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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

Blending Prescription Pain Treatments with Alternative Medicine

Certain non-prescription, alternative/ complementary measures can be easily, conveniently, and inexpensively incorporated—along with prescription medicine—into routine pain practice.

The practice of pain management in recent years has emerged along various tracks. Anti-inflammatory agents, opioids, and other prescription medications and devices have been the mainstay of the physician. Simultaneously, a variety of treatments with non-prescription procedures and chemicals have become very popular with the public.1-4 Advertisements, websites, and publications abound with many supportive reports of welcome pain relief with measures that are commonly called alternative or complementary. Physicians are often criticized for prescribing drugs for pain rather than using alternative treatments. In reality, however, almost all physicians who treat pain routinely recommend non-prescription measures in addition to their prescription treatment regimen. In addition, ambulatory patients who don’t have an acute emergency don’t complain to a physician until they have unsuccessfully attempted some non-prescription measures.1,2

This article is written to clarify some of the terminology and provide definitions to better understand the totality of the alternative pain movement. It is recognized that the aegis of much of this movement is profit without the benefit of controlled studies.2-4 Nevertheless, persons in pain want relief that is convenient, inexpensive, and easy to access with the least use of prescription medications and procedures that always carry at least some minimal, inherent risk. It is my belief and experience that some of the emerging, non-prescription measures are worth recommending to patients. While not always a substitute for prescription drugs, some non-prescription measures may enhance or complement a physician’s pain treatment.3-6 A brief description of most alternative treatments is given here along with some case examples. The term ‘blended’ is used to illustrate the point that opioids and other prescription measures such as a TENS (transdermal electrical nerve stimulation) can be blended or used in a complementary way with many non-prescription measures to enhance patient care.

Table 1. Common Terms and Recommended Definitions
  • Alternative – Any non-prescription chemical, device, or therapy
  • Complementary – The combined or blended use of prescription and non-prescription measures
  • Integrative – Synonymous with complementary
  • • Restorative or Reparative – Attempt to return body tissues and/or biochemistry to its normal state

Definition and Fallacy of the Term ‘Alternative’

The term ‘alternative’ simply means ‘non-prescription’ (see Table 1). Physicians must be aware that this term is often misleading and sometimes used in a pejorative sense to criticize the practicing physician. While most alternative medicine measures have few evidence-based, controlled studies, or specific indication approved by the U.S. Food and Drug Administration, many appear anecdotally to be clinically effective, inexpensive, and popular with patients.5,6 However, the number of studies involving non-prescription methods and agents are growing and are reported in publications that are often more familiar to patients than physicians.

It is somewhat misleading to state that alternative treatments are not regulated by the US Food and Drug Administration (FDA). While a product may not be labeled or advertised as a treatment for pain, they may still be regulated. Many alternative treatments are regulated under the FDA “Dietary Supplement Act” or regulations which govern the formulation of topical or skin cream agents. For example, an oral tablet, powder, or capsule must list the amount of amino acids, vitamins, minerals, and other nutrients and a skin cream marketed for pain relief must list its active ingredients such as menthol or salicylic acid.

The fallacy of the term ‘alternative’ is that it may imply or insinuate that an agent is an effective substitute for prescription drugs. This may or may not be the case. Prescription drugs and many devices such as TENS are prescription because the FDA well-recognizes that there may be some risk in their use. To be approved as a prescription medication or device, a commercial company will have to conduct some controlled clinical trials and studies to establish efficacy, safety, and risk determination. Most of the treatments known as alternative have not demonstrated efficacy although they may not carry any significant risk.5,6

Due to their non-prescription status, physicians can recommend any number of alternative treatments to complement or enhance prescription treatments.3,4 Some terms now used to describe this process are complementary or “integrative.” Both are appropriate and I use the term ‘blended’ to illustrate that prescription and non-prescription approaches can and should be simultaneously recommended to patients. Often, commercial producers and practitioners of alternative medication use the terms restorative and reparative rather than the term ‘treatment.’ Table 1 provides some simple definitions to establish terminology that I recommend be adopted so all parties can be clear about the growing use of non-prescription agents.1,2

Cautions and Admonitions

The caution and admonition to physicians and the public is that alternative does not mean “substitute,” and that severe forms of chronic pain that exhibit physical and mental impairment of the activities of daily living and/or demonstrate biologic changes such as hypertension, tachycardia, insomnia, anorexia, attention deficit, or hormone alterations will unlikely respond adequately to non-prescription measures. Patients and the public are done a disservice when any party pushes or advertises non-prescription pain treatments without warning the receivers of these treatments that chronic pain covers a spectrum of severity, and that the severe forms may carry serious, life impairing and shortening consequences if prescription measures are not sought and obtained.

Common Non-Prescription Treatments

Most of the popular alternative or non-prescription treatments which have emerged in recent years are summarized in Table 2. Some are briefly described and some case examples are presented to illustrate the blending or complementary use of prescription and non-prescription measures (see Table 3).

The Placebo Factor

Few alternative treatments have placebo-controlled, random studies to validate their effectiveness.3-6 Consequently, the physician who recommends them must recognize that the treatment may have only anecdotal reports or reports from his/her own patient to support the treatment. Nevertheless, keep in mind that a “placebo effect” does access neuropathways that induce a positive message to the immune system.

Table 2. Common Non-prescription Measures for Pain Treatment Which Are Often Called Alternative
Vitamins D3, B12, C, Folic Acid
Minerals Magnesium, Copper, Calcium
Amino Acids Taurine, Phenylalanine, Glycine, Gamma-Amino-Butyric Acid, Tryptophan
Herbal/ Plant & Animal Products Milk Thistle, Boswella, Aloe Vera, Fish Oils, Rosemary extract, Ginger, Turmeric
Hormones Pregnenolone, Dihydroepiandrosterone (DHEA), Adrenal Extract
Skin Temperature Agents Ice, Heat, Infrared, Warm Water
Creams/Lotions Menthol, Capsaicin, Salicylates, Boswella, Aloe Vera
Oral Anti-inflammatory Aspirin, Ibuprofen, Naprosyn, Glucosamine, Chondroitin, Methylsulfonylmethane (MSN)
Active Exercise Tai Chi, Yoga, Pilates, Feldenkras, Chigong
Passive Exercise/Manipulation Massage, Chiropractic, Repositioning
Electrical Palliation Acupuncture, Magnets, Acupressure, Ultrasound, Some Electrical Current Devices,* Copper Jewelry, Mineral Baths
Neuropathway Retraining Biofeedback, Hypnosis, Guided Imagery, Meditation, Relaxation
Light Therapy Laser, Ultraviolet Lamps
Physical Supports Braces, Canes, Wraps
* TENS (Transdermal-Electrical-Stimulation) and CES (cranial electrotherapy stimulation) require a prescription.
Table 3. Case examples of blending non-prescription alternative treatments with opioid therapy
1. A 39-year-old socialite female had end-stage pancreatic cancer whose pain was treated with a fentanyl transdermal patch. Additional control was achieved by use of a topical anti-inflammatory cream.
2. A 68-year-old female had a stroke and developed a central pain syndrome that responded poorly to six different opioids. Oxymorphone proved the best opioid and it appeared to be even more effective after a course of milk thistle.
3. A 50-year-old registered nurse with rheumatoid arthritis achieved reasonable pain control with high dosage of daily Propoxyphene. She claims she can work in a hospital emergency room for eight hours only if she wears magnetic soles in her shoes and a magnetic anklet.
4. A 50-year-old male works full-time as a security employee at a major airport. After an auto accident he developed cervical spine degeneration with severe neuropathies of his right arm. To control his pain he uses multiple daily opioids plus the daily use of a copper plate that he rubs over the painful areas on his arm.
5. A 55-year-old female has severe abdominal adhesions and neuropathies. To control her pain she uses morphine. To enhance her pain control, she regularly attends a weekly class that practices passive muscle exercises and massage.
6. A 40-year-old female with juvenile onset rheumatoid arthritis controls her pain with an opioid and glucosamine preparation. She has completely withdrawn from methotrexate and attends a gym for exercise on a daily basis.
Table 4. Patient education when discussing non-prescription or alternative treatments
  • Little proven effectiveness by evidence-based, controlled studies
  • Usually safe since not FDA-labeled
  • May only be effective for a short-time period
  • Health plan payers rarely fund alternative measures—so patients will have
  • out-of-pocket expenses

A physician who treats pain should have keen knowledge as to which treatments are prescription and non-prescription. While there is much information available about those alternative treatments that have no established value, patients, families, and third party payors nevertheless may believe that they are a legitimate, worthy substitute for established, proven prescription medications and devices that are FDA-approved. Every pain physician will recommend at least some “alternative treatments”—if for no other reason than their patients believe they help.

Physicians should clearly inform patients that alternative or non-prescription treatments are not proven, may have a placebo effect, and may not be effective for more than a few days. As long as they are safe, inexpensive, and the patient believes they are effective, there is no harm in utilizing them (see Table 4).

Clinical Application

When non-prescription alternatives are brought to the attention of a physician—or a physician recommends one or more—we recommend certain safe-guards. Above all, non-prescription “alternatives” can’t be over-recommended without certain cautions. To do so is misleading at best and fraudulent at worst. Physicians must inform patients that non-prescription, non-FDA-approved medications and measures are probably (with no certainty, however) safe although effectiveness is uncertain. Of utmost importance is that severe forms of intractable pain will not solely respond to non-prescription measures and may require potent opioids and other measures to control pain. Table 3 lists some case summaries of patients in which prescription treatments are blended with alternative treatments.

Vitamins

Recent studies reveal Vitamin D acts at receptors to relieve pain. Vitamin B-12 and folic acid biochemically or physiologically helps neuronal coverings heal and repair.

Minerals

Copper and magnesium are positively charged anions which apparently attract excess electrons from damaged and negatively charged human tissue. Copper is an ancient pain treatment whose use dates back centuries in Central American countries. Anecdotal reports and present day clinical observations indicate that some patients get pain relief with copper bracelets, anklets, and necklaces. Copper, as an oral tablet, is available in health food stores. Magnesium is commonly used as an additive to water for soaking painful areas (e.g. Epson Salts or “mineral bath”). The use of magnesium and copper as oral tablets, external body attachments, topical creams, or in bath water is theorized to work by extracting excess electricity or energy caused by damaged nerve tissue. Be advised that brass is a copper alloy and mineral baths at resorts are loaded with magnesium and other minerals.

Amino Acids

Certain amino acids are the precursors of endogenous neuroactive compounds that are believed to help relieve pain.6,7 Phenylalanine and tyrosive are the precursors of epinephrine, norepinephrine, and dopamine. Tryptophan is the precursor of serotonin and melatonin. Taurine and glutamine are precursors of gamma amino butyric acid (GABA) which is the major, neuro-inhibitor in the synaptic junction. GABA is a non-prescription amino acid and many pain patients report it to be an effective pain control agent. While its bioavailability by the oral route is questionable, it is likely good enough to help provide adequate levels at the synaptic junction.

Herbal Agents

Although the precise mechanism for herbal agents is unknown, anecdotal reports on their effectiveness are legendary and, for some—such as aloe vera and boswella—are centuries old.3,4 Milk thistle is believed to “cleanse” or otherwise enhance liver cell and enzyme activity. Herbal preparations are available in oral forms as well as topical creams.

Hormones

Proper levels of cholesterol lead to adequate pregnenolone levels which is the precursor of cortisol, testosterone, androstenedione, and estrogen among others.8 It may, per se, be a central nervous system pain control agent and it has been shown to enhance central nervous system Gamma-Amino-Butyric Acid (GABA) activity. Dihydroepiandrosterone (DHEA) is the precursor of testosterone, and has some direct androgenic effect on muscles and nerves.

Topical Agents

Cold and heat are age-old treatments for acute and chronic localized painful areas. Despite their legendary longevity of reported effectiveness, their mechanism of action is not totally clear. Heat likely causes an increase in blood flow and a release of immune active substances. Cold may decrease excess electricity or energy. FDA has specific regulations that allow the non-prescription marketing of cold producing, non-prescription topical agents, such as menthol.

Electrical Palliation Measures

These electrical measures have historically been believed to produce pain relief by blocking electrical impulses at the spinal cord “gate” for ascending pathways as well as the release of endorphins.10 Some new theories now suggest that the input of electrical impulses into the nervous system causes movement or transport of congested or trapped electricity in damaged nerves and possibly opens damaged electric pathways so electricity may move freely in normal fashion up and down nerves. Some highly charged metals such as copper and magnesium that are discussed above—as well as magnets, ultrasound, and acupressure—appear to manipulate excess electricity. All of these measures are grouped together under the heading of electrical palliation to make the point that pain is symptomatically relieved by a number of measures that manipulate electricity in nerves even though the precise mechanism by which each may work is unclear.

Physical Exercise and Manipulation

It has been known for centuries that strengthening and stretching of nerves, muscles, and other soft tissue structures provide pain relief. Interestingly, the precise mechanism is poorly understood. Stretching, strengthening, and massaging of soft tissue may help relieve pain by a variety of mechanisms including an increase in blood flow and healing. Active and passive exercises or muscle manipulation may also prevent or correct entrapment of nerves or promote a reduction of scar tissue. As with some of the electrical palliation measures, exercise may also reduce congestion and promote transmission of retained electricity. Acupuncture and electrical stimulators are well-recognized as symptomatic treatments for painful conditions.10 The duration of pain relief is, however, relatively short and lasts only a few hours or days.

Discussion

In reality, most pain physicians already practice some measures that are considered alternative. Measures that are usually called ‘alternatives’ are simply non-prescription measures that do not require FDA labeling and approval. Despite the lack of traditional evidence-based controlled studies, many alternative measures such as heat, copper, and mineral baths are centuries old and still exist today. Many alternative measures will not, in the foreseeable future, have controlled studies to validate them for the simple reason that they have no great profitability for any pharmaceutical or medical device company. It will, therefore, be up to practicing physicians to report their clinical observations and experiences. Hopefully, this will lead to identification of the most and least useful measures. Many physicians now practice enough alternative measures to begin sharing information and experiences. It is critical to inform all concerned parties that alternative doesn’t mean “substitution” for prescription medication and devices. One goal of this article is to classify or group the various alternative measures so that physicians can better understand why some measures may be effective based on a theoretical mechanism of action.

 

Summary

Alternative medicine is too often believed to be a separate approach from traditional medicine. This is an exaggerated belief, particularly in pain practice. There are several alternative or non-prescription measures that can easily, conveniently, and inexpensively be incorporated into routine pain practice. Physicians are encouraged to share and report their experiences with alternative measures in order to accelerate the blending of standard prescription treatments with other approaches that anectodally work. It is most important that everyone—physician and patient, alike— recognize that alternative does not mean “substitution” since some forms of severe chronic pain can only be adequately treated by prescription medications.

Last updated on: January 6, 2012
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