Book Notes: Pain Free 1-2-3

Chapter 2: Giving Your Body What It Needs to Heal Your Pain

In this section:

• Optimizing Nutritional Support
• Sleep: The Foundation of Pain Relief
• Treating Hormonal Deficiencies

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Optimizing Nutritional Support

Iron Deficiency and Excess

Although only checking an iron level is not useful by itself, dividing the iron level by the TIBC gives you a percent saturation, which is a useful measure. The ferritin blood level will often discover iron deficiency earlier, but is not reliable if inflammation is present. Combining these three tests is the best way to measure iron status. Some insurance companies balk at paying for all three tests, but they are worth doing. Even if a person’s iron percent saturation is low but still normal, that person will often feel fatigued and in pain, despite not being anemic. Significant iron deficiency can often occur in the absence of anemia.

As an example, a study reported in the British medical journal The Lancet showed that infertile females whose ferritin levels were between 20 and 40—a ferritin level over 9 is technically normal—were often able to become pregnant when they took supplemental iron.²⁰ Other research shows that low-normal iron levels cause poor mental functioning and poor immune function. This suggests that levels considered sufficient to prevent anemia are often inadequate for other body functions. Because of this, anyone whose ferritin level is below 40, or whose percent saturation is less than 22 percent, should be given a trial treatment of iron therapy. In addition, a surprisingly large number of people display early hemochromatosis on their iron studies. Hemochromatosis is a disease of excess iron. Early in the disease, pain and arthritis are often the only symptoms. If caught early, hemochromatosis is remarkably easy to treat. If caught late, however, it is disabling and even life-threatening. This is an additional reason to check the iron level carefully.

Vitamin B12 Deficiency

If a patient’s B12 level is under 540 pg/mL, I treat that person with a 1-cc (1,000 to 3,000 microgram) injection of Vitamin B12, one to five times a week, for fifteen injections. These shots are very safe and fairly inexpensive. Although most regular pharmacies carry only the 1,000-microgram-per-cc strength, holistic pharmacies (Cape Apothecary is an excellent one that can mail prescriptions worldwide—see Appendix C: Resources) can make up injectable vitamin B12 that contains 3,000 to 5,000 micrograms per cc. Usually, if a patient is going to benefit from the shots, I see improvement by ten weeks. I usually stop after ten to fifteen shots. If a patient feels worse when the injections are stopped, I resume giving the shots, usually giving one every one to five weeks (but as often as three to four times a week in some cases) for an extended period of time.

Magnesium Deficiency

Almost everyone with pain should take magnesium. An exception is if you have kidney failure with a blood test creatinine level over 1.7 mg per deciliter (mg/dL), which is rare in chronic pain patients. If your creatinine is 1.5 to 1.6 mg/dL, take just 150 mg of magnesium a day for two to three months and discuss your dosage and regimen with your physician.

Magnesium absorption is very difficult, which is why I like to use the glycinate form. Plain magnesium oxide is also available and is the most inexpensive form of magnesium, but your body may not absorb it well. If you choose to take magnesium oxide, take 500 mg per day.

In addition to helping muscle pain when taken by mouth or intravenously, intravenous (and often oral) magnesium has other benefits as well. Two grams of intravenous magnesium given over a few minutes will routinely knock out an acute migraine. In addition, it is very good for esophageal spasms when given twice a week for about a month. For those with spasm of the fingertips (Raynaud’s phenomenon—if your fingers turn white and painful when you put them in the freezer), muscle cramps, decreased circulation in the legs with pain, and walking and/or kidney stone pain, magnesium can also be very helpful. As one example, research suggests that oral magnesium and Vitamin B6 decrease the frequency of recurrent calcium kidney stones by 90 percent.²⁶

Vitamin D Deficiency

Researchers noted that it was a big surprise that the worst vitamin D deficiencies occurred in young people—especially women of childbearing age. In addition, all the African Americans, Hispanics, and Native Americans who participated in one pain study were vitamin D deficient, as were all of the patients under the age of 30. Dr. Plotnikoff notes that “the message here is that unexplained pain may very well be linked to vitamin D deficiency. My hope is that patients with unexplained pain will be tested for vitamin D status and treated if necessary.” ²⁸ I prefer to simply recommend 600 units of vitamin D instead of spending several hundred dollars on blood testing.

Although the RDA (which I feel is often inadequate) for vitamin D is 200 to 400 IU/day for most people, Dr. Holick believes that most people need approximately 1000 IU of vitamin D daily. It is not easy to get this from food alone. For example, one glass of fortified milk or orange juice has approximately 100 units of vitamin D and most multivitamins have 400 units or less.

To put it in perspective, a light skinned person wearing a swimsuit at the beach will get about 20,000 units of vitamin D in the time it takes his or her skin to get lightly pink. It is difficult during the winter for people living in northern climates to get the vitamin D that they need from the sun. During the summer at the beach however, you can get what you need in five minutes.²⁹ Another fringe benefit is that in one study, those taking over 400 units of vitamin D a day had a 40 percent lower risk of developing multiple sclerosis than those who were not taking supplementation.³⁰

Sleep: The Foundation of Pain Relief

In animal studies conducted by Carol Everson, Ph.D. at the University of Tennessee, sleep deprivation resulted in immune suppression, resulting in multiple infections (including yeast overgrowth in the gut).² Many other abnormalities also occurred because of the sleep disorder. These same processes seem to occur in people with fibromyalgia pain.³

Sleep has a distinct architecture with five key stages. Stages 1 and 2 sleep are fairly light, while stages 3 and 4 (or delta wave) sleep are the deeper stages of sleep. My experience, and that of many other clinicians, suggests that what is deficient in fibromyalgia and likely in many pain patients are the deeper, restorative stages of sleep (stages 3 and 4). These are the stages where you produce growth hormone, which results in tissue repair and healing. Unfortunately, most sleeping pills in common use keep people in light stage 2 sleep, which can actually make their problem worse. The good news is that there are a number of exceptions.

Several studies have shown that if you continually wake up people whenever they go into deep sleep, or even shake them lightly so that they go from deep sleep into light sleep, they will develop pain within one to two weeks and often within one night.^{4, 5}

In fact, inadequate sleep has repeatedly been shown to contribute to pain. In one study of fibromyalgia patients, it was found that increased pain sensitivity is associated with greater sleep disturbance⁶. Another study of female office employees in one large company showed that women who suffer from frequent muscle pain also have insufficient sleep.⁷ Another study by Dr. Moldofsky, a respected researcher on sleep in fibromyalgia, found that things that disrupted deep sleep resulted in normally healthy people waking feeling unrefreshed, with widespread muscle pain, tenderness, and fatigue. He concluded that “there is a reciprocal relationship between sleep quality and pain.”⁸ In another study of 105 fibromyalgia patients, it was also found that sleep quality was important in mediating pain and fatigue.⁹

Other sleep aids include:

1. Alprazolam (Xanax®). This is a short-acting cousin of Valium® that gives a good three to five hours of sleep with less hangover in the morning. I was pleasantly surprised to find that it improves sleep quality, because it is a cousin to Valium, which usually seems to worsen this in most people. It is very good for anxiety as well, and tends to be very well tolerated. It can be addictive however. The usual dosage is ½ to four 0.5-mg tablets at bedtime or during the night.

2. Xyrem® (GHB). This is an excellent (and possibly the best) sleep medication for pain and fibromyalgia. Because the DEA claimed (many suspect mistakenly) that it was being used as a date rape drug, it has gone from being inexpensive and over-the-counter to being tightly regulated and costing approximately $500 a month. If all else fails, this often works very well. It comes as a liquid that can dissolve your enamel and damage your teeth, so be sure to rinse your mouth well and swallow after taking the liquid to prevent this. Physicians must fill out special forms when prescribing Xyrem.

Treating Hormonal Deficiencies

Thyroid

The thyroid makes two primary hormones, including Thyroxine (T₄), which is the storage (inactive) form of thyroid hormone. The body uses it to make triiodothyronine (T₃), which is the active form of thyroid hormone. Most synthetic thyroid medications, such as Synthroid and Levothroid, are pure T₄. These synthetics are fine if the body has the ability to properly turn them into T₃. Unfortunately, many patients find that their bodies do not have this ability. Fortunately, natural thyroid hormone preparations, such as Armour Thyroid®, do contain active T3 as well as the T4.

The Problem with Thyroid Tests

Modern medicine has gone through many generations of thyroid tests, and with each new test, we found that we missed an enormous number of cases of hypothyroidism. To make matters more difficult, if the thyroid is under-active because the hypothalamus is suppressed (as is common in chronic pain), the TSH test, which is the test most often used, may appear to be normal, or even suggest an overactive thyroid.

In two studies done by Dr. G.R. Skinner and his associates in the United Kingdom, patients who were felt to have hypothyroidism (an under-active thyroid), because of their symptoms (including pain), had their blood levels of thyroid hormone checked. The vast majority of subjects had technically normal thyroid blood tests. This data was published in the British Medical Journal.¹ Since that time, Dr. Skinner has done another study in which the patients with normal blood tests who had symptoms of an underactive thyroid—those who your doctor would likely say had a normal thyroid and would not need treatment—were treated with thyroid hormone. A remarkable thing happened-well, maybe it wasn’t that surprising! The large majority of patients, despite being considered to have a normal thyroid, had their symptoms improve upon taking thyroid hormone (Synthroid®), at an average dosage of 100 to 120 micrograms a day. ²

These two studies, plus another, which indicated that thyroid blood tests are only low in about 3 percent of patients whose doctors sent in blood tests (and this is at an HMO where the doctor really suspected that the patient had thyroid problems), confirm what I have been saying all along.³ Unfortunately, our current thyroid testing will miss most patients with an under-active thyroid. Once again, doctors of decades ago were on target when they knew that one has to treat the patient and not the blood test. In fact, in November 2002 the American Academy of Clinical Endocrinologists again changed the normal range on the TSH thyroid blood test (so that a TSH over 3 warranted treatment), increasing the number of patients with hypothyroidism in the United States from 13 to 26 million. Less than a quarter of these patients have been properly diagnosed and treated.

I have found—either through blood testing or according to symptoms—that over 47 percent of my fibromyalgia patients have a low thyroid and that 83 percent of these patients have improved by taking a low dose of thyroid hormone.⁹ In another study, 152 women were evaluated who had symptoms of an under-active thyroid despite normal blood tests. In the first phase of the study, 49 women were given a high-protein, low carbohydrate diet that eliminated sugar, wheat and dairy for one month. This group experienced an 18 percent decrease in joint pain and a 14 percent decrease in muscle pain, combined with a 21 percent decrease in fatigue. All 152 patients were then given 22 days of thyroid therapy using T3, the active form of thyroid hormone. They were given 7 ½ micrograms twice a day, slowly increased to 37 ½ micrograms twice a day and then tapered off. After 22 days, all of their symptoms decreased by an average of 39 percent. One week later, they were switched to Armour Thyroid 60 mg twice a day for 3 more months. Fatigue decreased by 60 percent, headaches by 63 percent, depression by 73 percent, insomnia by 69 percent, joint pain by 58 percent, and muscle pain by 58 percent.¹⁰

Do You Feel That Doctors Missing Hypothyroidism Is a Major Problem?

Absolutely! To give you an idea of its importance, let’s look at the situation further.

Hypothyroidism, like most other illnesses that affect predominantly women, has been dramatically under-diagnosed. ^{2, 3} As noted above, the American Academy of Clinical Endocrinologists (AACE), the nation’s largest organization of thyroid specialists, has now confirmed this. After a 2002 meeting, the normal range for thyroid tests was dramatically narrowed. As noted in the AACE press release:

“Until November 2002, doctors had relied on a normal TSH level ranging from 0.5 to 5.0 to diagnose and treat patients with a thyroid disorder who tested outside the boundaries of that range. Now the AACE encourages doctors to consider treatment for patients who test outside the boundaries of a narrower margin based on a target TSH level of 0.3 to 3.0. AACE believes the new range will result in proper diagnosis for millions of Americans who suffer from a mild thyroid disorder, but have gone untreated until now.

“The prevalence of undiagnosed thyroid disease in the United States is shockingly high—particularly since it is a condition that is easy to diagnose and treat,” said Hossein Gharib, MD, FACE, and president of AACE. “The new TSH range from the AACE guidelines gives physicians the information they need to diagnose mild thyroid disease before it can lead to more serious effects on a patient’s health, such as elevated cholesterol, heart disease, osteoporosis, infertility, and depression.” ¹¹

Treating an Under-Active Thyroid

We are constantly learning powerful new tricks for treating hypothyroidism and there are many reasonable treatment approaches. I would recommend starting with a trial of Armour Thyroid. Our treatment protocol information checklist (see Appendix B: Pain Treatment Protocol) gives the “nuts and bolts” of how to begin and adjust all of the treatments discussed in this book.

Check a free T₄ (the thyroid blood test that measures the actual level of the main hormone produced by the thyroid) about one month after the 90 and 180 mg levels of Armour Thyroid are reached. Do not check a TSH test. It will often be inaccurate and low (because of the hypothalamic dysfunction) and your doctor will incorrectly think you’re on too much thyroid—even if your blood hormone levels are low normal. This will confuse both you and your doctor. Adjust the thyroid slowly to the dose that feels the best and not simply to where your blood test is above the lower limit of normal. When you find the dose that feels best, check to confirm that it is within normal range for the free T4 blood level. The free T4 is the only thyroid blood test I would check to monitor therapy. Your doctor may be concerned because excess thyroid hormone can cause osteoporosis (bone thinning). Having reviewed the medical literature, I have seen no studies showing any increase in osteoporosis in pre-menopausal women if the T4 thyroid blood level is kept in the normal range. Although many patients can stop taking thyroid hormone after 12 to 24 months, you can stay on Armour Thyroid or Synthroid® for as long as it is needed.

If your doctor is unwilling to prescribe Armour Thyroid (some feel it is too “old-fashioned”) you can also try Synthroid (T₄) ®. One hundred micrograms (0.1 mg) of Synthroid “equals” 1 grain of Armour Thyroid. Often, one hormone treatment works when the other does not. Adjust the dose as noted in Appendix B: Treatment Protocol.

Growth Hormone

This hormone is critical for tissue repair. Many people take growth hormone by injection at a cost of over $12,000 a year, to stay young. Although it can be helpful, I almost never prescribe it because of its cost, safety concerns and the need for injections. Growth hormone can be raised in three easier and less expensive (and often more fun) ways. We have already mentioned getting 8 to 9 hours of deep sleep each night. Exercise and sex also raise growth hormone. In addition, growth hormone stimulates DHEA production, and raising the DHEA, which can be done easily, may be responsible for much of growth hormone’s benefits.

Treating Low Testosterone

For men, I often treat with natural testosterone cream from a compounding pharmacy (I have it made up as 100 mg of testosterone per gram of PLO gel). Most men need 25 to 50 mg rubbed onto thin-skinned areas (for example, the inner upper arms from the elbow to two inches below the armpit) 1 to 2 times a day. Androgel ® 50 mg is another alternative. It is more expensive, unless you have prescription insurance.

For women, testosterone treatment is easier. Oral natural micronized testosterone (and natural estrogen and progesterone) are available through most compounding pharmacies. (For a compounding pharmacy that does mail-order prescriptions, see Appendix C: Resources). The usual dose is 2 to 4 mg 1 to 2 times a day by mouth or in cream form. If you take the capsules and also need to take estrogen or progesterone (see below), they can be combined in the same capsule at a lower cost. I usually begin by prescribing 2 mg, 1 to 2 times a day for 6 weeks to see the effect, then raise or lower the dosage if needed. With this dosing, most women feel more energy and have thicker hair, younger skin, and improved libido.

I check free testosterone blood levels 6 to 14 weeks after starting therapy and adjust the dosing accordingly. Blood levels are not reliable, however, if you are taking synthetic methyl testosterone instead of natural testosterone. Check the test 1 ½ to 3 hours after taking the tablets or applying the cream.

Potential Side Effects of Testosterone Treatment

In women, if acne, nightmares, or darkening of facial hair occurs, the dose is too high and should be decreased. These effects, which can also occur with DHEA supplementation, are generally reversible. These side effects can also be caused by an estrogen level that is too low relative to your testosterone, and may be avoided by supplementing both together. For women, it may help to begin the estrogen for 4 to 8 weeks before starting testosterone. This often decreases side effects.

In men, acne suggests the dose is too high. Monitor free testosterone blood levels, and keep them at the 70^th percentile of the normal range. Testosterone supplementation can also elevate thyroid hormone levels in those taking thyroid supplements. If you are on thyroid supplements, I would recheck thyroid hormone levels after 6 to 12 weeks of adding testosterone, or sooner if you get a racing heart or anxious/hyper feelings.