September 2012 Letters to the Editor
Benefits of Vitamin D In Pain Treatment
Dear Dr. Tennant,
As you know, I’ve been a long-time follower and admirer of PPM, and the first feature I read upon the arrival of each month’s edition is your editorial. I’ve learned a great deal from your personal observations and insights.
However, I was very disappointed to see no mention of vitamin D in your August editorial, “Cash Patient: A Clinical Dilemma.”1 Of the various low-cost, non-prescription, and over-the-counter products you mention as potentially benefitting pain patients, vitamin D has the most extensively supportive research evidence and would be among the lowest in cost.
A preponderance of reasonable and credible evidence suggests that, for many patients with chronic pain and particularly those with musculoskeletal-related disorders, properly dosed vitamin D could have both pain-relieving and/or opioid-sparing effects. I specify “properly dosed” because most practitioners do not seem to appreciate the necessity of daily dosing (not once weekly or monthly) of vitamin D3 (not D2) to achieve levels of at least about 50 ng/mL 25-hydroxyvitamin D (25[OH]D). (Lesser levels, which many consider adequate, might be subtherapeutic in persons with pain.)
I hope that this was just an oversight, rather than being indicative of some sort of bias against vitamin D.
Stewart B. Leavitt, MA, PhD
Dear Dr. Leavitt,
You are absolutely correct when you say that we should have mentioned vitamin D as a cost saving measure. Not only is this an oversight but an embarrassment, as I recommend vitamin D to my own patients. Any idea on saving patients money is welcome.
Forest Tennant, MD, DrPH
Comments From Readers
In the April 2011 issue of Practical Pain Management, Dr. Forest Tennant discussed many examples of relief of chronic myofascial pain by heat.2 By intuiting a circulatory mechanism, he was exactly on track.
A quarter century ago, Swedish researchers demonstrated impaired microcirculation in fibromyalgia patients.3 Electron microscopy of biopsied trapezius muscles revealed significant obstruction of their lumens by thickened Z-fibers. Ambient cold causes peripheral vasoconstriction in order to retain body heat, which further reduces an already impaired blood supply. Therefore, the Swedish researchers postulated that the pain of fibromyalgia is ischemic.3 This simple explanation is little known in the United States, permitting the proliferation of nebulous theories of neurohormonal, autoimmune, or cognitive-behavioral etiologies. These alleged mechanisms are often touted by promoters of pharmaceuticals and services of little proven benefit.
However, as Dr. Tennant pointed out, many patients do experience significant pain relief by applying local heat.
Tom Hickey, MD
Silver City, New Mexico
I appreciate Practical Pain Management, and look forward to reading every issue. As a dentist who no longer does any dentistry, I find your holistic approach to pain very useful for the health and comfort of my craniofacial pain patients.
Robert L. Wartell, DMD
Santa Fe, New Mexico