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Opioid Alternatives for Chronic Pain

Nearly 1 in 10 American adults experience chronic pain;1 that’s more than 25 million adults reporting pain every day for three months.1 In this population, primary causes of pain include: severe headache or migraine and problems of the lower back, neck, knees, shoulders, fingers, and hips.2 Worldwide, in 2015, more than 1.5 billion people suffered from chronic pain, and approximately 3–4.5% of the global population suffered from neuropathic pain.1

“For millions of people across the globe, excruciating pain is an inescapable reality of life,” writes Allyn L. Taylor, in a 2007 article published in The Journal of Law, Medicine & Ethics.3 Does it have to be this way?

Learn more at IFM’s Applying Functional Medicine In Clinical Practice (AFMCP), where experienced Functional Medicine clinicians detail practical tools for patients with diseases like chronic pain >

For centuries, opioids have been an accepted therapy for pain patients; a 2005 Medicaid study showed that more than 50% of opioid prescriptions were for doses higher than 90 MME (morphine milligram equivalents) and for periods of more than six months.4 However, research shows that the extended prescription of opioids (>8 weeks) for the treatment of chronic pain has questionable benefits.5,6 Obesity, deficient nutrient intake, and poor eating behavior were highly prevalent in a 2014 sample of chronic pain patients who underwent long-term opioid therapy.7 And yet, in 2014 alone, US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers; of these prescriptions, 65% were for short-term therapy (<3 weeks),6 but 3­–4% of the adult population (9.6–11.5 million persons) were prescribed longer-term opioid therapy.4

Millions of Americans are dependent on or abuse prescription opioids, and legislators have begun restricting ease of access to prevent misuse. On the heels of this opioid epidemic, chronic pain patients have begun seeking non-pharmaceutical treatments and opioid alternatives. The Functional Medicine model provides some guidance to clinicians looking to treat pain patients with opioid alternatives, through modifiable lifestyle factors like diet. In the following video, IFM educator Bette Bischoff, MD, RD, talks about how diet can influence chronic pain outcomes:

IFM educator Bette Bischoff, MD, RD, is a diplomate of the American Board of Internal Medicine, a registered dietitian, and a certified diabetes educator. She lectures nationally in academic settings.

There is increasing evidence that diet can contribute to systemic inflammation,8 and pain is commonly interpreted as a marker of inflammation.9 The most explored dietary triggers for chronic pain include cow’s milk antigens (a-lactalbumin, B-lactoglobulin, casein), wheat and wheat gluten, eggs, and soy proteins.8

A 2015 review in Clinical and Experimental Rheumatology found that among non-pharmacological treatments for chronic pain, nutrition is a promising tool for fibromyalgia syndrome patients.11 In fibromyalgia patients with celiac disease, more than one-third of patients who removed gluten from their diet were able to discontinue opioid therapy for chronic pain.10 Because food intolerances and allergies can be challenging to diagnose, and testing for these disorders is variable in terms of sensitivity and specificity, many researchers believe that elimination diets are the gold standard for diagnosis of food reactions.12,13,14 Encouragement of wholesome eating is an essential part of treatment management, while also investigating possible immune reactivity to food in patients with inflammation and pain.15,16,17

Dietary markers, including low fruit and vegetable consumption, have been identified for inflammatory arthritis.16 The journal Rheumatology published a study that found a gluten-free, vegan diet improved the signs and symptoms of rheumatoid arthritis (RA).8 A raw vegan diet, rich in antioxidants and fiber, was shown in another study to decrease joint stiffness and pain in patients with RA.18 In chronic pain patients with central sensitization, including those with whiplash, temporomandibular disorders, lower back pain, osteoarthritis, and fibromyalgia, among others, a study found that the ketogenic diet may diminish the hyperexcitability of the central nervous system.19

In patients with interstitial cystitis/bladder pain syndrome, nearly 90% report sensitivities to a variety of foods.20 Questionnaire-based literature suggests that citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods may exacerbate symptoms, while calcium glycerophosphate and sodium bicarbonate may improve symptoms. This suggests that a controlled method to determine dietary sensitivities, such as an elimination diet, may play an important role in patient management.20

Research into the role of nutrition in modulating chronic pain continues to accrete.21 How can nutritional assessment and counseling be integrated into your protocol for treating pain patients?

Learn More or Register to Applying Functional Medicine in Clinical Practice (AFMCP)

IFM’s 2019 Annual Conference explored the intersection between stress, pain, and addiction. view proceedings information

References

  1. National Center for Complementary and Integrative Health. NIH analysis shows Americans are in pain. National Institutes of Health. https://nccih.nih.gov/news/press/08112015. Published August 11, 2015. Accessed June 28, 2018.
  2. AAPM facts and figures on pain. American Academy of Pain Medicine. http://www.painmed.org/patientcenter/facts_on_pain.aspx#refer. Accessed June 28, 2018.
  3. Taylor AL. Addressing the global tragedy of needless pain: rethinking the United Nations single convention on narcotic drugs. J Law Med Ethics. 2007;35(4):556-570. doi:10.1111/j.1748-720X.2007.00180.x.
  4. Volkow ND, McLellan AT. Opioid abuse in chronic pain – misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253-1263. doi:10.1056/NEJMra1507771.
  5. Chou R, Deyo R, Devine B, et al. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain: Evidence Reports/Technology Assessments, No. 218. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
  6. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899.
  7. Meleger AL, Froude CK, Walker J. Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy. PM R. 2014;6(1):7-12.e1. doi:10.1016/j.pmrj.2013.08.597.
  8. Hafström I, Ringertz B, Spångberg A, et al. A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology. 2001;40(10):1175-1179. doi:10.1093/rheumatology/40.10.1175.
  9. Lee YC. Effect and treatment of chronic pain in inflammatory arthritis. Curr Rheumatol Rep. 2013;15(1):300. doi:10.1007/s11926-012-0300-4.
  10. Isasi C, Colmenero I, Casco F, et al. Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int. 2014;34(11):1607-1612. doi:10.1007/s00296-014-2990-6.
  11. Rossi A, Di Lollo AC, Guzzo MP, et al. Fibromyalgia and nutrition: what news? Clin Exp Rheumatol. 2015;33(1 Suppl 88):S117-125.
  12. Wood RA. Diagnostic elimination diets and oral food provocation. Chem Immunol Allergy. 2015;101:87-95. doi:10.1159/000371680.
  13. Dupont C. Diagnosis of cow’s milk allergy in children: determining the gold standard? Expert Rev Clin Immunol. 2014;10(2):257-267. doi:10.1586/1744666X.2014.874946.
  14. Ballmer-Weber BK. Value of allergy tests for the diagnosis of food allergy. Dig Dis. 2014;32(1-2):84-88. doi:10.1159/000357077.
  15. Seaman DR. The diet-induced proinflammatory state: a cause of chronic pain and other degenerative diseases? J Manipulative Physiol Ther. 2002;25(3):168-179.
  16. Vandenkerkhof EG, Macdonald HM, Jones GT, Power C, Macfarlane GJ. Diet, lifestyle and chronic widespread pain: results from the 1958 British Birth Cohort Study. Pain Res Manag. 2011;16(2):87-92.
  17. Totsch SK, Waite ME, Sorge RE. Dietary influence on pain via the immune system. Prog Mol Biol Transl Sci. 2015;131:435-469. doi:10.1016/bs.pmbts.2014.11.013.
  18. Hänninen O, Kaartinen K, Rauma AL, et al. Antioxidants in vegan diet and rheumatic disorders. Toxicology. 2000;155(1-3):45-53. doi:10.1016/S0300-483X(00)00276-6.
  19. Nijs J, Malifliet A, Ickmans K, Baert I, Meeus M. Treatment of central sensitization in patients with ‘unexplained’ chronic pain: an update. Expert Opin Pharmacother. 2014;15(12):1671-1683. doi:10.1517/14656566.2014.925446.
  20. Friedlander JI, Shorter B, Moldwin RM. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU Int. 2012;109(11):1584-1591. doi:10.1111/j.1464-410X.2011.10860.x.
  21. De Gregori M, Muscoli C, Schatman ME, et al. Combining pain therapy with lifestyle: the role of personalized nutrition and nutritional supplements according to the SIMPAR Feed Your Destiny approach. J Pain Res. 2016;9:1179-1189. doi:10.2147/JPR.S115068.

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