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John K. Chen, PhD, PharmD, OMD, LAc
Reprinted by Permission from Acupuncture Today
Pain is a sensation of discomfort, distress, or even agony that results from stimulation (by heat, cold or pressure) of specialized nerve endings. Even though pain serves as a protective mechanism, it may cause a tremendous amount of suffering. In such cases, pain must be managed so that sufferers may resume a normal lifestyle. The goals of pain management are to decrease pain intensity and increase the patient's physical activity. The objectives of this article are to explore the advantages and disadvantages of drug and herbal therapies, and to identify the most beneficial treatment for the patient.
Western Medicine
The ideal treatment for pain is to identify and eliminate the cause. However, symptomatic pain relief is often critical and necessary, such as in cases of traumatic injuries, acute migraine, burns, pain related to cancer and surgical procedures. Analgesic medications are the first line of treatment in Western medicine. It is essential that health care practitioners be familiar with the indications for, and functions, side-effects and toxicity of, these medications.
Salicylates
Salicylates are among the oldest and most commonly used analgesics. A naturally occurring substance found in willow bark, aspirin is the original prototype for the design of modern salicylates. Aspirin's therapeutic effect lies in its ability to irreversibly inhibit cyclo-oxygenase, an enzyme responsible for the conversion of arachidonic acid to prostaglandin peroxides. Interruption of this pathway leads to aspirin's analgesic, antipyretic and anti-inflammatory actions.
Salicylates are commonly used for mild-to-moderate pain of musculoskeletal origin. Salicylate side-effects and toxicity include headache, dizziness, mental confusion, tinnitus, nausea and vomiting. More severe adverse effects include renal damage, peptic ulcer, and Reye's syndrome in infants and young children.
Para-Aminophenols
Tylenol (acetaminophen) is the most commonly used drug in this category. Similar in mechanism to aspirin, acetaminophen is a weak inhibitor of cyclo-oxygenase in the periphery and at the hypothalamic thermoregulatory center. It has antipyretic and analgesic effects, but no anti-inflammatory effect. Acetaminophen is relatively safe at normal dosages. However, it may be hepatotoxic if given to alcoholics, individuals with hepatitis, or if taken in large dosages.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
There are a wide variety of anti-inflammatory drugs, including (but not limited to): Motrin or Advil (ibuprofen); Naprosyn (naproxen); Anaprox (naproxen sodium); Indocin (indomethacin); Relafen (nabumetone) and Voltaren (dicolfenac). Ibuprofen is the most commonly dispensed NSAID in the U.S.; dicolfenac is the most commonly used world-wide.
Similar to aspirin, NSAIDs exert antipyretic, analgesic and anti-inflammatory effects by inhibiting the cyclo-oxygenase required for conversion of arachidonic acid to endoperoxide intermediates (PGG2 and PGH2). Although NSAIDs are effective for mild-to- moderate pain and inflammation, their therapeutic action is often accompanied by side-effects, the most common and severe of which include gastrointestinal disturbances, inhibition of platelet aggregation and renal damage. Other adverse effects include allergic reactions, cardiovascular effects, central nervous system problems, rash, hematological disturbances and liver damage.
Opioid Analgesics
Derived from the unripe seed capsules of the poppy plant, opioids are considered the most potent analgesics available today. Examples include MS Contin (morphine); Dilaudid (hydromorphone); Demerol (meperidine); Tylenol with codeine (acetaminophen with codeine); Vicodin (hydrocodone with acetaminophen) and Darvocet (propoxyphene with acetaminophen).
Opioid analgesics exert their actions on the central and peripheral nervous systems through binding with mu, kappa and delta receptors. Though quite effective for pain relief, opioids have numerous side-effects and toxicities, including nausea, constipation, vomiting, hypothermia, escalating tolerance levels over time, dependence, respiratory depression and unwanted sedation.
Antidepressants
Tricyclic antidepressants (TCAs) are commonly prescribed for patients with chronic or neuropathic pain that does not respond to standard analgesics. The mechanism of the analgesic effect is unknown, but there is evidence that TCAs potentiate the analgesic effects of opioids. Common side-effects include tremors, seizure, withdrawal symptoms, arrhythmia, anticholinergic effects and coma. The most commonly prescribed TCAs include Tofranil (imipramine); Elavil (amitriptyline); Sinequan (doxepin); Norpramin (desipramine); Anafranil (clomipramine) and Vivactil (protriptyline).
Serotonin-selective reuptake inhibitors (SSRI) are a newer generation of antidepressants that have fewer and less severe side-effects than TCAs. Unfortunately, they also have less potent analgesic effects. Common side-effects of SSRIs include nausea, anxiety, headache, sexual dysfunction, weight loss and insomnia. Commonly prescribed SSRIs include Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine) and Paxil (paroxetine).
Anticonvulsants
Anticonvulsants are used primarily for patients with neuropathic pain. Tegretol (carbamazepine) and Dilantin (phenytoin) are most effective for treatment of brief, shooting, and electric-shock-like pain such as trigeminal neuralgia. Possible side-effects include diplopia, dizziness, sedation, GI disturbances, decreased leukocyte count, nystagmus and ataxia.
Summary
The goal of pain management treatment is to identify and remove the cause(s) of pain so that patients can resume a normal lifestyle. Unfortunately, pharmaceutical analgesic medications prescribed for pain management often lead to unwanted side-effects and complications. Some merely address symptoms or mask or dull pain rather than addressing and resolving the cause. According to JAMA, adverse drug reactions and fatal drug reactions are now the fourth and sixth leading causes of death. As a result, patients are actively seeking other modalities of pain treatment, including (but not limited to) acupuncture, chiropractic and herbal medicine. In part II of this article, we will explore herbal counterparts to typically-prescribed medications, and detail how these formulas can be used in case management. Traditional Chinese Medicine
According to traditional Chinese medicine (TCM), the fundamental etiology of pain is qi stagnation, blood stagnation, or both. It is often said that where there is pain, there is stagnation; where there is stagnation, there is pain. Therefore, effective pain relief most often requires the use of herbs that activate qi and blood, removing stagnation and thus resolving the cause of pain. As is true in all treatment involving Chinese medicinal herbs, they are most commonly prescribed in carefully-combined formulas (rather than singly) that directly address the causes and/or symptoms of the imbalance and treat without creating unwanted side-effects or complications.
In addition to treating qi and blood stagnation, successful treatment of pain also requires careful differential diagnosis of pain. The three main diagnostic keys are the location of the discomfort, the type of pain and the cause of pain. Location refers to the exact part of the body that is affected: upper body, lower body, external musculoskeletal muscle, internal smooth muscle and so on. The type of pain refers to the characteristics of the patient's pain, such as a sharp, stabbing pain or dull aching, pain at a fixed location as opposed to migratory pain, pain helped by cold or by heat, and other distinguishing characteristics. Lastly, identifying the cause of pain helps the practitioner differentiate soft tissue injuries from structural damage. For example, leg spasms and cramps often involve only soft tissue, while an acute sprained ankle is often accompanied by structural damage. Accurate evaluation of these three criteria is crucial for greatly enhanced diagnostic accuracy and successful relief for the patient.
Herbal Treatment for Headache
Headache pain may arise from internal or external causes such as invasion of wind, cold, heat, dampness, dryness, summer heat, accumulation of phlegm, and other pathogens in addition to qi and blood stagnation. Headache pain may represent excess or deficient conditions and may affect the occiput, vertex, sinuses and orbital region. It may also present with a complex of locations/symptoms, such as in migraine.
Corydalis (yan hu suo) is one of the strongest herbs available to relieve pain and reduce inflammation. Research studies have shown it to work directly on the central nervous system with analgesic effects comparable to those of morphine and codeine.1,2 Another herb, pueraria root (ge gen), has demonstrated remarkable effectiveness in relieving headache pain.3,4,5 Other herbs have proved effective in relieving various types of headaches, including (but not limited to) migraine, vertex, sinus and orbital headache.6,7,8
Many classical Chinese herbal formulas are also commonly used to treat headache. Cnidium & tea formula (chuan xiong cha tiao san) treats headaches due to wind cold. Evodia combination (wu zhu yu tang) relieves vertex headache due to cold and is also used to treat migraine. Coptis, phellodendron & mint formula (huang lian shang qing wan) addresses headache caused by heat. Notopterygium & tuhuo combination (qiang huo sheng shi tang) treats headache due to wind and dampness. Gastrodia & gambir combination (tian ma gou teng yin) relieves headache secondary to liver yang rising. Eucommia & rehmannia formula (you gui wan) tonifies kidney deficiency to relieve headache. Tangkuei & ginseng eight combination (ba zhen tang) tonifies qi and blood deficiency to relieve headache. Pinellia & gastrodia combination (ban xia bai zhu tian ma tang) relieves headache due to phlegm stagnation.
Herbal Treatment for Neck and Shoulder Pain
Neck and shoulder injuries can be divided into two major categories: acute and chronic. Acute injuries are generally characterized by redness, swelling, inflammation and sharp pain. Chronic injuries are generally characterized by stiffness, numbness, discomfort and dull pain.
Acute neck and shoulder problems are often caused by accidents, whiplash, improper sleeping or reading postures, and similar traumas. In addition to pain, redness, swelling and/or inflammation are sometimes present. Treatment consists of reducing pain, swelling and muscle spasms. Herbal formulas are designed to dispel painful symptoms while supporting the healing process. Strong analgesic herbs like corydalis (yan hu suo) are combined with anti-spasmodic herbs and blood-invigorating herbs to alleviate pain, promote blood circulation and open the meridian channels.
Chronic neck and shoulder problems are characterized by pain, numbness, stiffness, discomfort, limited mobility, slow recovery or continuing deterioration. Effective treatment must focus on activating qi and blood circulation, opening the channels and collaterals, and nourishing the muscles and tendons.
Corydalis is a main herb in the treatment of both acute and chronic neck and shoulder problems. In addition to having strong analgesic properties, it also has a distinctive facility for treating both acute and chronic cases of inflammation.9 Corydalis also protects against NSAID-induced gastric and duodenal ulcers by reducing gastric acid secretion.10
Classical formulas that treat neck and shoulder pain include the following specific applications. Lindera formula (wu yao shun qi san) is formulated for shoulder pain, while pueraria combination (ge gen tang) is more specific for stiff neck due to cold. Atractylodes & arisaema combination (er zhu tang) relieves deficient-type neck and shoulder disorders but may not have strong analgesic effects.
Herbal Treatment for Back Pain
Similar to neck and shoulder pain, back pain can be divided into two major categories: acute and chronic, with many of the key symptoms described in the categories above.
Many classic formulas tonify the kidney to relieve back pain and weakness. Tuhuo & loranthus combination (du huo ji sheng tang) eliminates wind and dampness and has a rapid onset to relieve acute back pain. Herbal formulas that tonify the kidney tend to be slower in action and are more suitable for chronic back pain. Cyathula & rehmannia formula (zuo gui wan) is more specific to address kidney yin deficiency; eucommia & rehmannia formula (you gui wan) focuses more specifically on kidney yang deficiency; and rehmannia eight formula (ba wei di huang wan) tonifies both kidney yin and yang.
Herbal Treatment for Musculoskeletal Pain and Painful Obstruction (Bi) Syndrome
Musculoskeletal pain is often classified as painful obstruction (bi) syndrome. Though there are many causes of this syndrome, cold and heat are the most common etiologies. Cold-type musculoskeletal pain is characterized by stiffness, pain and limited range of motion of the joints. In Western terms, cold conditions are associated with chronic arthritis and arthralgias such as osteoarthritis and fibromyalgia.
Heat-type musculoskeletal pain is characterized by redness, swelling, pain and/or inflammation of the muscles and joints. Patients typically present with muscle cramping and spasms. From a Western perspective, these patients have acute musculoskeletal disorders, typically involving inflammation of the muscles, bursae, tendons and ligaments.
Gentiana macrophylla root (qin jiao), a popular ingredient in some remedies, has been shown to have anti-inflammatory activities comparable to those of aspirin (salicylic acid).4 Aconite tsao wu (cao wu) and aconite wu tou (chuan wu) Other herbs have demonstrated exceptional anti-rheumatic, anti-inflammatory, analgesic and anti-pyretic functions.13,14
White peony (bai shao) and licorice (gan cao) have demonstrated remarkable properties in relieving spasms, cramps and pain of skeletal and smooth muscles. Clinical applications include dysmenorrhea,3 musculoskeletal disorders,15 trigeminal pain,16 muscle spasms and twitching in the facial region,17 pain in the lower back and legs,18 abdominal pain and cramps due to intestinal parasites,19 and epigastric and abdominal pain.20
If there are complications to the musculoskeletal disorders described above, classical formulas offer treatment options for the patients. Cinnamon & anemarrhena combination (gui zhi shao yao zhi mu tang) treats musculoskeletal and joint pain due to wind heat. Cyathula & plantago formula (ji sheng shen qi wan) treats musculoskeletal and joint pain arising from cold. Coix combination (yi yi ren tang) treats musculoskeletal and joint pain caused by dampness. Tuhuo & astragalus combination (san bi tang) treats musculoskeletal and joint pain due to deficiency of qi and blood and weakness of the liver and kidney. If the etiology is unclear, notopterygium & turmeric combination (juan bi tang) may be used for relief of general musculoskeletal and joint pain.
Herbal Treatment for Traumatic Injury
Traumatic injury is characterized by severe qi and blood stagnation. Types of injuries include bruises, contusions, sprains, broken bones, surgical incisions and related internal trauma, and other physical traumas.
For complications of traumatic injury, cinnamon & hoelen formula (gui zhi fu ling wan) is used to treat internal bleeding after traumatic or sports injuries; persica & rhubarb combination (tao ren cheng qi tang) is used to treat subcutaneous bleeding with severe swelling and pain.
Conclusion
Pain is universally understood as a signal of disease and is the most common symptom that brings a patient to a physician.21 Western clinical medicine and traditional Oriental medicine share common goals of alleviating pain and eliminating the causes of pain; however, the philosophy and clinical approach to pain management in the two disciplines is very different. Generally speaking, Western drugs have immediate and reliable analgesic effects. Unfortunately, Western pharmaceuticals often cause serious short- and long-term side-effects. In addition, the chronic use of drugs, especially opioid analgesics, is strongly associated with addiction and negative social consequences and connotations. As a result, more and more patients are turning to herbal medicine as their primary, complementary or alternative treatment for pain.
Herbal medicines definitely have outstanding analgesic, anti-inflammatory and anti-spasmodic functions and benefits. However, even though herbs and pharmaceutical drugs have many overlapping functions, they are not directly interchangeable or analogs of each other. The therapeutic effectiveness of herbal formulas is dependent on accurate diagnosis and careful prescription. When used properly, herbs are powerful alternatives to drugs for pain management.
References
- Pharmacology and Applications of Chinese Herbs 1983; 447.
- Zhu XZ. Development of natural products as drugs acting on central nervous system. Memorias do Instituto Oswaldo Cruz 86 (2):173-5, 191.
- Bensky D, et al. Chinese Herbal Medicine Materia Medica. Eastland Press 1993.
- Yeung HC. Handbook of Chinese Herbs. Institute of Chinese Medicine, 1983.
- Gao XX, et al. Effectiveness of pueraria root (ge gen) in treating migraine headache: a case report of 53 patients. Journal of TCM Internal Medicine (Zhong Hua Nei Ke Za Zi) 1977;6:326.
- Effectiveness of angelica (bai zhi) in treating occipital headache: a report of 73 cases. Air Force hospital in Hengyang, China. Modern Medical Journal (Xin Zhong Yi) 1976;3:128.
- Effectiveness of angelica (bai zhi) in treating chronic headache: a report of 62 cases. National Defense Hospital. Journal of Modern Medicine (Xin Yi Xue Yao Za Zi) 1976;8:35.
- Wang LS. Treatment of headache using xiong zhi shi gao tang: 50 cases. Shanxi Journal of Traditional Chinese Medicine 1985;10:447.
- Kubo M, et al. Anti-inflammatory activities of methanolic extract and alkaloidal components from corydalis tuber. Biol Pharm Bull February 1994;17(2):262-5.
- Study of Chinese Herbal Medicine 1976; p. 340.
- Military Hospital Unit #64. Effectiveness of aconite wu tou (chuan wu) in treating low back pain, a report with 225 patients. New Journal of Medicine and Pharmacology 1975;4:45.
- Zhang HT, et al. Treatment of frozen shoulders with aconite wu tou (chuan wu) and camphor (zhang nao). Shanghai Journal of Medicine and Pharmacology 1987;1:29.
- Liao JF. Evaluation with receptor binding assay on the water extracts of ten CNS-active Chinese herbal drugs. Proceedings of the National Science Council, Republic of China. Part B, Life Sciences. July 1995;19(3):151-8.
- Sun DH. Treatment of heat type of painful obstruction (Bi) syndrome with stephania (fang ji) in 120 patients. Shangdong Journal of Traditional Chinese Medicine 1987;6:21.
- Tan H, et al. Chemical components of decoction of radix paeoniae and radix glycyrrhizae. China Journal of Chinese Materia Medica Sep 1995;20(9):550-1, 576.
- Huang DD. Journal of Traditional Chinese Medicine 1983;11:9.
- Luo DP. Hunan Journal of Traditional Chinese Medicine 1989;2:7.
- Chen H. Yunnan Journal of Traditional Chinese Medicine 1990;4:15.
- Zhang RB. Jiangxu Journal of Traditional Chinese Medicine 1966;5:38-39.
- You JH. Guanxi Journal of Chinese Herbology 1987;5:5-6.
- Harrison TR, et al. Harrison's Principles of Internal Medicine, 14th edition, 1998.
1. Kalant H, Roschlau WH. Principles of Medical Pharmacology, 6th ed., 1998.
2. Gilman A, et al. Goodman and Gilman's The Pharmacological Basis of Therapeutics, 1990.
3. Harrison TR, et al. Harrison's Principles of Internal Medicine, 14th ed., 1998.
4. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA April 15, 1998. John K. Chen, PhD, PharmD, OMD, LAc La Puente, California
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