Vitamins and Minerals for Pain Management

US Pharm. 2022;47(3):25-33.

ABSTRACT: About one in five U.S. adults experiences pain daily or on most days, and for patients struggling with pain, the toll on their health and well-being is detrimental and can be debilitating. Appropriate pain management has been a growing concern since the rise of the opioid epidemic. When prescription pharmacologic agents do not alleviate their pain or are not easily accessible, patients seek alternative therapies. Vitamins and minerals are one option that has gained traction and has attracted researchers’ interest. Although evidence supporting the use of these agents is limited, pharmacists are in a position to help patients make educated decisions on the use of vitamins and minerals.

In the United States, chronic pain is one of the leading conditions for which people seek medical treatment, and the toll on their health and well-being is detrimental and can be debilitating. Based on the 2019 National Health Interview Survey, about one in five adults in the U.S. experiences pain on most days or every day.¹ Appropriate pain management has been a growing concern since the rise of the opioid epidemic. When prescription pharmacologic agents do not alleviate their pain or are not easily accessible, patients seek alternative therapies.  In 2011, chronic pain was reported to have an annual economic burden of $560 billion to $635 billion, of which direct healthcare costs comprised only $261 billion to $300 billion.²

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”³ As the definition implies, pain is relative to the individual afflicted; the optimal treatment depends on the pain classification. There are four common pain-classification schemes based on the pathophysiologic mechanism (nociceptive or neuropathic), duration (acute or chronic), etiology (malignant or nonmalignant), or anatomical location. ⁴ The goal of treatment for any type of pain is to improve quality of life, functioning, and comfort.

Over the past 3 decades, the approach to pain and its management has been a key focus area.⁵ In the 1990s, the inadequate assessment and treatment of pain was recognized as a health emergency and eventually labeled as “the 5th vital sign.” In the effort to improve pain control and in the wake of new pharmaceutical formulations, liberal opioid prescribing eventually led to a national opioid crisis. In response, research and guidelines have aimed to identify alternative pain-management modalities.^5,6 Most recent guidelines and best-practice reports have recommended individualized, multimodal, and multidisciplinary pain management encompassing medications, restorative therapies, interventional procedures, behavioral-health approaches, and complementary and integrative medicine. One limitation of these documents, however, is the lack of discussion of the role that vitamins and minerals may play in pain management. According to a survey conducted in 2002, more than one-third of Americans use complementary and alternative medicine.⁷ Given that pharmacists are often the only healthcare professionals available to answer consumers’ questions about OTC medications, it is important to understand the possible role of these agents in pain management.

The IASP defines neuropathic pain as “pain caused by a lesion or disease of the somatosensory nervous system.”⁸ This condition encompasses a number of etiologies, including diabetes, cancer, chronic alcohol consumption, herpes zoster infection, traumatic nerve injury, drug toxicity, and central processes including cerebrovascular accidents, spinal cord injuries, and multiple sclerosis.⁹ Broadly, current pharmacologic treatment strategies include serotonin-norepinephrine reuptake inhibitors such as venlafaxine and duloxetine, tricyclic antidepressants, and the anticonvulsants gabapentin and pregabalin as first-line therapies. However, given the complex nature of neuropathic pain, its spectrum of symptoms, and its prevalence in up to 10% of the population (according to validated questionnaires), there is a growing demand for new treatments.⁹ Research into vitamin supplementation—with or without a preexisting deficiency—has been gaining traction.

Vitamin B₁₂

In humans, vitamin B₁₂ functions mainly as a cofactor for the methyltransferase enzyme known as methionine synthase.¹⁰ This allows for the formation of methionine, which is later converted to S-adenosyl methionine (SAMe). SAMe is responsible for donating methyl groups to the formation of myelin sheaths around neurons. Animal models have exhibited several mechanisms through which vitamin B₁₂ is proposed to alleviate neuropathic pain in humans (TABLE 1). A recent systematic review of 325 articles found that the strongest areas of research on the use of vitamin B₁₂ in treating peripheral polyneuropathy are postherpetic neuralgia (PHN), diabetic neuropathy, and alcohol-related neuropathy. ⁹ This study found no articles that disproved the utility of vitamin B₁₂ for neuropathic pain.

Diabetic Neuropathy: Hyperglycemia (and hyperlipidemia) cause the increased production of reactive oxygen species (ROS), advanced glycation end products, and insoluble sugars such as sorbitol.¹¹ All of these end products induce cellular damage and a proinflammatory environment, particularly affecting the peripheral neurons. Although there is a positive trend in the use of vitamin B₁₂ for diabetic neuropathy, evidence is insufficient because most of the research trials lacked adequate follow-up periods or sample sizes and did not have a placebo arm for comparison. Additionally, many of these studies focused on the adjunctive use of vitamin B₁₂ with gabapentinoids and other B vitamins, thereby limiting the assessment of vitamin B₁₂ on its own.

PHN: PHN is a lingering pain that persists beyond 4 months following a rash induced by herpes zoster. ¹² Inflammation caused by the virus triggers fibrosis of nerves and spontaneous activity capable of maintaining pain in the absence of ongoing tissue damage. Five randomized, controlled trials included in a systematic review found that vitamin B₁₂ was helpful—whether as monotherapy or adjunctively—for PHN regardless of where the pain manifested.⁹

Alcohol-Related Neuropathy: Vitamin deficiencies resulting from chronic alcoholism lead to complications in the demyelination of peripheral neurons and to slow nerve conduction caused by alcohol-induced neurotoxicity.¹³ Symptoms are usually symmetrical and distal, including paresthesia, cramps, weakness, and pain. Vitamin supplementation in this case would help reverse those complications. It has been found that the addition of vitamin B₁₂ may provide a benefit in pain improvement.⁹

Zinc

The pathogenesis of chemotherapy-induced peripheral neuropathy (CIPN) is not well understood, but the mechanism appears to involve axonal degradation from chronic exposure to chemotherapeutic agents. ¹⁴ One possible cause may be an increase in ROS from the chemotherapeutic agents, so researchers are investigating the use of antioxidants to treat or prevent CIPN. The questionnaire-based Diet, Exercise, Lifestyle, and Cancer Prognosis (DELCaP) study found a correlation between multivitamin use and reduced incidence of CIPN in stage I–III breast cancer patients who received doxorubicin, cyclophosphamide, and paclitaxel, but there was no statistically significant risk reduction with individual supplement use.¹⁵ A study in mouse models with paclitaxel-induced CIPN demonstrated dose-dependent reduction of local allodynia following intraplantar zinc administration for up to 4 days.¹⁶ This study found that exogenous zinc inhibited TRPV1 (transient receptor potential cation channel subfamily V member 1; a nonselective cation transport protein), thereby preventing paclitaxel-induced sensitization of peripheral nociceptors. The Pathways study found that women who initiated zinc and other antioxidants after diagnosis were two to three times more likely to report CIPN at 6-month follow-up. ¹⁷ Further research is needed on the use of zinc for CIPN treatment before any changes to recommendations are made.

Vitamin E

Vitamin E, the primary fat-soluble antioxidant, is being studied relative to the role of ROS in neuropathic pain. A 2006 study using rat models concluded that vitamin E administration—as either a high-dose single injection (0.1, 1, or 5 g/kg with no equivalent human dose owing to variations in metabolic rates between species) or repetitive daily low-dose injections (50 or 100 mg/kg, equating to 3 g in a 60-kg human)—reduced behaviors associated with mechanical allodynia.¹⁸ Similar to the results of the DELCaP study, a phase III clinical trial in patients receiving neurotoxic chemotherapy found no difference in CIPN incidence regardless of whether vitamin E was administered.¹⁴ The researchers found a slight positive effect on neuropathy duration in patients who took 400 mg of vitamin E twice daily; however, they noted that the dose may have been too low to achieve a statistically significant benefit. A randomized trial that examined vitamin E supplementation versus placebo as an adjunct to standard pain management for diabetic neuropathy concluded that vitamin E was effective in reducing some pain, but no improvement was seen in overall quality-of-life scores.¹⁹

According to the IASP, chronic pain is “pain that persists or recurs for longer than 3 months.”²⁰ The principles informing the treatment of neuropathic pain and chronic pain are subject to overlapping, as forms of neuropathic pain can become chronic afflictions. The preferred first-line treatment options are nonpharmacologic therapies (diet, exercise, and behavioral) and nonopioid prescription medications; however, given the nature of chronic pain, many of the affected patients have been prescribed opioids.²¹ Because chronic pain is the leading cause of disability in U.S. adults, there has been a significant push for alternative treatments, including research into vitamins and minerals. ²²

Vitamin C

Vitamin C deficiency (plasma concentrations <11 mcmol/L) manifests as scurvy-related myalgia and arthralgia in the knees, wrists, and ankles due to bleeding within these areas.²³ Deficiency of this vitamin is rare in developed countries (<6% in the U.S.), but the populations primarily affected are hospitalized elderly patients, cancer patients, and critically ill patients. The use of vitamin C has been shown to be effective in several aspects of pain management.

Complex Regional Pain Syndrome (CRPS): Many randomized, controlled trials have demonstrated that vitamin C supplementation reduced the incidence of CRPS in wrist- and ankle-surgery patients, with the most efficacious dosage being 0.5 g or more per day.^23,24 The same dosage was also administered prophylactically for osteoarthritis in joint-replacement patients, who were then found to have no incidence of CRPS.

Rheumatoid Arthritis and Osteoarthritis: It has been noted that patients with rheumatoid arthritis present with average vitamin C levels less than half the level in healthy controls. ²³ One study reported a total reduction of pain in a single rheumatoid arthritis patient following twice-weekly infusions of high-dose vitamin C, and a study in osteoarthritis patients given 1 g of oral calcium ascorbate per day found that the reduction in pain was less than half of that reported for nonsteroidal anti-inflammatory drugs.²³ These data may also suggest more efficacy with parenteral versus oral administration in patients with arthritis.

Orthopedic Pain: Vitamin C exhibits regulatory effects on bone and collagen formation.²³ A study of 16 patients with Paget’s disease showed a reduction in bone pain following administration of 3 g of oral vitamin C per day for 2 weeks. However, the pain reduction was not greater than that observed with typical calcitonin treatment for the disease.

PHN: Serum levels of vitamin C are much lower in shingles patients than in healthy persons, and this has been found to increase the risk of PHN. ²³ Randomized, controlled trials have shown a reduced incidence of PHN and decreased long-term pain following parenteral vitamin C administration.

Cancer Pain: Cancer patients typically have increased vitamin C requirements and lower circulating levels than healthy individuals.²³ Questionnaire-based studies examining quality of life showed significant improvements (>30%) due to decreased pain following vitamin C administered orally or parenterally.

Decreased Opioid Requirements: Patients receiving opioids have been found to exhibit decreased withdrawal symptoms with coadministration of vitamin C.²³ Several studies have also observed that these patients required fewer morphine equivalents of opioids compared with patients who did not receive vitamin C coadministration.

Vitamin D

Vitamin D deficiency is associated with several etiologies of chronic pain, including type 1 diabetes, hypertension, metabolic syndrome, ischemic heart disease, falls, broken bones, depression, and cancer. ²⁵ More recent studies have also linked vitamin D deficiency to sickle cell disease, aromatase inhibitor–induced arthralgia, headache, PHN, pain in patients taking high doses of opioids, and various types of musculoskeletal and orthopedic pain. In these conditions, higher reported levels of pain and opioid use occurred in patients with deficient circulating levels of vitamin D.^25,26 In addition to its bone-regulation and hormonal effects, vitamin D regulates the inflammatory responses mediated by the adaptive immune system.²⁶ Similar to vitamin C supplementation, administration of vitamin D in these cases prevents pain associated with a deficiency of the vitamin (<30 nmol/L) and has little effect in patients with adequate levels. Current evidence is insufficient to change recommendations regarding vitamin D supplementation, and more research should be conducted.

Magnesium

Magnesium is an antagonist of N-methyl-D-aspartate voltage-gated receptors that exhibits antinociceptive effects by preventing and attenuating hypersensitivity to pain. ^27,28 It is also known to reduce neuromuscular excitability by antagonizing the effects of calcium on acetylcholine release.²¹ Further research must be conducted before changes to recommendations should be considered, but promising trends have been noted in the use of magnesium for the following conditions.

Perioperative Pain: In a systematic review of 27 randomized, controlled trials, data trends suggested that systemic administration of magnesium during general anesthesia may lessen postoperative pain without increasing the risk of adverse effects.²⁷ The usual regimen is a loading dose of 30 mg/kg to 50 mg/kg followed by a maintenance dose of 6 mg/kg to 20 mg/kg per hour. Magnesium has also been associated with increased hemodynamic stability during surgery as well as reduced anesthetic and opioid use. It has been found to be largely ineffective for attenuating pain associated with cesarean delivery, hysterectomy, inguinal hernia repair, and varicose vein surgery; however, it is worth noting that the studies reporting these results used a single dose rather than a loading dose plus continuous infusion. ²⁸

Migraine: Hypomagnesemia has been observed in patients who develop migraines, but the etiology of this condition is not fully understood.²⁷ Magnesium supplementation has yielded inconsistent results in preventing and treating migraines. This may be due to differences in magnesium formulation, dosing, and administration as well as migraine subtype.

Fibromyalgia: Patients with fibromyalgia have been found to have lower magnesium levels and magnesium intake.²⁷ Magnesium supplementation has been suggested to be beneficial because it reduces levels of substance P, which correlates to a decrease in fibromyalgia pain.

PHN: IV magnesium sulfate administered at 30 mg/kg over 30 minutes was shown to lessen or completely resolve pain in patients with PHN.²⁸ Studies have suggested that it is as effective as ketamine for reducing pain associated with PHN, but more research should be conducted before it is recommended as a treatment option. ²⁷

CIPN: A 2004 study reported that infusions of calcium and magnesium (Ca²⁺/Mg²⁺) before and after administration of oxaliplatin could prevent the development of CIPN.^27,28 Metanalyses and systematic reviews have yielded inconsistent results, and although their effectiveness remains inconclusive, these infusions have been adopted into clinical practice anyway.

Pain is a complex and multifaceted health condition that has variable effects on different individuals. Although a number of pharmacologic therapies are available to help manage pain, no uniform regimen works for all patients. Vitamins and minerals may be an alternative option for pain relief, particularly for neuropathic and chronic pain. Although evidence supporting the use of vitamins and minerals is limited, pharmacists are well positioned to help patients make educated decisions on the use of these nutrients.

REFERENCES

1. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain. 2022;163(2):e328-e332.
2. Smith TJ, Hillner BE. The cost of pain. JAMA Netw Open. 2019;2(4):e191532.
3. International Association for the Study of Pain. Definition of pain. www.iasp-pain.org/resources/terminology/#pain. Accessed January 2, 2022.
4. Abd-Elsayed A, Deer TR. Different types of pain. In: Abd-Elsayed A, ed. Pain: A Review Guide. Cham, Switzerland: Springer Nature Switzerland; 2019:15-16.
5. HHS.gov/Opioids. Pain Management Best Practices Inter-Agency Task Force report. www.hhs.gov/sites/default/files/pain-mgmt-best-practices-draft-final-report-05062019.pdf. Accessed January 2, 2022.
6. Institute for Clinical Systems Improvement. Pain: assessment, non-opioid treatment approaches and opioid management care for adults. www.icsi.org/wp-content/uploads/2021/11/Pain-Interactive-7th-V2-Ed-8.17.pdf. Accessed January 2, 2022.
7. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004;(343):1-19.
8. Murnion BP. Neuropathic pain: current definition and review of drug treatment. Aust Prescr. 2018;41(3):60-63.
9. Julian T, Syeed R, Glascow N, et al. B12 as a treatment for peripheral neuropathic pain: a systematic review. Nutrients. 2020;12(8):2221.
10. Buesing S, Costa M, Schilling JM, Moeller-Bertram T. Vitamin B12 as a treatment for pain. Pain Physician. 2019;22:e45-e52.
11. Feldman EL. Pathogenesis of diabetic neuropathy. UpToDate. Waltham, MA: UpToDate Inc. www.uptodate.com. Accessed January 2, 2022.
12. Ortega E. Postherpetic neuralgia. UpToDate. Waltham, MA: UpToDate Inc. www.uptodate.com. Accessed January 2, 2022.
13. Charness ME. Overview of the chronic neurologic complications of alcohol. UpToDate. Waltham, MA: UpToDate Inc. www.uptodate.com. Accessed January 2, 2022.
14. Kottschade LA, Sloan JA, Mazurczak MA, et al. The use of vitamin E for the prevention of chemotherapy-induced peripheral neuropathy: results of a randomized phase III clinical trial. Support Care Cancer. 2011;19(11):1769-1777.
15. Zirpoli GR, McCann SE, Sucheston-Campbell LE, et al. Supplement use and chemotherapy-induced peripheral neuropathy in a cooperative group trial (S0221): the DELCaP study. J Natl Cancer Inst. 2017;109(12):djx098.
16. Luo J, Bavencoffe A, Yang P, et al. Zinc inhibits TRPV1 to alleviate chemotherapy-induced neuropathic pain. J Neurosci. 2018;38(2):474-483.
17. Greenlee H, Hershman DL, Shi Z, et al. BMI, lifestyle factors and taxane-induced neuropathy in breast cancer patients: the Pathways Study. J Natl Cancer Inst. 2016;109(2):djw206.
18. Kim HK, Kim JH, Gao X, et al. Analgesic effect of vitamin E is mediated by reducing central sensitization in neuropathic pain. Pain. 2006;122(1-2):53-62.
19. Rajanandh MG, Kosey S, Prathiksha G. Assessment of antioxidant supplementation on the neuropathic pain score and quality of life in diabetic neuropathy patients—a randomized controlled study. Pharmacol Rep. 2014;66(1):44-48.
20. Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19-27.
21. CDC. About CDC’s opioid prescribing guideline. www.cdc.gov/opioids/providers/prescribing/guideline.html. Accessed January 2, 2022.
22. Zelaya CE, Dahlhamer JM, Lucas JW, Connor EM. Chronic pain and high-impact chronic pain among U.S. adults, 2019. NCHS Data Brief. 2020;(390):1-8.
23. Carr AC, McCall C. The role of vitamin C in the treatment of pain: new insights. J Transl Med. 2017;15(1):77.
24. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? J Bone Joint Surg Am. 2007;89(7):1424-1431.
25. Nadolski CE. Vitamin D and chronic pain: promising correlates. US Pharm. 2012;37(7):42-44.
26. Helde-Frankling M, Björkhem-Bergman L. Vitamin D in pain management. Int J Mol Sci. 2017;18(10):2170.
27. Shin HJ, Na HS, Do SH. Magnesium and pain. Nutrients. 2020;12(8):2184.
28. Na HS, Ryu JH, Do SH. The role of magnesium in pain. In: Vink R, Nechifor M, eds. Magnesium in the Central Nervous System. Adelaide, Australia: University of Adelaide Press; 2011.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

To comment on this article, contact [email protected].

Supplements for Pain – Whole Health Library

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How is Pain Normally Treated?

Chronic pain is a major treatment challenge. It is incredibly common and difficult to treat. Pain is a subjective experience that has many influences. Even in localized pain there are often multiple physiologic sources of pain. Pain is influenced by multiple factors, including:

• Peripheral structures such as muscles and ligaments
• The central nervous system
• Psychological and emotional states

Because of these multiple influences, treatment approaches that are too narrow are likely to fail.

Conventional medical treatments for pain include medications, interventional pain procedures (i.e., epidural injections, radiofrequency ablation), surgical interventions, and physical therapy. Which specific medications and procedures are recommended varies depending on the specific diagnosis and individual needs, but overall, these options have many limitationsnot to mention, many associated risksespecially when it comes to treating chronic pain. Patients often become frustrated with conventional treatment choices and turn to complementary therapies for pain more than any other diagnosis. [1]

What Are the Risks of Traditional Medications Used to Treat Chronic Pain?

Medication recommendations normally begin with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). These are generally regarded as the safest medications, but they are certainly not without risk. Acetaminophen carries the risk of hepatotoxicity, and NSAIDs cause gastrointestinal bleeding, interfere with platelet aggregation, can worsen renal function, and may increase risk of cardiovascular events.[2] Tricyclic antidepressant medications are recommended as adjunctive treatments for both nociceptive and neuropathic pain.[2] These may cause sedation and are on the Beers list for cautious use in the elderly.[3] Opioid medications are under increasing scrutiny due to their multiple adverse effects, their potential for causing addiction, and their failure to demonstrate functional improvement when compared to non-opioid analgesics.[4]

Why Should We Consider Dietary Supplements in the Treatment of Pain?

With medication options often being limited due to lack of effectiveness, increased risks, or adverse effects, there is a need for safe therapeutic options that reduce pain and augment the effects of other treatment modalities. Supplements can fill that void in some patients, reducing their pain so that they can pursue other active modalities. When discussing supplements with patients, it is recommended that supplements be discussed as part of an overall holistic treatment approach, as opposed to a quick fix or magic bullet.

If Supplements Are Effective for One Type of Pain, Are They Effective for Other Pain Conditions as Well?

Not necessarily. This makes it daunting to choose from among different supplement options. Products effective for chronic low back pain are not necessarily good choices for fibromyalgia, headache pain, or neuropathic pain. The differing causes and sources of pain in each of these conditions, not to mention the different mechanisms of action of various supplements, make it difficult to make generalizations. There are many supplements with proposed benefits in individual pain conditions. When evaluating research on a supplement, consider the condition being studied in addition to the benefits and limitations of the study.

To help guide choosing appropriate supplements for specific pain conditions, the remainder of this clinical tool is split into two sections. The first section will simply list supplements to consider for several common pain conditions. The second section will provide a more detailed look at these individual supplements, including research related to efficacy, dosing, and potential side effects.

Supplements to Consider for Individual Pain Conditions

Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

Chronic headache

• Magnesium
• Vitamin B2
• Butterbur
• Feverfew

Chronic low back pain

• Willow bark
• Devils claw
• Vitamin D
• Capsaicin topical cream

Fibromyalgia

• Vitamin D
• Magnesium
• Sleep-related supplements
• Energy-related supplements

Neuropathic pain

• Alpha lipoic acid
• Vitamin B12 (important to test, and replace if deficiency exists)

Osteoarthritis

• Omega-3 supplements
• SAMe
• Glucosamine and chondroitin
• Devils claw
• Willow bark

Rheumatoid arthritis

• Omega-3 supplements
• Gamma linoleic acid
• Devils claw
• Willow bark

Individual Supplement Details

Alpha lipoic acid

Alpha lipoic acid (ALA) is a chemical that the body produces itself. It has been found to increase blood flow to the nerves, reduce oxidative stress, and improve distal nerve conduction. It has also been found to improve glucose uptake and enhance insulin sensitivity. It has long been approved in Germany for the treatment of diabetic and alcoholic neuropathy. A meta-analysis in 2004 concluded that treatment with ALA for 3 weeks is safe and provides a 24% overall improvement in total symptoms score versus placebo.[5] The dose for prevention of peripheral neuropathy is 100 milligrams, one to two times daily. For active treatment, the dose is 600 milligrams daily or twice daily. Increasing to even higher doses has not been found beneficial. The most common side effects are GI-related, including upset stomach and nausea.

Capsaicin topical cream

Capsaicin is widely available a cream in various doses. It is useful as a short-term analgesic, and a review has shown it to be superior to placebo for acute episodes of chronic low back pain.[6] It is widely available in most drug stores.

Devils claw (

Harpagophytum procumbens)

Despite the amusing name, this is an herbal supplement with good evidence of effectiveness in pain conditions. A 2007 review of the evidence found five systematic reviews on devils claw with strong evidence of effectiveness for low back pain and osteoarthritis pain of the knee and hip.[7] This effect was not inferior to NSAIDs. The review concluded by stating, Since there is strong evidence for devils clawthe possible place in the treatment schedule before NSAIDs should be considered.[7] Doses should be at least 50 milligrams of the harpagoside constituents, which equates to 2.6 grams/day of the root. Effects are dose dependent. It is generally well tolerated.

Energy-related supplements

In some patients, it may be useful to actively try to boost energy levels. This may be useful in helping patients to exercise. A general class of herbal medications with this property is known as the adaptogens. There is no data on these supplements specifically in terms of their effects on fibromyalgia or chronic pain. Energy-boosting beverages, which typically contain high doses of caffeine or other stimulant compounds, are not likely to be beneficial. For more information on adaptogens, see the Adaptogens tool.

Gamma linoleic acid

Gamma linoleic acid (GLA) is an omega-6 fatty acid found primarily in vegetable oils. Specifically, it is found in evening primrose oil, borage seed oil, and black currant seed oil. A Cochrane review found moderate evidence for effectiveness of GLA in rheumatoid arthritis.[8] Specifically, GLA was found to decrease pain, improve disability scores, and improve overall well-being compared with placebo oils. Doses of GLA varied significantly in these studies, ranging from 500 milligrams to 2,800 milligrams daily. Evening primrose oil is preferred over borage seed oil because borage seed oil contains some chemicals (pyrrolizidine alkaloids) that are toxic to the liver. Side effects include headaches, nausea, and diarrhea.

Glucosamine and chondroitin

These are compounds found in the joint cartilage, synovial fluid, and connective tissue. Both may prevent cartilage destruction, and as such, they have been popular supplements for osteoarthritis (OA). Evidence of effectiveness has been mixed and controversial. A Cochrane review found efficacy for glucosamine sulfate, but this was specific to the Rotta brand, and not noted when findings were pooled together with research on other brands.[9] Improvement in knee OA was in both pain and function. Glucosamine hydrochloride supplements have not shown efficacy in OA. Glucosamine sulfate has also been tested in chronic low back pain and showed no evidence of efficacy.[10] At this point there is some evidence for the use of glucosamine and chondroitin in the treatment of knee OA, but not for other painful conditions. For patients with knee OA, it may be worth a trial of therapy, keeping in mind the effects may not be seen for 3 months. Dosing for both glucosamine and chondroitin is in the range of 500 milligrams three times daily.

Magnesium

Magnesium deficiency appears to be more common in patients with fibromyalgia, and deficiency is correlated with the presence of fibromyalgia symptoms. Supplementation with magnesium citrate has been shown to reduce the intensity of fibromyalgia symptoms.[11] Magnesium supplements can be calming for some patients, so it can be useful to take them before bed. A dose of 400-800 milligrams of supplement is often recommended. Magnesium oxide should be avoided as a supplement due to its laxative effects. Dietary sources of magnesium include whole grains, spinach, almonds, soybeans, and avocados.

Omega-3 supplementation

Supplementation with omega-3 fatty acids has been found in meta-analyses to improve joint tenderness and morning stiffness in patients with rheumatoid arthritis.[12] While efficacy is more established in inflammatory conditions such as rheumatoid arthritis, it is unknown what effect omega-3 supplementation has on pain with less of an inflammatory component.[13] Doses should be standardized based on the amount of EPA and DHA present in the supplement, and should exceed 2 grams per day of EPA and DHA to get the desired benefit. Omega-3 supplements are quite safe and may improve other aspects of health, such as lipid profiles. Cost varies significantly depending on the brand. Consumer Labs (http://www.consumerlab.com) provides information on individual brands and their overall content. These supplements are normally well tolerated. They can have a fishy aftertaste and cause dyspepsia in some people; this improves if the supplement is kept refrigerated.

S-Adenosylmethionine (SAMe)

This is a supplement with indications for both depression and osteoarthritis, which makes it an intriguing option for chronic pain. SAMe is a coenzyme present in nearly all the bodys tissues and is involved in dozens of reactions. It has several potential mechanisms of action, including having anti-tumor necrosis factor (TNF) effects, improving glutathione uptake and demonstrating anti-inflammatory properties. However, exactly how it helps depression and OA is not clear. Research has generally been positive with regards to efficacy, but many studies have been limited by size and quality. A 2009 Cochrane review of its use in OA, which included four studies, showed a very small beneficial effect in terms of pain and functional improvement. However, the review was limited by poor quality of the studies and was judged inconclusive.[14] A previous 2002 meta-analysis of 11 studies compared SAMe to placebo and NSAIDs. SAMe had an effect comparable to NSAIDs with fewer adverse effects. Again, the analysis was limited due to methodological problems with the included studies.[15] Currently there is not any evidence for its use specific to fibromyalgia.

Given the high coexistence of pain and depression, and given its overall good safety profile, SAMe is a supplement to consider for patients with pain. The major drawback is cost, as it is quite expensive. Cost can be $2-$4 per day. Dosages for depression are typically 400 milligrams, three or four times daily. The dosage for OA is 200 milligrams, three times a day.

Sleep-related supplements

Sleep is important to address in fibromyalgia and chronic pain and, as discussed, is often dysfunctional. There are many aspects to addressing healthy sleep, but some dietary supplements may be beneficial. For more information, see the Recharge module.

Vitamin D

The relationship between vitamin D deficiency and chronic pain is intriguing, but not yet clear. Epidemiologic studies have correlated low vitamin D levels and chronic musculoskeletal pain, with prevalence in one study exceeding 90%.[16][17] Vitamin D deficiency is known to cause osteomalacia and a resultant dull, achy pain, which can be either localized or widespread.[18] In addition, vitamin D deficiency is associated with muscle weakness and increased falls.[18] Despite the high correlation and a plausible mechanism of contributing to pain states, a recent Cochrane review found poor evidence to support vitamin D supplementation in chronic pain.[19] This finding was based on four studies, three of which were deemed of low quality. A smaller study published since the Cochrane review on vitamin D supplementation in Veterans showed that it improved pain, sleep, and quality of life. [20] Clearly, more research is needed in this area to guide future recommendations. At this time it seems reasonable to test vitamin D levels in patients with chronic pain and institute a trial of supplementation with low levels, given the safety of supplementation and the potential to have a positive impact on heath in other areas in addition to pain.

Willow bark (

Salix alba)

Willow bark contains salicin, which is related to aspirin. It has been used for centuries to relieve pain.[21] The mechanism of action is thought to be COX-2 inhibition, similar to aspirin, but without the effects on prostaglandins or coagulation.[22] There is evidence of efficacy in chronic low back similar to that seen for rofecoxib 12.5 milligrams.[21] Evidence in osteoarthritis is mixed.[21] The effect is dose dependent, and the willow bark dosage used in studies was standardized to 240 milligrams of salicin.

Other herbal anti-inflammatories

Other herbal medicines have known anti-inflammatory properties, most notably turmeric and ginger. Both of these supplements have some preliminary evidence to support their use, but overall evidence is not strong at this point. Ginger has shown some effectiveness for osteoarthritis of the knee and turmeric for rheumatoid arthritis.[7] Both are considered safe and are good additions to an anti-inflammatory diet, but clear recommendations cannot be made this time for chronic pain patients.[13]

Authors

This tool was written by Russell Lemmon, DO, Assistant Professor and integrative medicine family physician in the Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public Health.

References

1. A New Portrait of CAM Use in the United States. NCCAM. 2004;XI. Issue 3. ↵
2. Rosenquist E. Overview of the treatment of chronic pain. UptoDate. 2013. Accessed 12/1/2013. ↵
3. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. ↵
4. Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet. 2011;377(9784):2226-2235. ↵
5. Ziegler D, Nowak H, Kempler P, Vargha P, Low PA. Treatment of symptomatic diabetic polyneuropathy with the antioxidant alpha-lipoic acid: a meta-analysis. Diabet Med. 2004;21(2):114-121. ↵
6. Gagnier JJ. Evidence-informed management of chronic low back pain with herbal, vitamin, mineral, and homeopathic supplements. Spine J. 2008;8(1):70-79. ↵
7. Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. 2007;21(7):675-683. ↵
8. Cameron M, Gagnier JJ, Chrubasik S. Herbal therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2011(2):CD002948. ↵
9. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005(2):CD002946. ↵
10. Wilkens P, Scheel IB, Grundnes O, Hellum C, Storheim K. Effect of glucosamine on pain-related disability in patients with chronic low back pain and degenerative lumbar osteoarthritis: A randomized controlled trial. JAMA. 2010;304(1):45-52. ↵
11. Bagis S, Karabiber M, As I, Tamer L, Erdogan C, Atalay A. Is magnesium citrate treatment effective on pain, clinical parameters and functional status in patients with fibromyalgia? Rheumatol Int. 2013;33(1):167-172. ↵
12. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007;129(1-2):210-223. ↵
13. Teets RY, Dahmer S, Scott E. Integrative medicine approach to chronic pain. Prim care. 2010;37(2):407-421. ↵
14. Rutjes AW, Nuesch E, Reichenbach S, Juni P. S-Adenosylmethionine for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2009(4):CD007321. ↵
15. Soeken KL, Lee WL, Bausell RB, Agelli M, Berman BM. Safety and efficacy of S-adenosylmethionine (SAMe) for osteoarthritis. J Fam Pract. 2002;51(5):425-430. ↵
16. Macfarlane GJ, Palmer B, Roy D, Afzal C, Silman AJ, O’Neill T. An excess of widespread pain among South Asians: are low levels of vitamin D implicated? Ann Rheum Dis. 2005;64(8):1217-1219. ↵
17. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc. 2003;78(12):1463-1470. ↵
18. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc. 2003;78(12):1457-1459. ↵
19. Straube S, Derry S, Straube C, Moore RA. Vitamin D for the treatment of chronic painful conditions in adults. Cochrane Database Syst Rev. 2015(5):Cd007771. ↵
20. Huang W, Shah S, Long Q, Crankshaw AK, Tangpricha V. Improvement of pain, sleep, and quality of life in chronic pain patients with vitamin D supplementation. Clin J Pain. 2013;29(4):341-347. ↵
21. Vlachojannis JE, Cameron M, Chrubasik S. A systematic review on the effectiveness of willow bark for musculoskeletal pain. Phytother Res. 2009;23(7):897-900. ↵
22. Vlachojannis J, Magora F, Chrubasik S. Willow species and aspirin: different mechanism of actions. Phytother Res. 2011;25(7):1102-1104. ↵

Vitamins for the back and spine

Vitamins for the back and spine – which vitamin to inject for pain in the back and lower back

Gimranov Rinat Fazylzhanovich
Neurologist, neurophysiologist, experience – 33 years;
Professor of Neurology, MD;
Clinic for Rehabilitation Neurology. About the author

Publication date: June 14, 2022

Pain and discomfort in this area is a common problem. Almost everyone has experienced it.

After completing a full course of treatment, patients often wonder what vitamins to take for back pain. After all, everyone today knows about their necessity and the serious impact they have. [1]

Contents of the article:

• 1 What vitamins are injected for back pain?
• 2 Causes of back pain
  • 2.1 B vitamins by injection
• 3 Compatibility
• 4 Selected B vitamins for severe illness
• 5 References:

What vitamins are injected for back pain ?

Modern scientific research confirms the effectiveness of such therapy.

Causes of back pain

The use of vitamin injections for back muscles and strengthening of the spine began in the last decades, when the effectiveness of this method was proven. However, they are not always included in mandatory therapy. Therefore, it is extremely dangerous to prescribe them yourself, this should only be done by a specialist. [2]

It is important to know the cause of the shortage.

Every tenth inhabitant of developed countries visits specialists at least once a year with neurological problems leading to severe pain.

Doctors divide such patients into two conditional groups. Those whose discomfort is due to age and natural aging, degradation of bone and muscle tissue, and those whose illnesses are caused by an unhealthy lifestyle. For the former, intramuscular vitamins are often prescribed to prevent back pain.

Factors that provoke the development of diseases of muscles and bones include:

• Excessive physical activity.
• Lack of mobility.
• Wrong diet.
• Bad habits.
• Obesity.

In this case, without a special adjustment of daily life, even regular prophylactic courses of vitamins will not work.

What vitamins to take if your back hurts, the doctor will tell you after a thorough examination. Therapy is selected taking into account the characteristics of the course of the disease and the physical condition of the patient. Not only the combination of specific substances is important, but also the dosage. If it is chosen incorrectly, then there is a high probability of a lack of a positive effect and the appearance of side effects. [3]

Most degenerative and inflammatory diseases of the back are based on an unhealthy lifestyle, which includes, among other things, a lack of useful substances that help maintain the body’s blood supply and nourish new cells.

Therefore, when identifying diseases of this type, as an additional therapy that enhances the effect of drugs, doctors prescribe injections of B vitamins. Which vitamin to inject for back and lower back pain depends on the symptoms that have manifested and the problem that needs to be solved.

Prescribed:

• Vitamin B6 when it is necessary to support the muscle corset and improve tissue nutrition, relieve inflammation.
• Pyridoxine is prescribed for nerve root clamps, because it promotes their speedy recovery.
• B1 is used if it is necessary to normalize the work of the central and peripheral nervous system. With the help of it, the nerve fibers responsible for regulating the nutrition of body tissues are restored.
• Vitamin B12 injections for pain in the back and lower back are prescribed for damage to the nervous tissue and the risk of complete death. It helps to restore the protective shell damaged by clamps or due to an infectious disease. [4]

In addition to the vitamins of this group, osteochondrosis is also prescribed vitamin D . The range of positive effects has not yet been studied, but it reduces the feeling of numbness, relieves convulsions.

B vitamins injectable

For pain in the back and lower back, for the treatment of the spine vitamins of group B in the form of injections, tablets or drops.

Doctors consider injections to be the best option for administering the drug in case of back diseases, as it ensures that the active substances get directly to the place of the necessary impact. Depending on the factors, a course is selected from 10 to 20 injections.

Depending on the specific substance needed, add specific foods each day:

• B12 – kelp and its products, tofu soy cheese, lamb, liver and some fish.
• B1 – chicken, products containing grains, liver.

• B9 greens, avocados and bananas.
• B6 – eggs, lamb, cottage cheese, tuna, liver, cheese, nuts.

It is worth remembering that changing your diet is not a panacea. As a maintenance tool between courses of vitamin therapy, this is a way to maintain the required amount of nutrients in the body, but it cannot replace injections during an exacerbation of the disease.

It is up to the doctor to decide which vitamin injections to use for back pain, he will also tell you the name of the drug that is suitable depending on the specific features and accompanying substances. Self-administration in this case is extremely dangerous, since the wrong dosage or combination of active ingredients can bring not only benefits, but also harm during treatment.

Compatibility

The list of B vitamins for back pain and low back pain injections to relieve symptoms is wide, but choosing and using the one you like is dangerous on your own. Due to the specifics of compatibility, drugs may not work, or react with other drugs, worsening well-being.

Often, special complexes are prescribed, in which special neutralizing elements are introduced. But in most situations, several drugs are used at once. B vitamins do not combine with each other, therefore, when making appointments, the doctor will develop a treatment regimen. Injections with different medicines will be given every other day to get the benefit.

Individual vitamins of group B in severe diseases

Particular attention should be paid to the level of specific substances from the group in the body, as they benefit the body, and the lack is felt critical.

Attention is paid to vitamin B12, as it is an element of metabolic reactions in the body. It is involved in the synthesis of erythrocytes, nucleic acids, affects blood clotting. A sufficient amount is necessary for the formation and maintenance of the central and peripheral nervous system. Therefore, in case of severe diseases affecting the nervous tissues in the lower back, the course of this substance is prescribed without fail. With its deficiency, it is likely that damaged nerves will not be able to recover.

There is an opinion that tablets and injections with vitamins of the B group, in particular B12 , are the most effective remedy for back pain. But it is worth remembering that this is not the case. Such drugs are added to therapy additionally, since their main task is to enhance other drugs and maintain natural processes for the body. Such injections are an important part of therapy, but cannot replace it all.

References:

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Vitamins against pain – Internet pharmacy Dialog

For people far from medicine, the connection between B vitamins and pain is far from obvious. Vitamin deficiencies may be associated with frequent colds, hair loss, and brittle nails, but not with serious illness. However, this is far from the truth. The role of vitamins in the body is much more serious and deeper than it might seem after watching commercials. They participate in the most delicate metabolic processes, ensuring the normal functioning of the body.

Numerous studies have linked the deficiency of B vitamins, namely thiamine (vitamin B1) and pyridoxine (B6) , with serious disorders in the functioning of the nervous system, which is why these vitamins are called neurotropic. In particular, scientists have found that thiamine is involved in the regulation of protein and fat metabolism, improves nerve conduction and has an antioxidant effect, and pyridoxine helps stabilize the nervous system.

It is known that many patients with pain syndrome are deficient in B vitamins, so it is not surprising that studies have confirmed the effectiveness of the use of vitamins B1 and B6 as part of a complex therapy for back and neck pain, as well as for various neuralgia.

How does pain occur, and why can taking vitamins in combination with non-steroidal anti-inflammatory drugs (NSAIDs) help to restore physical activity faster and reduce the likelihood of recurrent pain attacks?

Let’s figure it out.

NSAIDs are the most commonly used drugs in the treatment of pain. They have anti-inflammatory, antipyretic and analgesic effects. And therefore they bring relief, but often the pain returns.

It is known that pain in the back and neck, as a rule, occurs due to damage to the sheath of nerve fibers in the spine, which disrupts the transmission of nerve impulses and causes a whole bunch of symptoms, from feeling a “knife in the ribs” to impaired mobility. And here 9 come to the rescue0003 thiamine and pyridoxine .

Vitamins B1 and B6 have an indirect analgesic effect. Vitamin B1 has a beneficial effect on the metabolism of damaged nerve roots, while pyridoxine is involved in the synthesis of neurotransmitters and increases the speed of the nerve impulse. All this, in addition to analgesic and anti-inflammatory effects, contributes to the restoration of nerve fibers.

We know that vitamins can and should be obtained from food. So is it possible to obtain the required amount of thiamine and pyridoxine through a special diet to achieve a therapeutic effect?

Unfortunately no.

The fact is that to ensure a therapeutic effect, it is necessary to take vitamins in a high dosage, which is impossible, given their content in available products. So, for example, to get the required amount, you would have to eat more than a kilogram of nuts daily, which are one of the best sources of B vitamins.

In addition, thiamine and pyridoxine are water-soluble vitamins, they are easily absorbed, and their excess immediately leaves the body with urine, without creating a reserve.

Neurotropic vitamins B1 and B6 not only help reduce pain, but also help repair damaged nerve fibers, speed up the healing process and reduce the likelihood of repeated attacks of pain. It has been proven that using B vitamins, you can reduce the dosage of NSAIDs, reduce the duration of their intake. This is important because NSAIDs can cause serious side effects in patients with gastrointestinal and cardiovascular disease.

Neurotropic vitamins are used as part of complex therapy for:

● neuralgia of various types;

● neuritis;

● neuropathy;

● osteochondrosis;

● pinched nerve;

● radiculitis;

● intervertebral hernia;

● intercostal neuralgia;

● neck pain;

● back pain.

Milgamma® compositum is a specially created neurotropic complex in tablets, which is intended for the treatment of neurological diseases, in particular, for the treatment of back and neck pain, with a deficiency of B vitamins. It helps to restore damaged nerve fibers and relieve pain, and may also help prevent relapse.

The composition of the drug in therapeutic dosages includes pyridoxine and benfotiamine – a fat-soluble compound specially developed by German scientists, which, having the properties of thiamine , is absorbed 5 times more efficiently.