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Part 2: Holistic Pain Management: Choosing Pain Relief with Ananda Mahony

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Part 2: Holistic Pain Management: Choosing Pain Relief with Ananda Mahony

Chronic Pain affects around 15-20% of the population, with huge monetary and psychosocial burdens on the patient and the community around them. 

Today we welcome back Ananda Mahony to cover Part 2 of Holistic Pain Management. Today Ananda dives in to the evidence-based herbal and nutritional interventions for pain as well as the other modalities that can be employed successfully to help improve patient's wellbeing and quality of life. 

If you missed it, you can find Part 1 here.

Covered in this episode:

[00:45] Welcoming back Ananda Mahony
[02:26] A multi-modality approach to pain
[03:59] The costs of pain management
[07:23] Evidence for herbal medicine for pain?
[08:58] Evidence and mechanisms for curcumin
[15:16] TLR4 and gut health links
[17:29] Anxiolytics: modifying pain perceptions
[20:05] The mechanisms of magnesium
[22:41] Quelling immune involvements in pain
[24:53] Neuroplasticity
[26:10] Exercise and pain management
[30:31] Role of "mini brains"
[33:06] Mitigating opioid dependence using herbs
[38:24] Drug therapies: opportunities or issues?
[41:44] Resources for further education

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. 

Joining us again on the line today is Ananda Mahony for part two of our series on naturopathic pain management. Ananda works with people who are struggling with chronic ongoing pain caused by a wide range of conditions such as neuropathy. Functional issues such as migraines, IBS and fibromyalgia, and autoimmune-injury-related pain amongst others. 

A naturopath for 20 years, Ananda has been in clinical practice for 12 years, and now has a specific focus on chronic and acute pain management. Ananda is a nutrition lecturer at Endeavour College of Natural Health in Brisbane and is a clinician in two successful integrative practices in Brisbane. 

She has a passion for education and continued learning which has led her to undertake her postgraduate studies in human nutrition at Deakin University. And more recently, Ananda has moved on to a master's in the science of pain management at Sydney University to align more closely with her special interest in clinical practice. Ananda is a member of the Australian Pain Society and the International Association for the Study of Pain.

Welcome again to FX Medicine, Ananda. And today, we're going to be investigating holistic pain relief. How are you?

Ananda: Great, Andrew. Thanks for having me back.

Andrew: My absolute honour. I’ve got to say the way that you treat patients, and it is truly holistically with care, I just...I adore. I love the way you see through the issues that present in your clinic to encompass a holistic approach. So, well done to you.

Ananda: Thank you. Thanks so much.

Andrew: Now, we're going to dive right into the topic from our first podcast. So, I'm going to just ask you straight off the bat, our first question, and that is, how effective are nutrients and herbs in relieving pain?

Ananda: Well, indeed, they can be effective. But unlike acute pain, chronic pain is a very different beast. And there's not a single drug or therapy that will ever achieve lasting benefit for chronic pain.. I did say nutrient, herb or therapy. And so really, I think if we just focus on a very narrow biomedical single-nutrient or even unimodal approach, we're not going to get lasting change. So, of course, nutrients and herbs with naturopaths is a part of a holistic approach, but I would argue that we need to step even outside of our holistic approach and into a multi-modality approach. 

And so then using herbs and nutrients in context, in that context, yes, there may be a significant benefit. But I think it's all the little approaches, the 1%, the 2%, the 10% that all add up, over time, to lasting change for chronic pain. And so, if we think about herbs in that context, say they’re…and nutrients, say that 10% or 5% of treatment, they're an important 5% or 10% of treatment, but they're just a small part of a much larger treatment approach.

Andrew: So I guess part of that sort of question about efficacy is.. involves cost. And when you consider that there's so many millions of dollars spent on pain relief, how cost-effective are nutrients and herbs given the right sort of situation?

Ananda: I think they can be cost-effective. But I probably will go then for…but, you know, to give you some real data on that, I don't have anything concrete in Australia. But they have done research looking at complementary multi-modal approaches. So chiropractic, herbs, massage, acupuncture. So multi-modal approaches even within complementary medicine. And they've looked at that approach and looked at cost-effectiveness in the U.S. context and shown that for lower back pain, in particular, because what the studied in a couple of research approaches, that it is quite cost-effective. 

I can't give you exact numbers. I just recall the research rather than the specific numbers. But, yes, they have been shown, and that incorporated these nutrients and herbs.

Andrew: You tweaked my memory. I actually recall a study on massage in cardiac surgery patients, and the research was done by Endeavour in Melbourne. And it was carried out from Professor Frank Rosenfeldt and his group, The Integrative Cardiac Wellness Group. You can look that one up at the Alfred Hospital in Melbourne. Where they found that just massaging the feet, now, the reason they chose the feet is because you had drips, drains, and cracked chest and sutures, and a lot of painful areas in the main trunk of the body. So they didn't want to do shoulder or back massage and things like that because it was really inappropriate. So what they did is a foot massage. Now, think about that. It's a foot massage. And they had massive reductions in pain relief needed, in inotropes, incredible results. The interesting thing I'd pull out here is the importance of human interaction. But just that touch, therapeutic touch.

Ananda: Yes, indeed. And in fact, there is some research, I think looking at massage with regard to opioid withdrawal and showing that that can be an effective part of opioid withdrawal. Again, I'd have to dig out that research because I'm just remembering this, from your remembering. 

But also on the aspect of social interaction. That is huge in chronic pain management. And if we look at the biopsychosocial approach, social is significant a contributor to, or I should say, isolation is a significant contributor to chronic pain and part of the therapy in chronic pain is getting people reengaged with their friends, their families, with activities and/or returning to work. So building relationships to support them and help pull them out of the situations that they’ve got into through through chronic pain such as isolation and withdrawal, and you know, maybe not returning to work. 

So, yes, social interaction from a foot message to engaging with others is a significant part of treatment in chronic pain.

Andrew: What about… I remember reading a Cochrane review on herbal therapies for low back pain. And it involved devil's claw, white willow, salix alba…

Ananda: Yep.

Andrew: Capsicum, which normally is that nociceptive sort of antagonism. And it was for low back pain. So it was a positive review of herbs for low back pain.

Ananda: That is a positive review. It showed, I think, low to moderate impact for low back pain. But if you look at the research overall, and there is a meta analysis that looked at 76 different studies of all different types of.. all unimodal approaches from acupuncture to surgery to herbs to physical exercise. And it was really.. 30 different, 36, I think, different modalities, and it showed that in isolation, none of them will have a lasting impact for the majority of people.

Andrew: Right.

Ananda: So, I again come back to taking a unimodal approach even if that Cochrane review was positive, which is fantastic that it was, because at least it showcases herbs as being beneficial. That's only a small part of the treatment. And so we have to kind of hold onto those and use those tools in out and an approach of chronic pain, and particularly lower back pain. But I don't think we can just rely on those as being the sole or the primary treatment, or management.

Andrew: Does this answer the question about why when you get single nutrients and herbs use, like for instance magnesium with cramps. That it doesn't work very well? You know, curcumin in various studies doesn't seem to inhibit NFkB, and yet it works with osteoarthritis symptoms. 

Where do we go with what sort of studies we need to be looking at to do them properly? Do we need a multi-modality approach here?

Ananda: Yes, I think so. Because chronic pain is in a linear relationship with nociceptive drive. We've got to look at all of those input, all those drivers that are coming into chronic pain and I would love to see unimodal approaches and whole case, you know, researching whole cases rather than just an aspect of that. But I don't know what that would look like, necessarily. But I think it's really critical to start looking at outcomes associated with multimodal approaches and studying those. Both from an effectiveness perspective for pain relief but also cost-effectiveness, as we talked about before, you know, see how they actually start to work.

And currently, there is some research in pain medicine and biopsychosocial approaches showing benefit in different areas, they return to work and cost-effectiveness. But that doesn't incorporate really important therapies such as complementary medicine that have a lot to offer, a multimodal approach to chronic pain. And I would love to see that research coming out of our field, out of our industry and profession, and see if we could contribute that kind of research. For me, it's not on the cards at the moment, even though I’d love to see it.

Andrew: It'll be good because one of the things which I see a lot of naturopaths basically do a face palm about is when you get these studies that use inappropriate dose, inappropriate timing, inappropriate formulation, and then they wonder why they've got a negative result. And it's very frustrating. And I should also mention here, it's very much like when you get an expert like Professor Michael Holick in vitamin D and he just face palms when he sees these studies which he has, in many cases, advised the investigators that they're doing it wrong from the outset and they do not listen. They continue using an inappropriately low dose and wonder why 'vitamin D doesn't work'. 

And yet the research is that they're using the appropriate dosing, the appropriate levels, the appropriate timing, the appropriate population groups. And I guess that, you know, the perfect, the poster child is obviously curcumin with pain, but it's not an opioid. It doesn't work like that.

Ananda: No, it doesn't. I think it has a lot of different mechanisms. It can be useful for chronic pain. Even, you know, from say from a peripheral and a central perspective, when, well when I look at chronic pain, I tend to work with more centrally mediated drivers.. I guess with this, I have to go back a little bit; When you’re working with chronic pain, it can impact across many different disease states and functional disorders. So of course you would be working with whatever the underlying disease drivers or peripheral input would be. Be that rheumatoid arthritis to lower back pain to neuropathy, you’d certainly be working on that level. But when I kind of narrow it down to working with what happens in chronic pain, curcumin has a number of different benefits.

And the first one is it can reduce inflammation that, in the periphery, that’s driving incoming input, or driving danger signals from the periphery that are interpreted as pain. Then the big one, I think, with curcumin or turmeric is that it modulates that neuro-immune interface, and that's where there's an amplification of responses in the central nervous system. So the pain, so the messages come in and there's an amplification of pain perception in the central nervous system and that's the glial adaptations. And I think curcumin can help quite effectively there to dampen down the activators of glial activity and dampen down the output of glial activity. And that glial activity directly correlates with the degree of pain and amplification of pain responses. 

So we're seeing, but no it's not necessarily worsened by the opioid system, but it is working in that neuro-immune interface which actually has downstream effects from the opioid system.

Andrew: So are we talking here about things which, I guess one of which the conditions is Complex Regional Pain Syndrome, CRPS? Is that the sort of aspect of amplification that you're talking about or is it just normal chronic pain?

Ananda: Yes to both.

Andrew: Okay.

Ananda: So, yes, it is normal chronic pain. Always involves a degree of glial activity. And the degree of that glial activity is associated with the degree of pain. 

Now, that doesn't mean we just go after the neuro-immune interface and think we're going to fix chronic pain. I just want to say that. But there is definitely glial activity associated with amplified pain responses. And that is where they're looking at new drug development. Where, you know, looking at dampening down, say, toll-like receptor four activity that then, you know, drives glial cell activity or glial activity and then increases inflammation into the synapses which then amplify that chronic pain response. 

So they are working on this with drugs. They haven’t found anything that is particularly good as a pain medicine in this area, but we have those tools. We have those tools already. And I think that we should start using those tools as part of what we do. If we're going to narrow down and take a very biomedical approach, well, then let's use the tools that we do have.

Andrew: You mentioned TLR4, toll-like receptor four, Ananda. Are you talking here about the importance of gut health with regards to resolving pain?

Ananda: Yes, in part. I think that gut health is critical too, particularly with some chronic pain like functional pain issues, IBS, fibromyalgia, vulvodynia, painful bladder syndrome.. then the health of the whole gastrointestinal system is fundamental. But with the toll-like receptor four, what I'm talking about is, and I think we discussed this briefly last in the first part of this, was the impact of DAMPs and, danger, sorry, pathogen-associated molecular patterns, DAMPs, PAMPs, xenogen associated molecular patterns. 

But I also talked about behavioural and cognitive associated molecular patterns. So things that, you know, trigger, if you like, that or the toll-like receptor four recognises, which then have an impact on glial activity.

So, yes, if that's a pathogen or xenobiotic that is associated with the gut, then that would impact on some glial activity and then on pain amplification. But, or if that's a thought process and if you think about IBS.. and I put IBS in the realm of the functional disorder that's associated with chronic pain. If you talk about the association with IBS, for example, where anxiety might trigger an episode. Well, what thoughts triggered that anxiety that then triggered that after episode? So, you can see the association there. 

So, yes, the toll-like receptor four is involved in, you know, what happens in the gut and whether the things that happen in the gut activate that. But I think it's broader than that as well.

Andrew: When we're talking about other conditions that are stress-driven, do you employ these anxiolytic-type herbs, even though it might not be a major symptom of the trigger of their pain. For instance, something like rheumatoid arthritis, where the depression is seen as a secondary sort of thing?

Ananda: Most certainly. Because the other thing is...when I'm talking about chronic pain, it can't divorce that, of course, from the underlying disease drivers and you have to address those. But with chronic pain, there's kind of three aspects that I look at and I've talked about incoming danger signals, I've talked about modulating the neuro-immune interface, but the third aspect of that is increasing descending inhibition. 

So that is essentially modulating pain perception, and if you like, increasing safety perception. And if anxiety in any type of pain is something that is associated with an increase in pain perception, then I want to modulate that. I want to dampen that down and increase safety perception. So, I would use things like Kava and anxiolytics, in that case, to increase safety perception, essentially.

Andrew: So, you mentioned decreasing descending inhibition. Are you talking about inhibiting the stress response back to which amplifies a pain response. Is that we're talking about?

Ananda: Sorry, I've said we need to increase descending inhibition and I know that sounds unusual. So what that means, it's not just about stress, descending inhibition is all the pathways that help with endogenous pain modulation. So they might be opioid, inkephalin, serotonin, GABA-associated pathways that actually, either directly or indirectly, act on the interneurons or the primary afferent fibre terminals to dampen down incoming danger messages. Increase safety messages. 

So, we would use that. And if anxiety was part of that, that was driving that, or we could use things that increase GABA and work via that GABA pathway to dampen down danger signals and increase safety signals. I'm kind of making it really simple because it gets very complicated.

Andrew: Yeah. Would magnesium, you know, the poster mineral of pain relief, is this where magnesium comes into play with protecting nerves? You know, it's inhibition of anxiety, stress or stressor symptoms, is that where magnesium plays a part?

Ananda: Yes, it can. But I would put that back in reducing danger signals from the periphery.

Andrew: Gotcha.

Ananda: Yes. So it works, you know, by working on calcium channels but also, of course, is one of the co-factors in all neurotransmitter formation. So you know, I kind of see magnesium is just like a little bit of a blanket that doesn't necessarily have one specific action, but it just helps support and dampen down across the board. By itself, it's not going to be terribly effective, but as part of a therapy or treatment plan, then it's going to be an important part of that. 

The other thing about magnesium that I think the form counts. The type of magnesium. Because you want to make sure that you're getting as much out of the magnesium as you can. Because glycine is involved in that descending facilitation, sorry, descending inhibition. 

And with chronic pain, you see reduced glycine receptors, reduced serotonin, opioid, all of those receptors are dampened down. So you want to make sure there's enough substrate there, if you like, to encourage the glycine receptors to be filled and then work on descending inhibition. So if you’ve got magnesium dyglycinate, you’ve got a two in one there. And so I always like things that you can get more benefit from. Giving one supplement or one nutrient.

Andrew: I'm so glad you mentioned that. Because there's so many different forms of magnesium and this is where you get into the ligand having an action as well as the mineral. So people always think the mineral is the acting thing. But sometimes it can be the ligand, as you mentioned, the glycine in this instance. That can have an accessory action to what you're trying to achieve and so that's why you choose that one over maybe, you know, magnesium oxide or even magnesium citrate. Whereas if it was, you know, a mitochondrial type disorder you might favour magnesium citrate, you know, that sort of balance.

Ananda: And I think we can become quite a little bit sophisticated about the way that we use the ligands, as you say, using them for different, you know, different benefit and different conditions.

Andrew: Now, you mentioned, also, the glial cell activation. That's obviously part of the immune system. Is this where we're going to be getting into the endocannabinoid system and the actions of herbs on the immune system? And I'm not necessarily talking about cannabis because in vitro, even herbs like echinacea can have actions on the endocannabinoid system. Is this where you start to employ other herbs at work on the immune system?

Ananda: Absolutely. I think that they're quite an important part of modulating that central neuro-immune interface. I don't use, as you say, it's not about cannabinoids, I think Justin Sinclair is the person to talk to about that...

Andrew: Oh, yes.

Ananda: I have heard you talk to him before, which was fascinating. But probably, my go-to nutrient for this is vitamin D. 

Andrew: Ahh

Ananda: So I use a lot of vitamin D and then I might employ some immune-modulating herbs. Sorry, not specifically for the endocannabinoids though. But I might employ some immune-modulating herbs but I tend to use quite a bit of vitamin D and then in combination with other...I call them, brain health herbs, if you like. Because there is increased neuronal damage and neuro-inflammation and therefore decreased analgesia across the brain, in chronic pain. In the prefrontal cortex, and in the raphe magnus, all the way across the brain. 

So if we, depending on the individual… but if we keep the brain healthy, then we're going to get better outcomes with chronic pain. So I employ those kind of ‘brain health category’ that I have which is curcumin, saffron, resveratrol, n-acetyl cysteine, vitamin D, and omega 3. So they’re all my go-to for the neuro-immune interface and for the health of the neurons and in the brain, essentially.

Andrew: Yeah. When we're talking about recovery from chronic pain, are we talking really about trying to achieve neuroplasticity to…

Ananda: Ahh, Yes.

Andrew: Yeah. So, we're trying to relearn new pathways. What about the damaged pathways? Do we heal them or do we just re-circuit them?

Ananda: I think there’s both. I'm not an expert in this area. I look at the work of Norman Doidge, The Brain's Way of HealingThat's one of the books that I, you know, did use to actually start some of that approach we see in chronic pain. But he doesn't, you know, necessarily advocate the use of herbs and nutrients. But neuro-regeneration is certainly part, or a potential part of that. He uses a lot of imagery and mindfulness and other approaches that work with neuro-regeneration or reducing neuro-degeneration in the brain. So I apply that work and sometimes I use herbs and nutrients to assist with that process.

Andrew: It's conjuring up more, more and more questions in my mind so, you know, I guess here is the facility of exercise? But I've got to ask the question; When is exercise helpful? And when does it do more harm than good? 

You know, there's the RICER, obviously, you know, the rest, ice, compression, elevation, and response. But then you've got to weigh that up against the use it or lose it. So when do you start to employ exercise and, I guess, how do you lead into that?

Ananda: Well, you would use RICER in acute pain where there's trauma or damage, and even with back pain where there has been trauma that's not ongoing. Or then you start to introduce movement as soon as possible. But that movement has to be paced appropriately and so that, you know, if you use too much movement...and what actually happens with chronic pain is that some people develop chronic pain because they've been told to rest excessively. And then there's de-conditioning or part of the story of them developing chronic pain is this, de-conditioning and there's increased disability and then there is fear about movement, and so that becomes part of the problem. And there's lots of work in this area, particularly in lower back pain, that looks at...what people are being told when they injure their back is actually contributing to the ongoing problem. 

However, too much and too soon, can increase sympathetic nervous system activity and increase pain. So, it is about pacing, and with chronic pain, there's a whole program around graded exercise. Which means to exercise to just below the pain threshold, just below. And if that's one minute, you do one minute. And then after a period of time, you might be able to go one and a half minutes, or it might be 10 minutes or, you know. But just below the pain threshold and then grade that up as things improve. 

That's why I love working with exercise physiologists or myo’s and physio’s work in chronic pain because they're all over that. And, you know, I know some about it, I know the theory about it, but the practical application given the different condition that people present with, you know, you’ve got to work with someone who is an expert in that field, I think. And, again, that's part of a multi-modality approach. You have that person there and you work in collaboration with them.

Andrew: Just a quick question on that, working to a certain threshold of pain. There's something about that that sort of twigs with me about the Irish headache pill. You take it 10 minutes before you feel a headache coming on. How do you know that you're getting to the stage of pain but you’re not there yet?

Ananda: The individual will start to feel pain and so that's when you stop.

Andrew: So as soon as they start to feel pain, you just go, "Okay, let's leave it there. We'll pull back."

Ananda: Yeah.

Andrew: Gotcha.

Ananda: And look, it might be, if they're feeling more pain later, then it might be, okay well, you go down to the point to where the exercise doesn't contribute to either immediate or delayed pain.

Andrew: Gotcha.

Ananda: So it's a little…you've got to work it out. It's not just a known thing. 

But often, people in chronic pain can do more than they think they can. And that's not about a physical response but it's more about what else is blocking them. Is it their fear of pain or their beliefs about their body being broken or damaged or mood, in a negative aspect, coming in, or low self-efficacy. So you find that those are the biggest factors holding people back from movement and exercise rather than actual, in many cases, physical disability.

Andrew: And therein lies a whole therapy on its own.

Ananda: Yes, which is why psychologists and physios and EPs are so useful.

Andrew: Right. Right.

Ananda: As part of chronic pain.

Andrew: Yeah. We say these words but we don't really understand. You've given as an understanding as to why. So I really thank you for that. I've got to ask you, Ananda, about something that I read a story about. I'm certainly not expert on this by any means. But I just read a story that tweaked my interest, and that is this new sort of discovery of these mini brains in the periphery

I'm wondering about how or what's its association with pain sensations? What’s its relevance to things like, you know, complex regional pain syndrome where you've got this feedback loop, this positive feedback loop, where the injury’s healed but the pain remains. What's the importance of these?

Ananda: I read about that and they're not actually sure about the importance of the mini brains as yet.

Andrew: Gotcha.

Ananda: But if I start to think about…if we think about what's happening in the dorsal horn and the brain and say that, you know, the brain is where we perceive pain. But the dorsal horn is more than just a relay system, it actually has, it akin to, you know, a computer and it can actually dampen down or facilitate messages going to the brain. Maybe, again, too, when we think about these mini brains, is they’re a little, you know, decision-making or computational thing occurring there in those mini brains which actually is deciding on the importance of this danger message and whether it needs to head into the dorsal horn and then up to the brain? So is this just another gateway or gate system? That's just me speculating though. I can't be sure.

Andrew: But I just wonder, though, whether these mini brains, in part, you know, ‘the answer’ is maybe not the correct term to use. But whether that has some answers as to why things like mindfulness and things like yoga and Pilates have dramatic effects on pain relief without the use of strong medications. Or even in tandem with those medications, they seem to make them work better.

Ananda: Possibly. It is unknown at this stage, but I'd say that the way that the yoga... yoga aside sorry, mindfulness, cognitive behavioural therapy, and meditation work by increasing descending inhibition. Yes, that's how they work. And if that, in a very small way is happening in the periphery, then perhaps they can work on that level as well.

Andrew: So just, you know, we've mentioned pharmaceuticals and from February 2018, opioids will become S4, that's prescription-only in Australia. And this reflects a worldwide problem with opioid addiction and abuse. 

How relevant are nutrients and herbs in controlling the abuse of opioids? And how can they best be used, or indeed introduced when you've got an existing problem?

Ananda: I think that...when I look at medications, it's really you take a detailed history and you think about what hasn't worked and what has worked. And often, you know, not often, but sometimes you finds that people are on opioids medications and it's just completely the wrong medication for the type of pain. And so then a medication review is worthwhile. 

But if it does work, you know, I then think, "Can I enhance that effect to lower the dose, or mimic it? And then can withdrawal be attenuated so that a person comes off that medication?” Obviously, with care and a team. But can we work in any of those levels to reduce the reliance on opioids or any of the on the pain medication drugs that are used? Because opioids, yes, you're right, they're associated with reward, addiction and craving, but they also may worsen chronic pain in the long term. 

Andrew: Yeah, yeah.

Ananda: And that whole opioid system becomes less effective with time, so more and more opioid medication is required. But one of the big things that is coming out now, and there's some research in both acute and chronic pain, is that morphine metabolites are seen as DAMPs and then act on toll-like receptor four, and then increase opposition to analgesia and into central sensitisation. So we see them, potentially, driving chronic pain mechanisms in the long run. So for me, I think that getting off opioids as soon as possible is critical. 

And there's one group that does that remarkably effectively, and that’s people who have had cancer, on an opioid for cancer treatment. But they're quite motivated often to get off opioids. Whereas patients with, and I’m not saying people who have had surgery relating to cancer don't have chronic pain, but some of them do. But if we say non-cancer chronic pain, that's where you tend to get more long-term opioid use. Like endone, for example, or it used to be codeine or Tramadol. Those medications tend to be more long term. And that's where I look at, "Can we enhance the effect to lower the dosage requirements or can we mimic it? And then, can withdrawal be attenuated?"

And there's some things, some research to show that curcumin can attenuate morphine withdrawal. And so that's a growing body of research, it's mostly in animals at the moment. But, you know, I watch those things and just because at the moment they're in animals, it doesn't mean I go, “Okay, well, maybe, I can translate that across.” You know, it's not that I won’t to use it. 

But there's other holistic treatments that can be used, massage comes in there. Magnesium may increase the effectiveness, and then mindfulness and cognitive behavioural therapy, certainly, and even lower level laser. Those are all the treatments that you might bring in to help reduce reliance on opioids. 

But I guess, probably, I'm not, you know, I don't work in the area of addiction. So if someone was addicted to opioids, it probably wouldn't be an area that I'd work in strongly. Mostly, I see patients who are motivated to come off the opioids and actually, are doing that with the pain specialist, anyway. And then we use other pain modulation techniques too so that their reliance for opioid as a pain medication isn't required. So I'm not really an expert in that area, but I will employ all of those strategies that I talked about, including curcumin. 

There's a big trend in the U.S. using a herb called Kratom. I'm not even sure how it's said. It's K-R-A-T-O-M.

Andrew: Yeah.

Ananda: And that’s a Mytragyna species, and they, it contains alkaloids that has an affinity for opioid receptors. And that has been used apparently, to help withdrawal of opioids. But it's also being strongly abused in the U.S.

Andrew: Oh is it? Of course.

Ananda: There’s side effects of toxicity associated with the dosages that are being employed. But it isn't interesting to watch to see if it can be employed effectively to help with opioid withdrawal.

Andrew: I've got one last quick question just before we go. And that is pharmaceutical medications, opportunities and issues? 

You know, we've seen issues with, for instance, dextropropoxyphene. I won't mention brand names but, you know, widening ST segments in people with heart issues and, indeed, I think it killed a couple of hundred people in the U.K. and was taken off the market there. They tried to take it off the market in Australia and the company that makes it lobbied and got it reintroduced. 

You know, we've got massive wholesale issues with opioids, as you say. What about interactions that we need to be aware of when we're using nutrients and herbs? The classic of which would obviously be St John's Wort. But how bad is this interaction? Have you seen horrid interactions or do you actually think that it's overinflated?

Ananda: No, I haven’t seen horrid interactions but, I guess, probably most of the patients that I see are on standard, either, the big ones that come through amitriptyline, Lyrica and Endone. And then standard over-the-counter medications. So they're the ones that I see most frequently. And you have to be a little bit cautious, sometimes, about making sure that there are no drug interactions but I don't necessarily see significant issues. 

And, in fact, there's even some misconceptions about drugs… some of the pain medications, for example lyrica. Which is called pregabalin, which is pregabalin, sorry. People assuming that that’s a GABA agonist. And so then being very cautious of that useful, you know, herbs or nutrients that might also be GABA agonists. When in fact it's not. It's a calcium channel blocker, and it reduces glutamate release. And that is widely touted, even amongst… I’ve heard GPs talk about it as being a GABA agonist. And its like, well no, we can incorporate GABA agonists very effectively with pregabalin because we're working by a different pathway, if you like.

Andrew: Why, when medicine is faced with such huge issues with pharmaceuticals, the perfect example of which is opioids in pain relief, will they ignore the actions of natural therapies given that there's some basis of therapy and that they have been shown to be safe?

Ananda: I think that we are well placed to work in with, you know, in chronic pain, in with that integrative model. And even though at the moment, we're not included at the big table, so to speak, in pain medicine, I think that we really have such a huge part to play in terms of not just the herbs and supplements that we use, but also, you know, foundational strategies like diet therapy, and lifestyle therapy are so important as part of that chronic pain treatment, that I think that we're, you know, the role that we're having and going to have will increase with importance. Well, that's my hope anyway. That's what I'm advocating for.

Andrew: Where can practitioners find out more about the treatment of pain? For instance, you’re a member of the Australian Pain Society and the International Association for the Study of Pain. Can anybody join these associations? Where can practitioners become more involved and aware, and educated on the aspects of pain?

Ananda: Yes. Certainly, anyone can join the International Association of the Study of Pain. And they produce a monthly magazine called Pain, not surprisingly, which is quite useful. 

In terms of the Australian Pain Society, I find that one…I don't find the organisation less useful, but I find the information source less useful. But there are some quite good articles in their quarterly magazine. And one, in particular, was a pain specialist who came out and advocated the use of nutrition and mindfulness and medication boundaries as part of the holistic treatment of chronic pain or the biopsychosocial treatment of chronic pain is the way that they expressed it. But, so they are useful.

Also very useful is, I think, the New South Wales Health Department has a very helpful pain education and pain support network. Which has a lot of information and publications, to the general public, but also to doctors and health care practitioners of that chronic pain. And so, I'm happy to send through some of those links and resources so that people can find out more and, you know, up-skill, I guess, about the underpinnings that drive chronic pain.

Andrew: This is going to team up so well with our first podcast, Ananda. And I wish we had time for more because there's so many aspects of pain which are so relevant, and we can investigate that. 

Unfortunately, we've run out of time but I urge all of our listeners to please listen to both podcasts and to try and catch up with you if you're in Australia whenever you're giving seminars on this. Because you look after your patients holistically, and that's what I love, you know. You don't just employ, you know, herbs and supplements because it's that bandwagon. You look at all issues so that in the end, they get relief of their suffering. 

So, thank you so much for taking us through your specialty with FX Medicine, Ananda.

Ananda: Thank you for having me, Andrew. It's been a great pleasure.

Andrew: This is FX Medicine, and I'm Andrew Whitfield-Cook.

Additional Resources

Ananda Mahony
PART 1: Holistic Pain Management: Pain Origins and Assessment
Australian Pain Society
International Association for the Study of Pain
Alfred Hospital: Integrative Cardiac Wellness Group
Dr Norman Doige
NSW Health: Pain Management Network

Research explored in this podcast:

Gagnier J, Oltean H, van Tulder MW, et al. Herbal Medicine for low back pain (Review). Cochrane collaboration 2016 Jan 41(2):116-133

MedicalXpress. Discovery of "mini brains" could change understanding of pain medication. 2017 Apr 4

Other podcasts with Ananda include:


The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.


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