USA Today piece on pain patches gives hospitalist a headache

Dr. Bradley Flansbaum, who blogs on The Hospitalist Leader, is Director of Hospitalist Services at Lenox Hill Hospital in New York City.  He’s also a keen observer of health care news coverage.  He wrote the following guest post. He wrote to me, saying, “I treat a lot of pain, and always approach any claims re: Lidocaine patches with caution.  The evidence is not strong. This piece is a lousy job for obvious reasons.”

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With greater focus on abuse of opioid analgesics the last few years, health care providers are seeking alternate means to treat pain.  As a hospitalist, I have recently noticed an uptick of admitted patients wearing “pain patches,” and of more concern, a willingness on the part of trainees to prescribe them.  It was with that in mind, that a recent USA Today piece caught my attention—not just for its misleading headline regarding patches, but also for its absence of heft to substantiate claims.

While the piece suggests there are a panoply of transdermal modalities to treat discomfort, only the lidocaine patch—cited as a treatment for fibromyalgia, has FDA approval and a “supporting” literature base, but only then for post-herpetic neuralgia.  The Salonpas patch, an over-the-counter remedy, the other product mentioned and touted as an alternative means to relieve suffering, is devoid of such support.  The company website highlights testimonials of success from both physician and non-physician providers, but peer-reviewed references are absent.

The implication of the article, which seems more a product promotion than an opportunity to inform, is that patches serve as mainstream alternatives to conventional treatments such as opioid and anti-inflammatory medications.  That is not the case, and based on current knowledge regarding Lidocaine patches, practitioners’ need to take pause:

• FDA approved for postherpetic neuralgia, but available evidence does not establish efficacy in unselected patients

Potential off-label uses:

• for carpal tunnel syndrome – lidocaine 5% patch might reduce pain but not clearly more effective than naproxen (level 2 [mid-level] evidence)
• for postoperative pain – lidocaine patch may have modest analgesic effect after surgery (level 2 [mid-level] evidence), but does not appear effective for persistent incisional pain (level 2 [mid-level] evidence)
• lidocaine patch may be effective for trigger points in patients with myofascial pain syndrome (level 2 [mid-level] evidence)
• lidocaine patch 5% does not appear effective for traumatic rib fracture pain (level 2 [mid-level] evidence)

This is the Cochrane 2008 Review:

Insufficient evidence to recommend topical lidocaine as first-line treatment for postherpetic neuralgia

• systematic review of 3 randomized or quasi-randomized trials with 314 patients
• 2 trials were limited to single-treatment evaluations
• 1 trial with 150 patients was based on published meeting abstract (DynaMed commentary — full report of this trial used for FDA approval application showed no difference from placebo in primary outcome)
• Reference – Cochrane Database Syst Rev 2008 Oct 8;(4):CD004846

The story contained no data on effectiveness.