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Dietary Supplements for MSK Pain: What’s the Evidence?

Clinicians often have little training in nutrition and, yet, patients are interested in knowing more about supplements for pain.

with Gabriel E. Sella, MD, PhD (HC), MPH, MSc, and Patricia Deuster, PhD

With black box warnings on many NSAIDs and an ongoing opioid crisis, patients are increasingly worried about the safety of pain medications. As an alternative to what may seem like “risky” or black-market medications, they may turn to supplements, which are often believed to be a low-risk choice. However, reputable information about which supplements are safe and effective is difficult to come by.

What exactly is in a supplement, not to mention its quality, safety, and effectiveness, is difficult information for both patients and providers to obtain. A survey of military physicians, where use of supplements is high,1 for example, found that 65% of respondents did not have a reliable source of information about dietary supplements.2 This lack of information and training on supplements is not benign; one study found that each year, 23,000 people in the US alone end up in emergency rooms because of adverse reactions to dietary supplements.3

Clinicians often have little training in nutrition and are thus often unable to give advice. “Physicians have no more than two weeks of nutrition training in medical school, and the National Boards do not include questions on nutrition,” said Gabriel E. Sella, MD, MSc, MPH, PhD, fellow of the American College of Nutrition, and member of PPM’s Editorial Advisory Board. Since supplements aren’t considered drugs by FDA, they are not subject to the same safety and effectiveness regulations that are applied to medications; unlike medications (prescription or over the counter), supplements are considered safe until proven otherwise.

It was this lack of awareness that led researchers at the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University in Bethesda, MD, to determine whether current research on supplements is adequate for making decisions about their use for chronic musculoskeletal (MSK) pain. The study did not establish formal practice guidelines, but instead offered evidence-based conditional recommendations that may be used to inform clinical and policy-making decisions.

What exactly is in a supplement, not to mention its quality, safety, and effectiveness, is difficult information for both patients and providers to obtain. (Image: iStock)

Not Just Special Ops

The resulting study was the second in a series of articles designed to offer evidence-based recommendations to aid policy decisions for military special operators. However, the results provide useful information to clinicians outside the military as well. “While the goal of the study was to make recommendations for military service members, the findings are absolutely relevant to the general population,” Patricia Deuster, PhD, director of CHAMP and one of the study’s authors, told PPM.

A committee called the Holistic Evidence Review Board (HERB) was conceived to establish what questions were relevant to clinical decision-making regarding supplement use. An independent review team, including subject-matter experts from both civilian and military sectors, then examined the current research to assess the evidence on the efficacy, safety, and outcomes of the supplements studied. Conditional recommendations were made using modified Delphi methods. In the end, a total of 19 dietary ingredients were subject to study.

The Good and Not So Good

The team found eight ingredients that may be effective in relieving MSK pain with little or no risk of adverse events when used as a part of a balanced diet, a dietary supplement, or a topical application. However, researchers cautioned that patients should consult a healthcare provider before use. The ingredients include: avocado soybean unsaponifiables, capsaicin, Curcuma, ginger, glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D.

Substances that, due to a lack of reliable information, did not meet the criteria for safety and effectiveness in treating MSK pain included: boswellia, collagen, creatine, devil’s claw, L-carnitine, methylsulfonylmethane, pycnogenol, rosehip, S-adenosyl-L-methionine, vitamin E, and willow bark extract. The researchers pointed out that these substances may be useful for other illnesses, such as osteoarthritis and fibromyalgia, but evidence was lacking in their effectiveness for MSK pain specifically.

Useful Information

“Supplements offered on the market and claims made on their labels may not always align with the scientific evidence for benefit and/or potential risk,” Dr. Deuster told PPM. Instead, “clinicians can use [the evidence provided by this study] to help individuals make better-informed decisions.” Dr. Deuster advised that clinicians counsel patients to carefully read the labels on any products they are considering using and consider any product claims with an objective eye.

While pleased with the study results overall, Dr. Sella noted that he did not think the study makes up for the lack of nutritional information and training available to physicians. He believes that, due to lack of proper training, physicians should avoid counseling patients about nutritional-related matters and in-stead, “refer those people to colleagues who are qualified. The field is rather open and needs leadership on the side of medical schools and insurance companies,” he said. •

Last updated on: February 3, 2020
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