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Nature's Pain Killers: An interview with Carl Germano, RD,CNS,LDN
By Richard A. Passwater, Ph.D.
It's been a great pleasure to see my friend and former colleague, Carl Germano, RD, C.N.S., L.D.N., research new frontiers for natural products and write about them in his books. He has taken on new responsibilities that enable him to bring innovative products to our industry. Carl is a certified nutritionist with 23 years' experience in clinical practice and product development. He is the senior vice president of product development and research for Nutratech, Inc., in Fairfield, NJ. He also is an adjunct professor in nutrition at New York Chiropractic College, and he is co-author of The Brain Wellness Plan, author of The Osteoporosis Solution and co-author, with Dr. William Cabot, of Nature's Pain Killers (Kensington 1999).
Passwater: Carl, you have gone from brain health (The Brain Wellness Plan) to bone health (The Osteoporosis Solution) and now to chronic pain relief with Nature's Pain Killers. What has led you to such a different yet important topic?
Germano: Chronic pain afflicts millions of Americans, both young and old, on a day-today basis. When I look at the statistics behind some of the major ailments that have chronic pain at their core-such as arthritis, asthma, fibromyalgia, back pain, bursitis, carpal tunnel syndrome and so on-I am saddened that both over-the-counter and prescription medications often do not bring the long-term results in a safe and effective manner.
Additionally, for many, long-term use of non-steroidal anti-inflammatory drugs (NSAID) and surgery can lead to serious complications and side effects. Lastly, the doctor who wrote the foreword to my book, Dr. Prithvi Raj, M.D., F.A.C.P.M., editor-in-chief of Pain Digest and professor of anesthesia at Texas Tech University, said it best @Patients who suffer from chronic pain are at a disadvantage, since they do not usually get a well balanced, multidisciplinary regimen.@
Furthermore, it is no surprise that medical models of chronic pain management have failed to produce a reliable, effective treatment. The good news is that today we can offer patients a comprehensive multidisciplinary team and multi-component nutritional protocol that will result in effective and safe relief of chronic pain. Utilization of chiropractors, acupuncturists, massage therapists, psychologists and nutritionists are equal in importance to the primary care physician in addressing chronic pain.
Additionally, we have a nice arsenal of phytoanalgesic botanicals and nutraceuticals that make for an effective treatment plan for safe long-term use. Many of these natural agents affect the heart of chronic pain-inflammation!
Passwater: I see that you included an entire chapter on the pain-immune connection. The connection of the immune system, the brain and all other organ systems seems to be a common theme throughout all of your books. Please tell our readers about this important, but often overlooked, connection.
Germano: Pain perception is hard-wired in our nervous system via neurotransmitters and other chemical messengers. Equally important, our immune system produces chemical messengers that can either transmit pain signals to the brain or cause inflammation. We now have learned that our immune system plays a dual role in this scenario; it can be both helpful and destructive.
When it comes to pain, we now know that those with chronic pain have elevated levels of destructive inflammatory messengers that must be suppressed. The reason that they must be suppressed is that if they are not, they set up a chronic pain feedback loop with the brain. What this means is that an interaction between the brain and the immune system causes pain signals to remain permanently turned on-resulting in further chronic pain. Therefore, interrupting these pain signals becomes paramount from both a medical and nutritional point of view.
Some of the most recognizable substances that cause pain include prostaglandins, immunotransmitters (cytokines), peptides such as Substance P, glutamate and nitric oxide. Since inflammation is at the heart of pain, the principal substances that produce inflammation include histamine, kinins, leukotrienes, complement and prostaglandins.
Passwater: It is interesting that you mentioned prostaglandins as substances that cause both pain and inflammation. Could you elaborate further on the role of prostaglandins and leukotrienes?
Germano: Prostaglandins and leukotrienes are compounds that are produce(] via the metabolism of fats in our diets. Both of these compounds are simplistically categorized as either "good" or "bad." The good prostaglandins and leukotrienes are beneficial and constructive to the body while the bad ones are very destructive, having roles in increasing cancer, heart disease and inflammation.
It is interesting to note that the consumption of high amounts of saturated fat gives rise to the production of the bad prostaglandins and leukotrienes resulting in our recommendation to decrease animal fats and to increase more of the unsaturated fats that come from fish. From a clinical perspective, the enzymes that are involved in the production of the destructive prostaglandins and leukotrienes, called cyclooxygenase-2 (COX-2) and lipoxygenase (LOX), are the target of both medical and nutritional intervention in order to suppress these inflammatory substances. Hence, the introduction of LOX and COX-2 inhibitor drugs.
Additionally, it also is interesting to note that drugs that interrupt pain-such as acetominophen, NSAIDs and COX-2 inhibitors are focused on inhibiting the destructive, inflammatory prostaglandins. I am happy to say that we have several interesting dietary supplements that also work in the same manner as these drugs-and they are safer and just as effective over the long run!
Passwater: Before we get to the nutritional substances, tell us about the common drugs used and why they are not good for long-term chronic pain treatment.
Germano: Essentially, while NSAIDs and steroids are useful, they should remain limited to short-term use; there are significant side effects that can occur with long-term use. NSAIDs are the most commonly prescribed drugs for inflammation and orthopedic problems. Their side effects include nausea, liver disorders, kidney damage, ulcers, skin rashes and bone marrow suppression. Interestingly, long-term use actually can make the condition of arthritis worse since they interfere with GAG (glycosaminoglycan) synthesis.
The steroid category represents stronger approaches to pain and inflammation, and the associated side effects also are more severe. These include infection, delayed wound healing, peptic ulcer, Cushing syndrome, osteoporosis and fractures, muscle weakness, diabetes and psychosis.
Passwater: With that said, enlighten us as to the safer nutritional approach to treating chronic pain.
Germano: The nutritional approach for the treatment of chronic pain is a comprehensive approach and addresses key areas of focus:
Nutrients that inhibit the immune system's inflammatory cytokines, which otherwise would become elevated in chronic pain conditions.
Nutrients that inhibit the "bad" prostaglandins and leukotrienes that cause inflammation.
Nutrients that increase endorphins - the natural pain-relieving substances in our brain.
Nutrients that are involved in the repair of tissue once it is damaged from inflammation.
Nutrients that provide antioxidant support, since inflammation that damages tissues gives rise to increased free radicals.
Nutrients that can assist in relieving the stress and anxiety associated with chronic pain conditions.
So, you see, the protocol can be comprehensive, and it depends largely upon the clinical symptoms and conditions that the patient brings to you initially. Any combination of nutrients in one or more categories maybe incorporated into a total protocol for chronic pain relief.
Passwater: Lets get specific. What nutrients would be considered for addressing lipoxygenase (COX-2) inhibition?
Germano: Basically, the following are lipoxygenase inhibitors that may be used:
Perilla seed extract.
Omega-3 fatty acids.
The list of nutrients that would be considered for COX-2 inhibition include:
CAPE (caffeic acid phenethyl ester).
Standardized stinging nettle.
Standardized willow bark.
Omega 3 fatty acids.
Passwater: What nutrients are considered in reducing the inflammatory cytokines?
Germano: The nutritional agents that have been shown to suppress the inflammatory cytokines include:
Standardized stinging nettle.
Vitamin D, which inhibits the inflammatory cytokines interleukin-1 (IL-1) and interleukin-12 (IL-12).
Omega-3 fatty acids, which reduce IL-1 and IL-6.
Vitamin E, which when deficient, decreases levels of 11,6.
Standardized curcumin, which decreases IL-1 and IL,8.
Pycnogenol, which decreases nitric oxide.
Quercetin, which inhibits IL-8.
Passwater: What do you consider to be the top players for tissue repair once inflammation and pain strike and further damage tissue?
Germano: I believe in a two-pronged approach-one that includes nutrients that provide direct tissue repair, as well as those that provide antioxidant support. Among these are:
- NAC (n-acetyl cysteine), which helps boost glutathione levels that are reduced during inflammation.
- Glucosamine, which helps rebuild hyaluronic acid and cartilage.
- Chondroitin sulfate, which rebuilds cartilage and is anti-inflammatory.
- SAMe (s-adenosyl-L-methionine), which is important for cartilage synthesis, is analgesic and has antidepressant activity.
- Niacinamide, which assists in chondrocyte activation, an important element in cartilage synthesis.
Antioxidants. I do not believe one should focus on just one or two antioxidants, but should consider a comprehensive formula that includes:
- Vitamin C.
- Folic acid.
- Lipoic acid.
Passwater: Finally, what would you consider for treating the depression, anxiety and stress that commonly are associated with chronic pain conditions?
Germano: The nutrients that have proved themselves over and over in this category include:
5-HTP, which boosts serotonin levels.
St. Johns wort, which also increases serotonin levels.
Rhodiola rosea, which helps maintain serotonin levels and is adaptogenic.
SAMe, which boosts serotonin levels.
Phosphatidylserine, which decreases destructive cortisol levels that are elevated during chronic stress.
Standardized kava kava, valerian and passionflower, for their reliable sedative and anti- anxiety properties.
Passwater: Well, this four-pronged approach of using anti-inflammatories, antioxidants, antidepressants and tissue repair nutrients seems very comprehensive and would seem to provide for a more holistic and complementary approach than the single "magic bullet" approach that is used in conventional medicine.
Germano: As you know, and I hope many of your readers know, I am not an advocate of the single magic bullet approach. With all diseases, there are many paths and directions to an illness. No single drug or nutrient has the capability of addressing the many pathways to the condition. Therefore, I have always found that a multi-component nutritional protocol best serves the patient's needs and future direction towards complete rehabilitation.
Passwater: The Nature's Pain Killers book also addresses other modalities that are important for the treatment of chronic pain. Can you touch upon these?
Germano: Absolutely. Just as there is no single drug or nutrient that can be wholly effective, neither is there one single health care modality. While the primary care physician is at the center of the patient's care, the complementary approach also must embrace chiropractors, acupuncturists, massage therapists, nutritionists and psychologists as critical members of the health care team. If a physician shrugs off these important contributors, then it is time for the patient to get another physician. Each of these auxiliary practitioners warrants his or her own interview, as the therapies to be employed require a significant amount of time to explain. Nevertheless, they are fully outlined in the book. (See Figure 2)
Passwater: Well, it's been a pleasure to have the opportunity to chat with you again. You've gone in a new direction, but our paths still will be crossing. Before you go, do you have a parting message for our readers?
Germano: Pain is a fact of modern life and can be a direct result of our day-today interaction with people, our jobs, physical activity, age, sedentary lifestyle and relationships. just as we must deal with stress, we must cope with pain in ways that don't damage other parts of our lives. Due to the failure of Western medicine, many patients have turned to alternative medicine for answers. Today, we have amassed a great arsenal of natural remedies for pain, as well as important disciplines that can provide effective and safe relief. How well an individual recovers from chronic pain can depend upon how well-educated that individual is. Natures Pain Killers can provide you with an easy-to-understand guide you need to finally take charge of your lain and improve (he quality of your life. Good luck on your journey to good health. WF
© 2000 Whole Foods Magazine and Richard A. Passwater, Ph.D.
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