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America is in pain. It's estimated that 100 million of us live with chronic pain, which far exceeds the 60 million people living with cancer, heart disease, stroke or diabetes. Pain exacts a physical, psychological, emotional and often, financial toll on each victim and is an expensive public health problem. Conventional solutions available for treatment are costly, have limited efficacy, and risk serious side effects including addiction. Widely available over-the-counter (OTC) pain killers are labeled with strongly worded language listing dangers, and many of the prescription versions now carry a black box warning, the highest level of caution issued by the FDA for drugs found to have serious and/or life threatening risks. Consumers seeking safe, effective analgesic alternatives are turning to turmeric, making orange the new black for pain.
There are six FDA approved oral analgesic categories, each with specifics risks and benefits:
1. Acetaminophen, the most popular over-the-counter analgesic in the US, is effective for mild to moderate pain. It has a low margin of safety and overdose complications can easily occur beyond the recommended maximum of 4 grams/day. Risks include liver damage which can lead to death. Acetaminophen is the most common cause of acute liver failure in the US, and combining it with alcohol or drugs that are metabolized in the liver, raises the risk of toxicity. The FDA has continuously upgraded its warnings on this drug, now advising of the risk of life threatening allergic reactions and requiring black box labeling of prescription acetaminophen, which has also been limited to 325mg per dosage unit. Acetaminophen is not an anti-inflammatory agent, which limits its usefulness because inflammation mediates pain.
2. Non-aspirin non-steroidal anti-inflammatory drugs (NA-NSAIDs) block COX-1 and COX-2 enzymes, which produce prostaglandins, the chemicals that induce pain, inflammation and swelling. The maximum recommended dose of 3200mg/day should not be exceeded, and use should be limited to ten days, unless otherwise directed by a doctor. Risks include life threatening allergic reactions and gastrointestinal bleeding. In 2015, the FDA strengthened its warnings for NA-NSAIDs because they all increase the risk of heart attack and stroke, even with short term use, even in healthy people, although the risk is higher in those with pre-existing cardiovascular disease. Prescription NA-NSAIDs are black boxed, and OTC versions now must include updated cardiovascular risk information in Drug Facts labels. More Americans die annually of NA-NSAIDs complications than of AIDS.
3. Antidepressants, when used as analgesics, are not effective for acute pain because the pain benefit is not immediate. Their mechanism of action is not fully understood but it is believed they have some anti-inflammatory activity. These drugs offer moderate pain relief for chronic conditions, but on the down side, all commonly used anti-depressants carry a black box warning for suicidal thoughts or actions, with highest incidence in those below the age of 24. These drugs can lose effectiveness if tolerance develops, and many users experience significant sexual dysfunction.
4. Anti-epileptic drugs (AEDs) work best for nerve pain, conditions in which nerves are damaged (herniated disc, shingles, diabetes) or overly sensitive (fibromyalgia). All AEDs are required by the FDA to carry a label warning of an increased risk of suicidal thoughts and actions with chronic use. AEDs have been associated with weight gain, behavioral changes, confusion, drowsiness and swelling of hands and feet.
5. Opioids (narcotics) are generally second line drugs, available by prescription only, for treating moderate to severe pain that is not controlled by non-narcotics. They act by reducing pain messages received by the brain and can also produce a "high," which increases the potential for abuse. Tolerance to opioids is common, leading to a need for ever higher doses to keep pain controlled, which increases the risk of developing dependence or addiction. Common side effects include drowsiness, constipation, nausea and vomiting. Drug interactions with alcohol, sleeping pills, antihistamines and some antidepressants can be life threatening. Drug withdrawal symptoms can occur if chronic opioids are abruptly stopped. More Americans die annually from drug overdoses than in automobile accidents. CDC guidelines list non-opioid treatment as the preferred therapy for chronic pain.
6. Steroids are potent anti-inflammatory agents that are effective for all levels and types of pain from mild to severe, but limited in use due to common side effects, which are cumulative and dose related. Typical side effects include weight gain, mood and behavioral changes, muscle weakness, insomnia, and bone loss that can lead to osteoporosis. Life threatening risks include clots and gastrointestinal bleeding. Serious side effects make steroids recommended for use at the lowest dose and for the shortest time period that works. Depending on the length of use, tapering rather than stopping the drug abruptly may be required.
Black box warnings, serious and possibly life threatening side effects, drug interactions, limits on length of use, and tolerance, dependance, and addiction potential, characterize available FDA-approved treatments for pain. It's no surprise that consumers are seeking alternatives such as safe, non-toxic, tried and true remedies found in nature. Turmeric is a go-to choice for pain relief without serious side effects.
Turmeric is not FDA approved because it can't be patented, which makes it unlikely any company will invest in expensive clinical trials required for a substance to become an approved drug. Turmeric components, most notably curcumin, have achieved patent protection through strategies that include specific extraction methods, delivery systems and unique composition ratios. The GreenMedInfo database has over 2000 studies referencing the healing power of turmeric and its components. For the purposes of this post, I narrowed the field of investigation to turmeric use for osteoarthritis (OA) pain.
Arthritis is an umbrella term that includes over 100 types of joint disease associated with symptoms of joint pain, stiffness, swelling and/or reduced range of motion. It affects over 50 million Americans of all ages, women more than men, and is the leading cause of disability in the US. There is no cure for arthritis, and the pain it causes ranges from mild to severe. OA is degenerative joint disease related to injury, overuse, excess weight, the wear and tear of aging, and genetic predisposition. As the population ages, it's expected to occur more frequently and last longer.
Turmeric has been investigated for its promise to deliver effective treatment with a strong safety profile. Turmeric and its curcumin and ar-turmerone components are GRAS (generally recognized as safe), an FDA classification given when there is "reasonable certainty of no harm under intended conditions of use." For dry powdered turmeric root in diet or in supplement capsules, the recommended adult consumption is 1 - 3 grams per day. Turmeric has been used therapeutically in doses up to 8 grams daily. Side effects are mainly gastrointestinal, including stomach upset and diarrhea, and very rarely ulcers. Turmeric can lower blood pressure and blood sugar, and should be taken with caution by those who have a history of kidney stones, gall bladder disease, are on blood thinners, antacids and some other medications. Serious side effects are generally seen only at very high doses.
Turmeric has been a mainstay in the arthritis treatment toolbox since Antiquity, and its evidence-based efficacy and safety continue to be affirmed by modern, peer-reviewed laboratory, animal and human studies. Beyond being a stand-alone remedy, turmeric has been investigated for use in conjunction with FDA-approved painkillers, to lower the dose of those drugs. It is also being explored as treatment to ease narcotic drug withdrawal. Here is a summary of some very promising, recent investigations of turmeric as an anti-inflammatory and antioxidant for primary OA treatment, with links to GreenMedInfo:
-A 2016 meta-analysis of prospective, randomized clinical trials using turmeric extracts for 8 - 12 weeks to treat OA. Outcomes were evaluated with the standardized WOMAC index for pain, stiffness and function measurement, and the standardized PVAS tool to assess pain. Researchers concluded the extract improved pain, stiffness and joint function as compared to placebo, and found similar improvement in pain when compared to NA-NSAIDs ibuprofen and diclofenac.
-A 2016 review of clinical and preclinical studies using turmeric extracts, curcuminoids and enhanced curcumin, found improved quality of life in curcumin users and confirmed findings of the meta-analysis for efficacy in pain reduction and physical function. The review of laboratory studies of turmeric suggested its effect in OA results largely from curcumin's ability to stop cell death of chondrocytes, the building blocks of cartilage and healthy joints.
-A 2016 lab study of 8 natural products, including curcumin, as possible alternatives to Prednisolone (steroid) for inflammation, a key feature of OA. Multiple cellular pathways are available to fight inflammation, but most drugs target inflammation using only one or a few of the available avenues. This study looked for activity in 5 different inflammatory pathways. Curcumin was the only compound tested that showed activity against all 5 pathways, beating even the reference therapy, Prednisolone. The researchers concluded, "This broad profile is consistent with the ability of curcumin to combat numerous inflammatory diseases via multiple pathways. This makes curcumin a promising alternative for glucocorticoids (steroids) like Prednisolone."
-Multiple studies of the non-curcumin components of turmeric. Turmeric is composed of curcuminoids, turmerones (oils) and water soluble polysaccharides. Of these, curcuminoids have been the most scientifically validated, but it is known that the other components are bio-active. A 2015 study of the polysaccharide fraction of turmeric demonstrated its action as an anti-inflammatory agent, supporting a 2013 comparative analysis of the anti-inflammatory activity of all 3 components of turmeric. Another 2013 study of the polysaccharide fraction, a curcumin-free extract of turmeric, found it to be effective in treating painful knee OA. Here, the investigators focused on the ability of the polysaccharide fraction of turmeric to scavenge free radicals, acting as anti-oxidants, addressing the oxidative damage which causes cartilage deterioration typical of OA. Turmerones have also been shown to increase the absorption of curcumin, working synergistically to make the curcumin more bioavailable.
Turmeric may be the long sought "magic bullet," acting as an anti-inflammatory and anti-oxidant, selectively targeting the pain of arthritis through multiple pathways, without harming other parts of the body. Unfortunately, economic incentives drive investigators to develop patent protected treatments which generally involve breaking turmeric apart into its components or processing it by chemical extraction. For those who ascribe to the "whole being greater than the sum of its parts," dietary turmeric and/or a whole food turmeric supplement are worth exploring for their benefits in the pain and progression of osteoarthritis. Yes, turmeric makes orange the new black for pain.
For evidence-based research on the benefits of turmeric, visit the GreenMedInfo.com Research Dashboard.