Medical Foods Hold Promise In Chronic Pain Patients
The United States is in the midst of a public health challenge with regard to chronic pain. Given the intensifying focus on opioids, and the grim statistics on patient visits with regard to pain, practitioners throughout the spectrum of health care often feel overwhelmed by the challenges related to effective pain management.
Despite the inherent differences in patient populations and their pathologies, there are common approaches to the medical management of chronic pain. Chronic pain treatment generally relies on pharmacologic, and nonpharmacologic, therapies prescribed with a rationale that focuses on mechanistic synergies.1,2 The clinician’s goal is to maximize the patient’s functionality by enhancing the analgesic response, and to minimize treatment-related side effects or toxicities.
However, since most chronic pain conditions do not have any curative interventions, decisions as to any long-term pain management strategy must be considered together between clinician and patient. Further, the importance of comprehensive pain management that includes a biopsychosocial approach cannot be underestimated, and may help reduce clinical dependence on medication-based treatments. For the right patients, incorporating an inherently safe option with documented efficacy—like medical foods—into a regimen that includes active exercises, nonopioid and minimal opioid analgesic therapies, and cognitive and behavioral approaches can offer the most effective approach to pain of numerous etiologies. (See Related Article).
Adding medical foods into the pain management mix may enhance the ability to maintain or promote analgesia, reduce analgesic doses, and likely lessen actual and potential toxicities of analgesic and coanalgesic agents.
Limitations of Current Analgesic Therapies
Analgesic medications are a mainstay of chronic pain therapy, including nonsteroidal anti-inflammatory agents (NSAIDs), acetaminophen, opioids, and in certain pain states, adjuvant analgesics.3 However, all of these medications have significant limitations, including questions concerning efficacy, the risk of significant adverse events, and drug-to-drug interactions. NSAIDs are commonly prescribed, but their analgesic efficacy is often modest and comes with a number of serious adverse effects.4,5 The most frequent NSAID-related adverse effects are within the gastrointestinal (GI) tract, including ulceration, gastritis, and gastroesophageal reflux.
It has been estimated that NSAID-related GI bleeding is responsible for 100,000 hospitalizations and 16,500 deaths per year.6,7 The annual risk of GI bleeds in patients over age 65 years is estimated to be 2.5%.8,9 Hematopoietic toxicity (eg, bleeding) may occur, and hepatic, renal, and cardiovascular systems may be impacted.7,10 NSAID-induced adverse events are dose-related, and elderly patients are at highest risk for these outcomes.11 As a result of these risks, the American Geriatrics Society recommends that NSAIDs be restricted, or even eliminated, in individuals older than 65 years.4 (See Related Article)
Acetaminophen is another medication commonly relied on to manage chronic pain, but its efficacy is questionable, and it is associated with significant risk of adverse events.12,13 For example, a Cochrane Database systematic review of trials evaluating acetaminophen versus placebo for the treatment of low back pain found that there was high-quality evidence of no benefit for acetaminophen (4 g per day) over placebo for reducing pain intensity at any time over 12 weeks of treatment.12 The review also found that acetaminophen had no beneficial effect on quality of life, function, global impression of recovery, or sleep quality, at any time point.12
Another large study in patients with low back pain reported that neither a fixed dosage schedule nor an “as needed” regimen of acetaminophen were associated with any benefits.13 The poor efficacy of acetaminophen, combined with the risk of severe liver toxicity, presents sufficient doubt about the near-universal reliance on this class of medications for the treatment of chronic low back pain.
With regard to opioids, emerging adverse effects, such as hormonal abnormalities, are becoming better understood.14,15 Opioids are also associated with a number of well-known short- and long-term nutrition-related side effects, including constipation, nausea, sedation, an increased risk of falls and fractures, depression, and sexual dysfunction.16 The current opioid crisis has escalated to a point where Surgeon General Vivek Murthy, MD, MBA, has taken the unprecedented step of writing a letter to every single physician in the United States to highlight the grave concern with regard to opioid safety.17
In addressing the escalating use of opioids, Dr. Murthy wrote, “The results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly—almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed. Now, nearly 2 million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C.”
Imploring all of us to reconsider our prescribing habits, Dr. Murthy recommends better patient education that relies on a more rational approach to opioids, starting with the recognition that they are potentially addictive. Given the limited efficacy and substantial risk of treatment-related toxicities, there is a clear unmet need for alternative analgesic therapies that are safe, and that have demonstrated efficacy in the treatment of chronic pain. Medical foods are an appealing option given their strong safety profile, and their design to target the underlying neuronal pathways that generate chronic pain syndromes.