An Integrative Approach to Chronic Pain Management
Alternative Response to A Pharmaceutical Disaster
Karen Sadowsky Kaufman, MS, CCN
It has been estimated that some 20 million people
relied on COX-2 inhibitors, such as Vioxx®, taking them on a daily basis
to relieve the crippling pain associated with arthritis. In the wake of
recent studies linking long-term use of COX-2 inhibitors with increased
incidence of fatal heart attack and stroke, many arthritis sufferers are
seeking safer methods for dealing with this painful condition.
While chronic pain often necessitates medical therapy, particularly in
extreme cases, an integrative approach that combines simple dietary
modifications, regular exercise, and nutritional supplements can
dramatically improve quality of life and reduce the requirement for
non-steroidal anti-inflammatory drugs (NSAIDs) to control pain.
Unfortunately, physicians rarely recommend alternative therapies to
patients, either because they are unaware of their potential benefits,
or for fear of criticism from their colleagues and peers.
Diet and Arthritis
The "inflammatory cascade" begins with a fatty acid called arachidonic
acid (AA). AA is cycled through the COX enzymes to form a family of
eicosanoids. Eicosanoids include prostaglandins (PGs), thromboxanes (TXs),
and leukotrienes (LTs), which are small fatty acid metabolites that have
hormone-like activities critical to maintaining normal physiologic
In addition, these fatty acid metabolites are mobilized when the body is
confronted with an acute injury. When AA is the substrate for the COX
enzyme, the PGs, TXs, and LTs that are produced are quite
pro-inflammatory (Fig. 1).
If the long-chain fatty acid at the top of the inflammatory cascade is a
different fatty acid such as the omega-3 fatty acids found in
fish—eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)—then the
subsequent eicosanoids that are produced are not harmful and actually
reduce inflammation. The epidemiological data from the Greenland Eskimos
sparked interest in the potential benefits of the omega-3 fatty acids 25
years ago and at this point, numerous scientific studies have affirmed
Research has shown that certain foods, such as fatty cuts of meat, organ
meats and egg yolks provide arachidonic acid to the body. Therefore, it
would be beneficial to reduce the consumption of these foods.
If one then increases the intake of foods rich in the omega-3 fatty
acids (fish, some seeds and nuts), the omega-3 fatty acids displace AA
as the primary substrate for the COX enzymes. This leads to the
production of a species of eicosanoids that are far less
pro-inflammatory than AA.
In addition to cutting back on foods that are high in AA, I also
recommend avoiding foods containing partially hydrogenated oils.
Partially hydrogenated vegetable oils, which contain trans fatty acids,
actually promote inflammation to an even greater degree than AA.
Additionally, trans fatty acids have been shown to be more prone to
initiating atherosclerosis than the saturated fats found in meats.(4-6)
In addition to increasing the consumption of fish, nuts and seeds (all
high in omega-3 fatty acids), it's a good idea to reduce intake of
sugars, starches, and other carbohydrates that break down into simple
sugars, and trigger excess production of insulin, a powerful promoter of
Many people find that these simple dietary modifications often reduce
the severity of pain enough to make exercise possible again—and exercise
has been shown to aid in reducing chronic pain suffered by people with
Essential Fatty Acids
Glucosamine, Chondroitin and MSM
Glucosamine and chondroitin belong to a group of substances called
glycosaminoglycans (GAGs). People first learned about these nutrients by
observing that veterinarians routinely prescribed them for dogs with
osteoarthritis. Following the 1997 publication of The Arthritis Cure, by
Jason Theodosakis, MD, glucosamine and chondroitin rocketed to the top
of the list of best-selling nutritional supplements.
Initially, glucosamine and chondroitin were viewed with skepticism by
the medical community, yet the number of positive reports from their
patients eventually forced rheumatologists and orthopedists to take
notice. Glucosamine and chondroitin soon became the subject of intense
research. The weight of evidence from the published research is
Glucosamine and chondroitin seem to not only provide the patient with
analgesia (pain relief), but also delay the structural progression of
osteoarthritis.(9-10) Although most of the studies have focused on
osteoarthritis of the knee, a recent case report established the
benefits of glucosamine and chondroitin in symptomatic disc
In one double-blind trial published last summer, four groups of
volunteers were treated three times daily with either 500 mg
glucosamine, 500 mg methylsulfonylmethane (MSM), a combination of both
agents, or placebo. Over the course of the 12-week trial, pain levels in
all treated groups fell. The group experiencing the greatest
improvements, however, was the group receiving the combination of both
glucosamine and MSM.(12) This recent trial not only established the
efficacy of glucosamine and MSM when used individually, but also
indicates even greater pain relief when the two agents are used in
Another fascinating study compared S-adenosyl-methionine (SAMe) to the
COX-2 inhibitor, Celebrex®. People reported significant pain relief from
Celebrex® at the end of the first month. However, it was not until the
end of the second month that users of SAMe reported significant pain
relief.(13) Nevertheless, it may be worth waiting the extra time to
experience pain relief from SAMe, since SAMe has few reported side
effects and many additional health benefits.(14)
Digestive Enzymes: Not Just For Digestion
In Europe, people commonly take proteolytic enzymes (normally used to
aid in the digestion of food) to promote healing from inflammatory
conditions and sports injuries.
Anecdotally, we know that when these enzymes are taken on an empty
stomach they have the ability to relieve pain, inflammation and
swelling. Recently, a double-blind prospective study compared the use of
an oral enzyme combination (consisting of rutosid, bromelain, and
trypsin) to a conventional prescription NSAID, diclofenac, available in
various prescription brand names.
The results of the study revealed that the oral enzyme combination was
at least as good, if not better, than diclofenac at providing pain
relief, and without the side effects of an NSAID.(15)
Phytonutrients Reduce Inflammation
A number of plant-derived nutrients have been shown to aid in
controlling inflammation. Since these phytochemicals are able to
modulate COX-2 enzymes naturally, without shutting down the entire
metabolic pathway (as pharmaceutical COX-2 inhibitors do), the good and
protective eicosanoids can continue to function to some extent.
Most of the literature on plant phytochemicals has focused on two
agents: turmeric (a spice with the active ingredient curcumin); and
resveratrol (best known as the beneficial ingredient in red wines).
Resveratrol is also extracted from other sources.
Turmeric is an Indian spice that makes curry yellow. Reports of the
anti-inflammatory benefits of turmeric go back to 1985, well before our
current understanding of COX enzymes. Turmeric has been associated with
reducing inflammation, decreasing platelet aggregation, and limiting the
expression of COX-stimulated colon cancer cells.(16-18)
Resveratrol is found in the skin of dark red grapes and plums. It is one
of the phytochemicals in wine that is most associated with health
benefits. Recent studies hint at an intriguing role for resveratrol in
cancer, heart disease, and pain. Initial investigations have suggested
that resveratrol exerts its beneficial effects through an interaction
with the COX-2 enzyme.(19-21)
Dehydroepiandrosterone (DHEA) is a hormone produced by the adrenal
glands. One well-studied application of DHEA is its role in reducing
pain and inflammation in people with Systemic Lupus Erythematosis
DHEA seems to be helpful in a number of other chronic inflammatory
diseases as well, including Crohn's disease,(23) rheumatoid arthritis
and inflammatory arthritis.(24) This adrenal steroid seems to improve
the patient's subjective measure of disease activity such as pain and
fatigue. How it does this is still not clear, but it appears that DHEA
is involved in directly reducing inflammatory cytokines, independent of
the COX pathway. There is even a recent report in the literature where
DHEA administration has prevented the development of osteoarthritis in
DHEA is typical of many dietary supplements, in that it provides a broad
range of beneficial effects with few, if any, adverse effects—in
contrast to pharmaceuticals with narrow ranges of benefits and long
lists of side effects.
In addition to its profound anti-inflammatory properties, clinical
trials with DHEA indicate that it may also be an effective treatment for
osteoporosis in both men and women.(26,27) Dosages in the clinical
trials have varied from a low of 25 mg to a high of 100 mg. Women should
be aware that if they take too much DHEA they may grow a few facial
hairs, or experience an episode of acne. However, these side effects are
easily and rapidly reversed once the dosage is lowered.
More than 25 years ago, epidemiological data on Greenland Eskimos
triggered a spate of research into the role of essential fatty acids
contained in fish oils. Today, the benefits of eating fish rich in
omega-3 fatty acids are well established.
Additionally, a large body of research suggests that consuming fish oil
capsules can aid in reducing the symptoms of systemic lupus(28) and
rheumatoid arthritis.(29) Supplementing with the omega-3 fatty acids
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) also works in
much the same way as the dietary modifications discussed at the outset
of this article.
The EPA and DHA contained in fish oils compete favorably with AA, and
are processed by COX enzymes. The family of eicosanoids produced from
omega-3 fatty acids are far less inflammatory than those produced by AA,
which is an omega-6 fatty acid. Supplementing with fish oil capsules
should be considered in addition to the dietary changes suggested above.
Generally I recommend that clients opt for monounsaturated fatty acids
(such as olive, canola, walnut, grapeseed and macadamia nut oils) as
their primary edible oils. Additionally, I recommend avoiding most of
the polyunsaturated fatty acids found in the American diet, such as
corn, sunflower and soybean oils, which are rich in omega-6 fatty acids.
The one exception is supplementation with the botanical lipid, GLA.
GLA (gamma-linolenic acid) is an omega-6 fatty that possesses
significant therapeutic properties. GLA has been shown to reduce the
pain and inflammation of systemic inflammatory diseases—most notably,
rheumatoid arthritis.(30) GLA works in much the same way as the omega-3
fatty acids, replacing the arachidonic acid utilized by the COX enzymes.
In doing so, GLA supports the production of anti-inflammatory
eicosanoids and cytokines.
Supplementing with a combination of omega-3 fatty acids (from fish oil)
and omega-6 fatty acids (from GLA) prevents the accumulation of
arachidonic acid in the blood, and helps to reduce the pain associated
with inflammation.(31) One group from Surrey, England, suggests that
combing antioxidants and fatty acids will ameliorate the symptoms of
inflammatory systemic illnesses, based upon the growing body of
Nattokinase and Serrapeptase
Patients concerned about being at increased risk of heart attack or
stroke from their use of Vioxx will be relieved to learn that this risk
dissipates quickly after discontinuing the medication.(33) And while
there is no clear evidence of a need for conventional anticoagulant
therapy, the addition of clot-busting supplements, such as nattokinase
and serrapeptase, might be considered. Nattokinase, an enzyme developed
from fermented soy cheese, has strong fibrinolytic (clot-busting)
Serrapeptase, an enzyme derived from silkworms, has been shown to reduce
inflammation and pain. Noted German physician Hans Nieper, MD, believed
that in addition to its other health properties, serrapeptase can
stimulate plaque regression.(35)
The suggestions presented here are by no means a complete list of every
strategy that may be helpful in dealing with chronic pain and
inflammation. Many of these items are relatively inexpensive, however,
and generally have few, if any, side effects. In many cases the
nutrients discussed here have additional, global health benefits.
source of nutrients and supplements.
did we qualify them ?
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