Nutraceuticals: potential roles and potential risks for pain management

N-of-1 Randomized Trials of Ultra-Micronized Palmitoylethanolamide in Older Patients with Chronic Pain

BACKGROUND

Ultra-micronized palmitoylethanolamide (um-PEA) represents an attractive option for chronic pain control in complex older patients at higher risk of adverse effects with traditional analgesics.

OBJECTIVE

The aim of this study was to determine the effectiveness of um-PEA versus placebo on chronic pain intensity and function in individual geriatric patients.

DESIGN

We performed randomized, blinded N-of-1 trials with two 3-week um-PEA versus placebo comparisons, separated by 2-week washout periods.

PARTICIPANTS

The study included outpatients aged ≥ 65 years with chronic, non-cancer, non-ischemic pain in the back, joints, or limbs.

INTERVENTION

Patients were randomized to Um-PEA 600 mg or placebo twice daily.

MEASUREMENTS

Pain intensity was measured using an 11-point visual numeric scale. Functional impairment was measured using a Back Pain Functional Scale. Impact of each N-of-1 trial was measured on the clinician's intention to treat and confidence.

RESULTS

Ten of 11 eligible patients consented over 7 months [all female, mean age 83.2 years (SD 4.6)]. Three patients interrupted the trial: one had diarrhea (under placebo), one for low adherence, and one for intercurrent pneumonia. A small statistically significant effect in favor of um-PEA was seen at the mixed method analyses in two patients (effect size equal to 8% of the baseline pain). A statistically significant impact on function was found in one patient. After the trial, um-PEA was prescribed to four patients; in two patients the clinician changed their pre-trial intention to treat; the clinician confidence in the treatment plan either increased (5) or remained the same (2).

CONCLUSIONS

Our experience confirmed that N-of-1 trials may help make personalized evidence-based decisions in complex older patients, with special feasibility considerations. CLINICALTRIALS.GOV: NCT02699281.

Complementary therapies for cancer pain

Pharmacologic treatment of pain does not always meet patients' needs and may produce difficult side effects. Complementary therapies, which are safe, noninvasive, and generally considered to be relatively free of toxicity, may be used adjunctively with standard pain management techniques to improve outcome and reduce the need for prescription medication. Approaches such as acupuncture, massage therapy, mind-body interventions, and music therapy effectively reduce pain, enhance quality of life, and provide patients with the opportunity to participate in their own care. Such therapies have an important role in modern pain management.

Perioperative anesthesia clinical considerations of alternative medicines

The presence of nutraceutical agents in the United States health care system dictates the need for a general understanding of these agents by all physicians and health care providers. Increasing trend toward reimbursement of herbal medicines by the insurance companies and managed care organizations have further encouraged their use. Because herbs are listed under the "supplement" category by the Food and Drug Administration, the Dietary Supplement and Health Education Act establishes no protocol for standardization of the products labeled as "supplements" thereby increasing the risk for adverse effects associated with the use of these products. Moreover, there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded safety and efficacy trials on these drugs. Reports indicate that within the last 2 decades,more than 100 herbogenic deaths have occurred [100]. Many serious complications have been reported, including renal failure and need for renal or hepatic transplantation after taking nutraceuticals [101-107]. The anesthesiologists should have a detailed knowledge and understanding of the potential risks and purported benefits of herbal medicines and should thoroughly inquire about patient's use of herbal products [108- 11 ]. In addition,the education of each patient regarding the serious, potential drug-herb inter-actions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA), suggests that all herbal medications should be discontinued 2 to 3 weeks before an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he or she should be urged to bring the container so that the anesthesiologist can review the contents of the herb or preparation. Although this idea holds some promise in the elective-care settings, anesthetic care in emergency settings should be based on a thorough drug-intake history from the patient or a relative, if possible.Unfortunately, the anesthesia literature has not addressed this new group of health supplements, despite many of these drugs having the potential to cause serious health problems and drug-herb interactions. There is a need to conduct additional scientific clinical trials to study the anesthetic responses to commonly used nutraceutical agents.