For further discussion regarding these findings and related clinical implications, Clinical Pain Advisor interviewed Patricia Deuster, PhD, MPH, CNS, professor and director of the Consortium for Health and Military Performance in the department of military and emergency medicine, director of the Human Performance Resource Center at Uniformed Services University, and one of the review authors.

Clinical Pain Advisor: What are some of the reasons underlying the high rates of dietary supplement use to manage MSK pain? 

Dr Deuster: Current pain management options such as nonsteroidal anti-inflammatory drugs, injections, and physical therapy may be perceived as either ineffective or associated with multiple side effects. Dietary supplements are now being marketed as solutions to mitigate or combat MSK pain. Quick-fix claims like “Stop pain now” are advertised on products to the public. Most consumers believe that taking dietary supplements is a low-risk action, so trying them out as a way to reduce pain and/or enhance performance seems logical when other options may not seem to be available.

Clinical Pain Advisor: What were some of the most important findings from your review?

Dr Deuster: We identified several dietary ingredients that may help alleviate MSK pain with little to no risk of harmful side effects. Some of these dietary ingredients can be taken as part of a balanced diet, others as a dietary supplement, and some as a topical application, such as a cream or a patch. These include avocado soybean unsaponifiables, capsaicin, curcuma, ginger, glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D.

Other dietary ingredients have also been marketed as being effective for reducing MSK pain; however, there is insufficient reliable evidence to support such claims regarding their effectiveness and/or safety. These include boswellia, collagen, creatine, devil’s claw, l-carnitine, methylsulfonylmethane, pycnogenol, rose hip, s-adenosyl-L-methionine, vitamin E, and willow bark extract. Note that our analyses focused solely on MSK pain relief; these ingredients may be effective for other uses. Providers can read more about our analyses and recommended ingredients at https://www.hprc-online.org/articles/dietary-ingredients-to-relieve-musculoskeletal-pain and also within our recent series of papers.3-6

Clinical Pain Advisor: Based on these conclusions, what are your main recommendations for clinicians?

Dr Deuster: Supplements offered on the market and claims made on their labels may not always align with the scientific evidence regarding benefit and/or potential risks. The article mentioned above includes the body of reliable evidence, based on our in-depth analyses of the scientific literature. It highlights ingredients that may be effective for MSK pain as well as factors — including potential side effects and quality of the scientific evidence — to consider when selecting nondrug products. Clinicians can use this evidence to help patients make better informed decisions. We also recommend checking for verified/certified products at the NSF International Certified for Sports or United States Pharmacopeial Convention websites.

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Clinical Pain Advisor: What are remaining needs in this area in terms of research and education?

Dr Deuster: Our analyses identified safety reporting of dietary ingredients as the highest priority to address in future research, followed by dosing/formulation of ingredients and data on additional outcome measures. Other priority research areas include the study of specific ingredients — such as boswellia and curcuma — given their potential benefit for pain relief, as well as the nature of combinations of selected dietary ingredients that would be most beneficial with minimal adverse events. A full list of research priorities is noted in our series of papers.3-6

Education is of utmost importance. Because dietary supplements are not regulated by the US Food and Drug Administration in the same manner that drug products are, they are not evaluated for their safety or effectiveness before they reach the consumer. Manufacturers of the products are responsible for ensuring that the ingredients used are safe and that the labeling and claims made are truthful and not misleading. We offer simple tips on how to spot potential red flags on product bottles on our Operation Supplement Safety Score Card.  

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References

1. Clarke TC, Nahin RL, Barnes PM, Stussman BJ. Use of complementary health approaches for musculoskeletal pain disorders among adults: United States, 2012. Natl Health Stat Report. 2016;(98):1-12.

2. Palazzo C, Ravaud JF, Papelard A, Ravaud P, Poiraudeau S. The burden of musculoskeletal conditions. PLoS One. 2014;9(3):e90633.

3. Boyd C, Crawford C, Berry K, Deuster P; HERB Working Group. Conditional recommendations for specific dietary ingredients as an approach to chronic musculoskeletal pain: evidence-based decision aid for health care providers, participants, and policy makers. Pain Med. 2019;20(7):1430-1448.

4. Crawford C, Boyd C, Paat CF, et al. Dietary ingredients as an alternative approach for mitigating chronic musculoskeletal pain: evidence-based recommendations for practice and research in the military. Pain Med. 2019;20(6):1236-1247.

5. Crawford C, Boyd C, Berry K, Deuster P; HERB Working Group. Dietary ingredients requiring further research before evidence-based recommendations can be made for their use as an approach to mitigating pain [published online April 15, 2019]. Pain Med. doi:10.1093/pm/pnz050

6. Cota S, Williams N, Neff R, Deuster P. How evidence-based recommendations may direct policy decisions regarding appropriate selection and use of dietary ingredients for improving pain. Pain Med. 2019;20(6):1063-1065.