Nancy Melville

September 23, 2014

PHOENIX, Arizona — As patients with chronic pain get proactive trying to address their pain using the array of dietary supplements promoted as offering relief, pain specialists are more likely than ever to be confronted a virtual laundry list of drugs and supplements that patients are taking — and pressed for advice on all of them.

An important place to start with such patients is to look closely at that laundry list for any red flags for interactions — and if the list is any longer than about 5 items, that's a red flag in itself, said David Kiefer, MD, during an invited talk here at the American Academy of Pain Management (AAPM) 25th Annual Clinical Meeting.

"It can depend on the literature, but when it comes to polypharmacy or polyherbacy, if there are at least 5 to 8 supplements or medications a patient is taking, there is a very high chance that one of those will cause an interaction," said Dr. Kiefer, a clinical assistant professor at the University of Wisconsin's School of Medicine and Public Health in Madison.

"This is something I talk to all of my patients about, and I will often call the pharmacist to check on potential interactions," he said.

Dr. Kiefer recommended also having a designated staff member responsible for research on interactions as well as the quality of products, and who is familiar with the various sources to quickly find that information.

"If you're going to recommend something to a patient, you want to make sure what's on the label is what's actually in the capsule," he said.

With chronic pain issues the leading reasons for the purchase of dietary supplements in the multi-billion-dollar industry, most pain specialists hear the names regularly. In terms of true efficacy, the verdict is out, but top contenders include the following:

Turmeric: Used for osteoarthritis, rheumatoid arthritis, and other joint pain. "I mention this one first because I think it is the most interesting in terms of potential," Dr. Kiefer said. Randomized controlled trials looking specifically at the compound of curcumin in doses of 1 to 2 g per day have found some benefits for joint pain.

"I would say the quality of the clinical evidence for this is low, but there are a lot of animal and basic science studies that steer us into thinking that this might be a really interesting compound, so it's certainly something to pay attention to," Dr. Kiefer said.

Dr. Kiefer noted that there is also debate over how well curcumin is absorbed, so he recommends that the supplement be taken with a fatty meal. In addition, data have shown that when it is combined with black pepper, the absorption is greater.

Avocado-soybean unsaponifiables: Four studies have shown that 300 to 600 mg of the avocado sterol compounds per day are associated with reduced knee and hip pain and swelling after 3 to 6 months of therapy. The compounds have also been evaluated for cholesterol and anti-inflammatory effects.

Omega-3 fatty acids: Widely promoted for a host of health benefits. Some studies have shown the fatty acids, specifically 2 to 4 g of marine-based docosahexaenoic acid and eicosapentaenoic acid, can offer some benefits for arthritis.

"I will often plant that seed in patients' minds that if you take omega 3s, it's like lubricating your joints," Dr. Kiefer said.

Cat's claw (Uncaria tomentosa): "Clinical trials show that after a few weeks, patients will report some benefits in joint pain, and this is coming up more and more in clinical practice," Dr. Kiefer said.

Some studies have shown that the pentacyclic and tetracyclic alkaloids in cat's claw, specifically, offer immunostimulant properties and are linked to increased phagocytosis, anticancer, antioxidant, and anti-inflammatory effects, Dr. Kiefer said.

Ginger: Long a staple in naturopathic medicine, any benefits of ginger are much more likely to be gained from dried formulations. "In order to receive the anti-inflammatory clinical effects that have been studied, the dried formation, which includes a higher content of shogaols, is important," Dr. Kiefer said. "It would be difficult to eat enough per day for any effect if you have mild to moderate arthritis."

With all of the compounds, a combination product may offer improved benefits as well, particularly if ginger is included, Dr. Kiefer suggested.

"I've had the best clinical effect in my experience using combination products that have a little bit of ginger in them."

Glucosamine: Representing a nearly 20% chunk of the multi-billion-dollar supplement market, glucosamine is among the most popular for chronic pain, but despite the popularity and heavy marketing, the verdict on benefits for pain such as knee osteoarthritis is still out. Large meta-analyses conclude only a small improvement over placebo or none at all.

While some report improved benefits with combinations such as glucosamine and chondroitin, any efficacy may lie somewhere in certain specific subgroups of patients, Dr. Kiefer said.

"There are a lot of nuances in the research — some studies have looked mainly at relatively severe disease patients, so in terms of relevance to our patients I think it's important to look at subgroups."

With any of the supplements or combinations, another key factor in achieving pain relief relies heavily on patience, consistency, and the tincture of time, Dr. Kiefer noted.

"If someone is going to try these, make sure they give it a chance — some of these can take from 8 weeks to 3 months for any benefits to be realized. That's one of the big differences between them and pharmaceutical products."

He emphasized making sure patients understand that supplements will rarely serve as a simple tradeoff for a medication, and clinicians may want to urge patients to take a more individualized, bigger-picture approach.

"Rather than simply replacing medications with herbal supplements, I try to recommend a more integrative or holistic approach that incorporates all aspects of the patient's lifestyle," he said.

"I try to focus on taking on the whole person — I will ask them to think about the last time they were pain free, and say something along the lines of 'yes, I know you have this debilitating joint pain,' but then will launch into a discussion of the mind and, when appropriate, even spirituality, when necessary."

Dr. Kiefer noted that the University of Wisconsin in fact works with the Center for Investigating Healthy Minds, which has gained important insights on the value of empathy in working with the Dalai Lama, no less.

"The Dalai Lama has gone to the Center for Investigating Healthy Minds to meditate and have his brain scanned with functional magnetic resonance imaging (fMRI), and we have learned some fascinating insights on the vital role of empathy in medical practice and how it can transfer from one person to another and is shown on MRI with neuronal connections."

"So I have found that bringing empathy to treatment can make a huge, positive difference."

Evidence Still Lacking

Michael H. Moskowitz, MD, MPH, a pain management specialist with Bay Area Pain Medical Associates in Mill Valley, California, said that he has observed some improvement among patients with supplements and agreed that good evidence is still lacking.

"The most helpful dietary supplements in the experience of [my practice] are GABA [gamma-aminobutyric acid], magnesium, low-dose baking soda, vitamin C, hyaluronic acid with type 2 collagen, curcumin and glucosamine and chondroitin together, fish oil," he told Medscape Medical News

"Others can be helpful, but most of the efficacy claims are based on mechanisms, not actual solid studies with patients who have significant pain disorders."

While the common use of such complementary therapies often is not the result of a recommendation by the doctor, physicians nevertheless can be critical in helping guide patients to their safe usage.

"I think physicians can be most helpful in being available as a resource to look at things like interactions with supplements between each other and supplements and the medications we prescribe," he said.

"The truth is that the real science out there, from a clinical perspective, is mostly anecdotal."

"That doesn't mean that supplements are not useful. It just means we don't know most of the time which ones will be [useful]," Dr. Moskowitz added. "The other problem is that people are often taking advice from clerks at health food stores, who often only know what they have been told or read and know nothing about interactions."

Dr. Kiefer has disclosed no relevant financial relationships. Dr. Moskowitz reports a relationship with Neuroplastic Partners LLC.

American Academy of Pain Management (AAPM) 25th Annual Clinical Meeting. Presented September 20, 2014.

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