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11 Articles in Volume 10, Issue #9
Activated Glia: Targets for the Treatment of Neuropathic Pain
Acute Herpes Zoster Neuritis and Postherpetic Neuralgia
Acute Treatment of Cluster Headache
Chronic Overuse Sports Injuries in the Adolescent/Pediatric Population
Clinical Recognition of Central Abnormal Neuroplasticity
H-Wave® Stimulation: A Novel Approach In Electromedicine
Homeopathy Enters Contemporary Pain Practice
Immune-modulating Effects of Therapeutic Laser
Pain and Addiction: Words, Meanings, and Actions in the Age of the DSM-5
Partial Plantar Fasciectomy With Autologous Platelet Concentrate
Tethered Spinal Cord Syndrome: Pathophysiology and Radiologic Diagnosis

Homeopathy Enters Contemporary Pain Practice

Editor’s note: Botanicals have been studied and administered as medicinal agents for thousands of years. Until now, however, homeopathy hasn’t been well accepted in mainstream medicine, much less pain practice. Thanks primarily to some German and Italian companies, there have been marketed homeopathic solutions, topical creams, and oral agents that contain a blend of a few botanical agents that have been found effective and filtered out from the thousands of plants found in nature. Practical Pain Management has learned of this development and has taken the opportunity to observe homeopathic agents being used on bonafide pain patients. To our pleasant surprise, we have learned that modern day homeopathy can be a great adjunct to standard pain practice. To this end, we have asked Dr. Joan Lewis, who is an anesthesiologist and pain specialist, to write this article. Pain practitioners interested in homeopathy can begin by reading this excellent introduction to an age-old therapy that has progressively, and rightfully, earned its entry into contemporary pain practice.

History of Botanicals and Homeopathy
Classical homeopathy utilizing botanicals has been used as a remedy since the 18th century and is known to Western civilizations, principally through the work of Samuel Hahnemann. Naturopathic physicians have been well trained in the selection of herbal remedies, although this topic is usually omitted in conventional medical curriculums. Administration of a homeopathic medication containing a very small amount of active substance can produce different effects based on the concentration (or dilution) of the substance. This principle is known as hormesis—whereby very low doses produce a beneficial effect and higher doses produce a harmful effect. From the conventional medical perspective, this effect can be observed in an inoculation when the introduction of a minute amount of a substance (that in larger doses is harmful) stimulates the beneficial production of antibodies and does not overwhelm the immune system. The appropriate prescribing of homeopathic preparations allows for the selection of a remedy based on the patient’s specific symptoms and constitution.

A significant opinion from our perspective as pain practitioners should acknowledge that the option of homeopathy is safe, cost-effective, and can be utilized in combination with modalities and/or medications already in place. Measured outcome studies utilizing objective nationally standardized variables against which subjective responses can be compared are a desirable determination of efficacy.1

Bioregulatory Medicine and Research

Bioregulatory medicine (BRM) is an emerging field of medical care that targets the body’s normal maintenance of homeostasis through auto-regulation. When we painstakingly memorized the components of the Krebs’ cycle or the electron transport chain, the study of physiology explained our (then) more limited understanding of the extraordinarily complex choreography undertaken by the body when addressing a straightforward chore—e.g., building the right protein for increasing muscle bulk, combating a foreign protein invasion, precisely regulating serum osmolarity to remain within specific set points, or alternatively warehousing and degrading cellular waste products for elimination. It should come as no great surprise that subsequent research now reveals much more complex and elaborate interrelationships among body systems than had been previously appreciated. Biological response-modulating substances influence these systems, not by ablating the reaction completely but by allowing the body to restore its normal auto-regulation through the practitioner’s administration of infinitesimal dosages of substances that gently dislodge an abnormally functioning system back toward normal oscillation around a set point. Even ultra-low doses of medications such as seen in homeopathy can produce a significant impact on the body, by a principle known as “hormesis”—where differing concentrations of the same medication produce divergent results.2,3

Hormesis

Research published on hormesis has underscored its validity.2 Hormesis addresses the phenomenon that the intake of a very small amount of a substance which, in large doses, can be toxic or damaging to the person, serves a protective function.5,6 Modern medicine has taken advantage of this phenomenon with vaccinations, for example. Another example is caloric restriction as a pro-longevity strategy.3,4 The beneficial physiologic response to a transiently-manifested form of stress (or toxin) that induces the development of tolerance to low oxygen states, toxins, and dietary restriction has been observed.2,3

The understanding and acceptance of hormesis is critical to the practitioner’s understanding of the research and efficacy of homeopathic medicinal products in concentrations that radically differ from the dosing for conventional medications. For example, some homeopathic medications show an impact at concentrations in the range of 10-3 to 10-6.

A Brief Explanation of Homotoxicology (HTX)

Homotoxicology is a therapeutic modality within integrative medicine. In this system, a medical diagnosis is made then followed by an individualized assessment according to the severity of the patients’ disease. This takes into account the burden of exogenous and endogenous influences on the patient’s self-regulatory mechanisms. Treatment is then given, predominantly using homeopathically-prepared medicines, to support the inherent self-regulatory ability of the patient by means of detoxification and drainage, immunomodulation, functional organ support and support of the cellular metabolism. Research on combination homeopathic products has helped reveal their mechanisms of action on targeted portions of bioregulatory systems that helps to explain their efficacy.8,9

The therapeutic goal of the practitioner is the appropriate assignment of homeopathic products that support the specific physiologic detoxification systems associated with the known disease state. Progress can be slower than with conventional medications but results can be rewarding because the underlying physiologic reactions can begin to function normally and optimally.

How HTX Differs from Conventional Medicine

Conventionally-trained medical physicians have been taught the actions of conventional medications and developed expertise in avoiding side-effects while these medications impacted targeted end organs. In large part, our medical responsibility consisted of trying to avoid the adverse effect of those medications’ doses upon interrelated body systems between the median lethal dose (LD50) and the median effective dose (ED50). Those far-reaching “associated organ system impacts” were known to account for the bulk of side-effects arising from our armamentarium of conventional medications. While these medications can be very effective, side effects are well documented.

We know that the use of medications designed to address disease states could include stopping an otherwise auto-regulatory physiologic system—such as the impact of steroids on the cyclo-oxygenase pathway. Most of us involved in the conventional medical educational process did not receive education about alternate medication options (such as homeopathic medications) which possessed significantly less side-effects than conventional medications. Homeopathic medications utilize doses that are significantly smaller than milligrams to accomplish this gentle effect and, in this regard, are very different from conventional medications. Homeopathic doses are measured in nanograms or picograms and these low doses very subtly encourage the normal auto-regulation of a dysfunctional body system to get back on track.

Pain practitioners will readily recognize the cyclo-oxygenase cascade, which is frequently invoked by chronic disease states and responds by producing substances that result in cell inflammation and further painful sensations (see Figure 1).

Figure 1. Role of Traumeel« in the inflammation cascade (reprinted with permission from Cesnulevicius K, unpublished). Each cell commits to recruiting and activating other cells based on multiple inputs, generally requiring evidence of both injury and infection (not shown) before it joins fully in amplifying the inflammatory process. Conventional medications directly interact with the inflammatory cascade by inhibiting the arachidonic pathway at the initiation of the cascade and consequentially, impact downstream signaling. Ultralow dose medications with bioregulatory properties, such as Traumeel, influence the inflammatory cascade in a multitargeting and synergistic fashion. This is achieved by the inhibition of several pro-inflammatory pathways via interleukin-1b (IL-1b), tumor necrosis factor alpha (TNF-a), and the stimulation of anti-inflammatory pathways, like transforming growth factor (TGF-b). Actions on multiple targets complement each other to produce a synergistic effect towards the resolution of the symptoms and underlying pathophysiological mechanisms. Interactions among leukocytes, endothelium, platelets, and coagulation factors; the generation of stop signals; and the flow of information over subsequent days, including the transition to wound healing, are not shown. *The inhibition of prostaglandins by NSAIDs is not specified. ºBaldwin and Bell.13 #Porozov et al.8 $Data are taken from Heine and Schmolz.12 Figure abbreviations: APCs: antigen presenting cells; COX: cyclo-oxygenase; Hsps: heat-shock proteins; IL: interleukin; NSAIDs: nonsteroidal anti-inflammatory drugs; TGF: transforming growth factor; TNF: tumor necrosis factor.

 

The inflammation cascade is a sequence of physiological events, involving complex interactions between immune cells, and between immune cells and tissue cells.11 There can be different inputs starting this cascade, although the arachidonic pathway is the classical one. During inflammation, the immune cells differentiate into many specific subtypes (for example TH1, TH2, Treg), producing different cytokines and creating a network of complex interactions aimed toward resolving an underlying problem to rebalance the system on cellular, tissue and organism levels (see Figure 1).

Given this information, it seems to be a logical progression to utilize this approach through the modulation of established bioregulatory mechanisms to safely attenuate a patient’s pain—and what could be safer than combination homeopathy that utilizes natural botanicals? Indeed, since the normal physiologic pathway is maintained, there are extremely rare side-effects from homeopathic products, if any, and usually consisting mainly of hypersensitivity reactions.

Indication-Based Use

This is the most straightforward approach to treatment and is usually the approach chosen by practitioners new to the field of homotoxicology. Because the products are safe, the pain relief can be rapid and profound; side effects are minimal so that the options for pain treatment are not limited. There are few obstacles to the physician’s peace of mind in utilizing this approach. Because homotoxicology relies upon conventional and bioregulatory diagnostic categories (in contrast to classical homeopathy), a diagnosis must be established before this approach is utilized and makes this a logical and convenient choice for practicing physicians. For example, the selection of a commercial homeopathic product could easily be applied in clinical situations such as sciatica or arthralgia.

Indication-Based Approach Based on a Disease State

First, we should define the specific symptoms of the diagnosis. As an example, these may include inflammation, ache, or a decline in motor function of the limb. Each of these pain components can be specifically addressed with the correct choice of medication(s), keeping in mind that one should advise the patient that relief, although in some cases immediate, may not occur for up to a week as the normal physiologic responses slowly begin to normally auto-regulate.

Length of Effectiveness

The duration of effect from homeopathic injections can last from days to several weeks or have no impact on the pain. Some patients experience permanent relief. Although most patients report some effect, it is currently impossible to predict before injections are given what duration and magnitude of therapeutic effects will occur. Presumably, the alteration of the normal pathway through the magnitude or possibly the duration of the disease process may provide a partial explanation of the duration of effect. Paradoxically, patients with long-standing pain conditions may respond rapidly with pain relief.

In cases where there is no relief from the pain following the injections, one should consider that there may be an accumulation of stored toxins in the extracellular matrix (ECM) that were stored because of overwhelmed bioregulatory responses to detoxification. Just as we are aware that the local anesthetic Lidocaine does not function in an inflamed area (just ask the patient with an abscessed tooth receiving a local anesthetic before drilling), normal biological process may be impeded by the accumulation of waste products or toxins in the ECM and the resultant persistent inflammation may prevent therapeutic effectiveness. Chronic inflammation is more likely to be a significant factor in chronic disease states over the course of years. Currently, the extracellular matrix is a focus of research targeting pain relief. In the event of a poor response, the practitioner might consider a cellular detoxification program.

How to Choose the Right HTX Medication

Commercial homeopathic products are labeled for a condition such as trauma, pain, spasticity, or inflammation. The practitioner may choose to use either combination therapy or a single medication in the treatment approach. This can be determined in collaboration with the patient with the assurance that homeopathic combination therapy is a safe option and there are no drug-drug interactions. Following the injection, oral homeopathic medication may be maintained to prolong the effect of the injection. Dose is not really a factor with homeopathic medications, but a single ampule of each medication is usually adequate for an injection procedure.

The frequency of injection treatments can be tailored to the response from the patient. In general, weekly treatments constitute the usual approach and injections can be administered up to the point when they are no longer needed.

Injection Procedure

Homeopathic medication(s) can be injected in the areas of pain utilizing a small gauge (27g or 30g) needle of appropriate length. The patient can indicate by his or her response to palpation where the specific point tenderness is present so that these areas can be targeted for injection by the physician. Homeopathic medication may be administered intradermally, IM, subcutaneously, or intravenously. Trigger point injections, injections into tendons, and periosteal injections are often used. A small gauge needle (30g) significantly minimizes discomfort of the injection procedure and frequently makes a local anesthetic at the site of the injection unnecessary. A series of injections can be given every 1 or 2 weeks for up to 8 weeks.

Cost Factors

Many third party payers do not cover homeopathic medications, but formulary inclusion applications are in progress for some medications. Patient demand may drive this inclusion, as more informed patients are beginning to demand safer and more effective alternatives for their pain. The medications are inexpensive and patients are generally willing to pay for them when they are aware of the efficacy.

Adjunct to Standard Pain Treatment

Homeopathic products may be used as a primary or secondary treatment to standard pain measures—including paraspinal interventions, opioids, electromagnetic measures, and physical therapy. There are no known drug interactions between homeopathic agents and any prescription medication. As far as is known, homeopathic agents do not rely on the cytochrome P450 system for metabolism.

Summary

Some patients may have immediate relief following the first injection of a homeopathic agent while others may require a series of injections or experience a delay of up to a week before obtaining relief. Generally, anecdotal evidence suggests that the onset of relief is more rapid when the injections are repeated in a series. The duration of relief, as well as the duration of therapy, varies considerably according to patient reports. In this category, injections are given for symptomatic relief on an as-needed basis. The selection of a commercial homeopathic agent is one that is labeled for a specific clinical indication such as anti-inflammatory, muscular or joint pain, or trauma. Homeopathic agents are inexpensive and can be used as a primary pain treatment or as an adjunct to standard pain treatments. No systemic, toxic complications are known with these botanical agents thus making them a safe approach to pain treatment.

Last updated on: March 7, 2011
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