She peels open a painkilling patch, puts half on each shoulder, and then crawls into bed. The next morning she can get back to work cutting men's hair.
"It's kind of like a Band-Aid, I guess, but it works," says Smalling, 59, a stylist in Dallas.
She says her prescription lidocaine patch supplements her regular painkiller enough that, 20 years into a disease characterized by chronic pain, she hasn't had to resort to narcotics.
Europeans already get roughly one-quarter of their pain relief from topical treatments, such as patches and creams; the Chinese relieve about half their pain that way, an industry analysis finds. In the USA, where 88% of pain relief comes in a pill, Americans are slowly getting used to the idea of patches, says Patrick Carroll of Hisamitsu America, maker of Salonpas over-the-counter pain patches. The active ingredients are 10% methyl salicylate, a topical analgesic, 3% menthol.
"I think it's just a cultural thing that we've been bred on popping pills," Carroll says.
Baby Boomers are leading the trend, hobbled by the aches of middle age and concerned about the risks of pills.
While patches aren't danger-free — every medication carries some risk — the most common complaint is minor skin irritation around the site. Patches also need to be placed in areas where they'll stick — not a bending elbow or hairy forearm.
The main downside is cost. A five-pack of Salonpas arthritis pain patches is about $9, the same as nearly 100 Advil pills.
Manufacturing a patch is more complicated and therefore more expensive than making a pill, says Phil Nixon of Pfizer's Pharmaceutical Sciences Technology & Innovation division in Groton, Conn.
Patches also must be disposed of out of the reach of pets and children, because they still have medication on them, says Smalling's doctor, Scott Zashin, a clinical professor of medicine at the University of Texas-Southwestern Medical School.
There are two basic types of patches: The first provides a drug locally — for example, over-the-counter pain relievers such as Salonpas. In the second, the medication seeps through the skin into the bloodstream. Nicotine patches, for quitting smoking, work this way, as do patches for attention deficit hyperactivity disorder, menopause symptoms and Alzheimer's.
A few types of medications are particularly well-suited to patches, Nixon and others say. By entering the body through the skin, medications bypass the liver, where they could do damage, or be broken down and made less effective. Robert Shmerling, a rheumatologist at Beth Israel Deaconess Medical Center in Boston, says he occasionally tries patches for arthritis patients who have stomach problems that can be a side effect of over-the-counter pain medications.
Some patients also prefer a patch to a pill because the drug enters the bloodstream slowly and continuously, rather than in a large dose, Nixon says. And for older people with memory problems, a once-a-week patch may be easier to manage than a daily regimen of pills.
For smokers who want to quit or make it through a day of travel or meetings, a patch is more discreet than nicotine gum or lozenges, says Jonathan Winickoff, a pediatrician and tobacco control expert at Massachusetts General Hospital and Harvard Medical School. Nicotine patches deliver the drug 24 hours a day, he says, so people wake up without the intense urge to smoke. Patches double your chance of success vs. going cold-turkey, he adds.
Though patches are used to deliver a wide range of medications to the bloodstream, a lot of newer drugs, called biologics, are too big to pass through the pores of the skin.
Researchers are working on patches that will solve that problem using either ultrasound to open the pores or dozens of "microneedles" so tiny their pricks cannot even be felt. They'll be painless, so they won't carry the fear factor of "real" shots, promises MITprofessor Robert Langer, who is working to advance microneedle technology.