no recent history of drug or alcohol abuse.
    • Were expected to live for a period longer than six months.
    • Had no evident cognitive or psychiatric morbidity.
    • Were neither pregnant nor nursing.
  • Patients were ineligible if their condition involved nonsurgical pain etiologies (e.g., malignancy, dermal pathology,  chemotherapy-induced neuropathy) at the painful site.

Setting:

  • Multisite
  • Ten clinical centers
  • United States

Study Design:

Double-blind, randomized, two-period crossover trial

Measurement Instruments/Methods:

  • Rating of pain intensity
  • Brief Pain Inventory (Short Form) (BPI-SF)
  • Neuropathic Pain Scale (NPS)
  • Patients' Global Impression of Change Scale
  • Short-Form McGill Pain Questionnaire (SF-MPQ)
  • Pain Catastrophizing Scale
  • Profile of Mood States Short Form
  • North Central Cancer Treatment Group Patient Quality-of-Life Linear Analog Self-Assessment Scale

Results:

  • Average weekly pain intensity ratings were not significantly lower while patients used the lidocaine patch versus the placebo.
  • BPI-SF interference scores were lower in patients receiving the lidocaine patch in the first period: general activity (p = 0.02), work (p = 0.04), relations with others (p = 0.02).

Conclusions:

Pain interference scores were significantly lower in the group that received lidocaine patch first. Significant differences in postsurgical pain intensity, with the lidocaine patch applied to incisional areas, were lacking overall.

Limitations:

  • The number of patches used varied.
  • The study lacked power.
  • Patients self-reported pain by means of telephone and email. Patients applied the patches themselves; whether they applied them correctly is unclear.
  • In regard to weekly measures: Change may have occurred at times when measurements were not taken.

Nursing Implications:

Further research is needed to determine whether lidocaine patches augment the analgesic regimen for incisional pain.

O'Connor, J.M., Helmer, S.D., Osland, J.S., Cusick, T.E., & Tenofsky, P.L. (2011). Do topical anesthetics reduce periareolar injectional pain before sentinel lymph node biopsy? American Journal of Surgery, 202(6), 707–711; discussion 711–122.

doi: 10.1016/j.amjsurg.2011.06.040
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Study Purpose:

 To determine whether lidocaine-prilocaine cream decreases injection pain related to sentinel lymph node biopsy

Intervention Characteristics/Basic Study Process:

Eligible subjects were randomized to either the treatment or control group, then provided with a syringe that contained either the study medication (lidocaine-prilocaine cream) or a placebo cream that looked identical to it. Subjects also received instructions on how to apply the cream and a copy of the postprocedure survey, which asked patients to evaluate ease of application as well as level of pain. The subjects were to apply the given cream and then a barrier dressing to the area. Patients went to one of three radiology departments to receive an injection of the Tc sulfur colloid for the sentinel lymph node biopsy. Postoperatively, over the telephone, the patients completed the survey with help from a researcher. 

Sample Characteristics:

  • The sample was composed of 39 patients.
  • All patients were older than 18 years.
  • All the patients were female.
  • All the patients had breast cancer
     

Setting:

  • Multisite
  • Inpatient and outpatient settings
     

Phase of Care and Clinical Applications:

Phase of care: active treatment

 

Study Design:

Triple-blinded prospective randomized placebo-controlled trial

Measurement Instruments/Methods:

  • Scale measuring ease of cream and dressing application, a five-point Likert-type scale    
  • 10-point pain scale, to measure pain
  • A tool that recorded whether patient would recommend cream (yes/no)
     

Results:

Thirty-nine subjects completed the study. Subjects from both groups rated the cream as easy to apply, and both groups responded similarly in regard to dressing retention. Authors reported no significant difference in median injectional pain scores between the treatment and control groups. Authors noted two trends: The treatment group was more likely than the control group to recommend the cream, and the control group was more likely to rate the injection as painful or extremely painful.

Conclusions:

The pain scores of subjects who received the lidocaine-prilocaine cream were not significantly lower than those of the control group.

Limitations:

  • The study had a small sample size, with fewer than 100 patients.
  • The study comprised variability in injection techniques and volumes.
  • Study design was based on the prediction of a large difference (4) between the two groups on a 10-point Likert scale.  
     

Nursing Implications:

This study does not indicate that a topical anesthetic, lidocaine-prilocaine cream, had a significant effect on injectional pain; however, the finding may be a consequence of the study design. Further studies, with larger sample sizes and smaller predicted differences in the study groups, may produce a different result.

Guideline/Expert Opinion

National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf

http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
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Type of Resource/Evidence-Based Process:

These guidelines do not provide any information about search strategy or any specific evaluation of evidence. Notes state that most direct evidence is of low quality, but recommendations do result from unanimous consensus.

Guidelines & Recommendations:

The guidelines provide detailed recommendations regarding:

  • Screening and assessment
  • Management of pain in opioid-naive as well as opioid-tolerant patients
  • Ongoing care of adult patients with cancer and related pain management
  • Comprehensive pain assessment and use of pain ratings
  • Interventions for specific types of pain syndromes
  • Opioid prescribing, titration, and ongoing management
  • Management of adverse effects related to opioids
  • Psychosocial support and patient and family education
  • Nonpharmacologic interventions.

Limitations:

In general, opioids are first-line interventions. The NCCN guidelines suggest that antidepressants and anticonvulsants can be first-line treatments for adjuvant pain, although the recommendation for using them as such is still based on anecdotal experience or guidelines relating to patients who do not have cancer.

Nursing Implications:

The NCCN guidelines provide comprehensive algorithms for pain management, from screening to ongoing maintenance. The guidelines recommend considering a variety of nonpharmacologic interventions. Psychosocial support, including coping-skills training, is recommended, as is comprehensive patient and family education. The guidelines provide useful information and an overview of the full range of pain management. The work points to the ongoing need to consider multiple adjuvant and supportive interventions to achieve pain relief that works for the individual patient.


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