From Practical Pain Management
Discussion about diet and nutritional recommendations for patients with pain has been glaringly absent from pain journals, meetings, and teachings. We dedicate this issue of Practical Pain Management to diet and nutrition because we believe it’s important and will significantly improve pain care.
In this issue, I present a diet that I personally recommend to patients with chronic pain. Other members of the Practical Pain Management editorial board have also weighed in. Opinions and methods vary, but at least we have embarked on this critical issue.
My recommended pain diet is a work in progress, and hopefully it will improve over time as we learn more about the interrelationship between the endocrine–nutrition system and pain. Other than those recommended for weight loss or hyperlipidemia, diets are difficult to evaluate. This will continue to be the case. Some dietary advice for patients’ with chronic pain, however, appears rational.
Pain, per se, and opioid therapies have profound impacts on the endocrine–nutrition system. Both jointly affect glucose and cortisol serum levels. These levels can be unstable and vary greatly from the norm in patients with chronic pain, resulting in a catabolic state that must be rectified with a high-protein diet. The catabolic state in patients with severe, chronic pain is characterized by low protein intake, muscle wasting, weakness, and diminished mental capacity. The amino acids found in protein not only build muscle and cartilage, but also are precursors of endorphin, dopamine, serotonin, and γ-aminobutyric acid (GABA), all of which are critical for pain control.
There are many outcomes of pain treatment that an optimal diet can positively impact. Included are such variables as better sleep, more energy, and enhanced mental functioning. Opioid complications, such as hyperalgesia and constipation, may be curtailed by a prescribed diet combined with certain supplements. I seldom see these complications in my private practice, and a relative lack of these conditions may be related to my vigorous dietary recommendations.
There are some dietary supplements that may serve as positive adjuncts to chronic pain treatment. Some of these are mentioned throughout this issue. Which of them work and in what circumstances? I’m biased toward vitamin B12, carnitine, taurine, and GABA. What are your favorite dietary supplements for patients with chronic pain? In preparation for this editorial, I looked to see what Current Therapy 2011 thought about dietary supplements for pain. It listed these five for pain and arthritis: aloe vera, cat’s claw, chondroitin, glucosamine, and S-adenosyl-l-methionine (SAMe). The latest edition of The Merck Manual lists all of the above, with the exception of aloe vera. It adds feverfew and green tea as useful for some painful conditions. If Current Therapy and The Merck Manual don’t agree, how can we expect uniformity in opinion with regard to dietary supplements?
Unfortunately, there is very little incentive to study dietary supplements, so we won’t see double-blind, randomly controlled trials to give us an “evidence base” that a supplement works. We’re on our own. Furthermore, the FDA Dietary Supplement Act allows just about any claim to be made by the seller of supplements short of a promise of cure. But you’ll see plenty of personal endorsements and indications for “support” of treatment.
Despite the difficulties in evaluating diets and dietary supplements, it’s just common sense that patients with the most severe chronic pain need dietary advice and counseling. If we don’t do it, who will? My call here is to have every practitioner begin making specific recommendations on diet and dietary supplements. Then we should have our old-fashioned hallway discussions on what our recommended diet and supplements are and why they seem to help or hurt. Now is the time.
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