Supplements are used by up to 75% of the adults in the US (Statistic from 1A program NPR 1/31/18), often without any beneficial effect at all, at great expense ($37 billion per year), and profound questions about the contents and safety of the products given they are virtually completely unregulated in the US.  Read about the problems with regulation of supplements, vitamins and oils here.  Read about supplement safety concerns here. 

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Supplements include herbs, vitamins, minerals, and many chemicals synthesized called supplements.  Almost none of the supplements in the US, including vitamins, come from food.  They are made using chemical reactions in giant industrial vats, no different than making chemicals.  So there is very little "natural" about supplements. Supplement manufacturing only is loosely regulated by the FDA in the manufacturing plant, the performs only 400 inspections a year and more than half the time finds something wrong.  But the FDA cannot shut down manufacturers- they can only send warning letters, and ask manufacturers to voluntarily recall the product unless the products are actually killing people such as ephedra and L-tryptophan that resulted in many deaths.  It required several US Senators, activists working for 9 years, over 19,000 adverse side effect reports and alarm of doctors to finally get the FDA to ban ephedra.  Of course, it was quickly replaced by the supplement industry by another herb Citrus aurantium, that contains an analog of ephedra with the same side effects (EMBO Rep. 2016 May;17(5):619-25).  The FDA does not require testing of supplements for either efficacy or safety, and does not approve supplements like they do drugs, biologics, foods, or medical devices.  Frequently, the manufacturers place incorrect information about the amount of different chemicals in the bottles, the actual chemical in the bottle, the heavy metals or pesticide content.  Many supplements such as weight loss, arthritis treatment, and mens health (erections) supplements illegally contain prescription drugs that can harm or kill.  The ingredients in most supplements are mainly obtained from China, that have very low manufacturing standards and frequently contain lead, mercury, and other heavy metals.  The lot analysis sheets from these chemicals (many are chemically altered herbs or are synthesized chemicals outright) from China are sometimes fabricated, with the raw material shipped from China to the US for repackaging as a "supplement" at times being contaminated or may have none of the active ingredient.  Only recently have adverse events been required to be reported to the FDA, and only the most severe of those.  There are 23,000 Americans seeking care in Emergency Departments for adverse events from supplements, most of which are never reported to the FDA. 

 

WHAT TO AVOID IN SUPPLEMENTS

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1. Ayurvedic Medicines from India

Ayurvedic herbal medicines are a traditional medicine system in India, but several have been found to have high levels of lead with lead poisoning (Intern Med J. 2017 Jul;47(7):823-825).  Recently a patient was found to have strychnine poisoning from a southeastern Asia herbal treatment (J Emerg Med. 2017 Apr;52(4):493-495).  Ayurveda medicine herbal remedies have caused lead poisoning, since the herbs are frequently grown in lead contaminated areas and are not tested before use (Indian J Clin Biochem. 2017 Jun;32(2):246-247).  In some areas, 9% of chronic non-specific abdominal pain patients have lead poisoning due to Ayurvedic medicines and 97% of those with elevated lead levels and chronic abdominal pain were using Ayurvedic medicines (Clin Toxicol (Phila). 2017 Feb;55(2):97-101).  Not only is lead seen in ayurvedic medicines but also arsenic.  Arsenic exceeds safety thresholds in Ayurvedic medicines, and is higher than the amounts seen in herbs or rice. (Chemosphere. 2017 Sep;182:433-440).  Ayurvedic medicine continues to use Aristolochia, a substance known as far back as three centuries ago to cause renal failure and death (EMBO Rep. 2016 May;17(5):619-25). 

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2. Traditional Chinese Medicines or Anything with Chinese Writing on the Packaging

Toxicity from Traditional Chinese Medicine (TCM) herbs and deconcoctions are not uncommon- so common that this type of medicine should be avoided.  TCM uses eleven different herbs causing liver failure (Clin Toxicol (Phila). 2017 Nov;55(9):996-1000) and one commonly used herb bai-qu-cai, that is thought by Chinese practitioners to be hepato-protective and used to treat liver disease is actually hepatotoxic (Eur Rev Med Pharmacol Sci. 2017 Mar;21(1 Suppl):46-52).  Liver failure due to TCM in China is common, resulting in 37% of all causes of liver failure using Chinese herbs to treat osteopathy, arthropathy, dermatosis, gastropathy, leukotrichia, alopecia, and gynecologic diseases. (Chin Med J (Engl). 2017 Jan 20;130(2):160-164.)  A commonly used Chinese herb Periploca forrestii Schltr. caused liver failure in 22 patients with one death over a one year period (Zhonghua Gan Zang Bing Za Zhi. 2016 Sep 20;24(9):692-695).   Toxicity and death have occurred from the TCM Sophoro tonkinesis, used to treat many maladies and coughs and colds (Zhongguo Zhong Yao Za Zhi. 2017 Nov;42(21):4086-4092).  Liver toxicity is produced from treatment with the volatile oils of  Artemisiae argyi foliuma commonly used traditional Chinese medicine (BMC Complement Altern Med. 2017; 17: 491.)  Lead poisoning, manifest initially by severe abdominal cramps, has been reported many times from traditional Chinese medicine (Tohoku J Exp Med. 2017 Oct;243(2):127-131,  Case Rep Emerg Med. 2017;2017:9050713.)  A traditional Chinese medicine herbal tea made from the Solanaceae plant lead to many poisonings when it was later discovered the raw material was contaminated prior to packaging- a method commonly seen in the US where raw materials come from China, then are repackaged as supplements or herbs in the US  (Toxins (Basel). 2017 Sep; 9(9): 284.) 

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3.  Male Enhancement Supplements

There is an ongoing series of FDA suggested recalls stretching back years for products labeled as supplements but are actually laced with prescription drugs, and some in dangerous amounts.  These prescription drugs are not listed anywhere on the labels and the drugs are often intentionally mislabeled as supplements.  Frankly, supplements for male enhancement do not work unless they are laced with prescription drugs.  The manufacturers of these drugs pull them off the shelf, remove the labels, then put a new company name label on the same bottles then resell them.  The FDA tests only a tiny fraction of supplements each year and may take decades to detect this mislabeling fraud, then lacks the enforcement capability to do anything meaningful about it. Khloe Kardashian's husband Lamar Odom nearly died from hypotension due to taking these supplements in 2015, and those with blood pressure problems or heart disease may face fatal consequences from using these laced supplements.  

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4.  Dietary Weight Loss Supplements

Similar to the intentional mislabeling in male enhancement, the shell game of dietary supplements for weight loss has continued for years, exposing tens of thousands to cancer causing prescription drugs that were removed from the US market years ago by the FDA.  This is not simply a few isolated incident, but is a pervasive pattern. Because the FDA cannot adequately monitor the nearly 100,000 supplement products on the market and tests only a small fraction, those discovered to be mislabeled by the FDA are but the tip of the iceberg.  Supplements for weight loss do not work, therefore they are laced with illegal drugs.  

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5.  Most Combination Arthritis Supplements

Similar to male enhancement drugs, to augment the effect of arthritis combination supplements, the FDA has shown for many years the industry is lacing their supplement products with prescription NSAIDs such as diclofenac, meloxicam, and several others.  Some of these supplements have been found to contain up to 6 simultaneous NSAIDs in dangerous amounts, that can lead to gastric bleeding, intestinal bleeding, intractable vomiting, and kidney failure.  In patients who have had a prior heart attack, these laced supplements increase the chances by 80% of having another heart attack.  For those patients taking blood thinners such as Xarelto, Warfarin (coumadin), etc., the combination with the NSAIDs in these supplements can be deadly.  However many who die from these combinations never knew what was killing them since the supplements are intentionally mislabeled.  If you must use supplements for arthritis, it is safer to use single agent supplements such as turmeric, devil's claw, ginger, etc. 

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PROVEN USEFUL SUPPLEMENTS FOR PAIN

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Despite all these serious concerns about supplements notwithstanding additional serious concerns about supplement-supplement interactions (have not been studied) or supplement-medication interactions (small amount of studies), supplements, if obtainable as a real and pure supplement may actually be beneficial as shown below for pain.

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REVIEW OF STUDIES: SUPPLEMENTS/HERBALS/MINERALS/VITAMINS FOR PAIN

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• Capsicum frutescens  (cayenne) cream or plaster has moderate evidence of effectiveness in reducing low back pain more than placebo.  (Cochrane Review-Spine Phila Pa 1976 2015Nov30)

• Fish oil was shown to be effective in the treatment of rheumatoid arthritis but not osteoarthritis (Nutrients. 2017 Jan 6;9(1).)

• Vitamin D reduces pain but the effect of the pain reduction is very small (Pain Physician. 2016 Sep-Oct;19(7):415-27)

• Vitamin D for chronic non specific pain has no effect (Clin Rheumatol. 2017 May;36(5):1201-1208)

• Anti-oxidants have no effect in reducing soreness after exercise (https://www.ncbi.nlm.nih.gov/pubmed/29238948)

• Short term pain relief in osteoarthritis was shown for collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term.  Undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin showed a short term treatment effect.  Green-lipped mussel extract and undenatured type II collagen demonstrated medium term effects on pain.  No supplement showed a long term effect on pain. Br J Sports Med. 2018 Feb;52(3):167-175

• Brazilian arnica (Solidago chilensis M.) has very low quality evidence of reduction in pain and flexibility compared with placebo used twice daily (Cochrane Review-Spine Phila Pa 1976 2015Nov30)

• Devils Claw (Harpagophytum procumbens) has low level evidence of effectiveness.  ((Cochrane Review-Spine Phila Pa 1976 2015Nov30)

• White willow bark (Salix alba) is better than placebo for short-term improvements in pain and rescue medication- moderate quality evidence. (Cochrane Review-Spine Phila Pa 1976 2015Nov30)

• Symphytum officinale L (comfrey root extract) demonstrated low quality evidence that the ointment is better than placebo (Cochrane Review-Spine Phila Pa 1976 2015Nov30)

• Aromatic lavender essential oil applied by acupressure demonstrated very low quality evidence of effectiveness.    (Cochrane Database Syst Review Dec 2014)

• Coenzyme Q for statin induced myopathy- no effect Mayo Clin Proc 2015 Jan 90(1): p24

• Supplements for chronic gout-  (a) Vitamin C compared with standard allopurinol:  Vitamin C is less effective than allopurinol.  (b)  enriched skim milk powder with glycomacropeptides (GMP) compared with unenriched skim milk:  only 10% absolute response rates- no clinically relevant reduction in gout flares. (Cochrane Database Syst Rev 2014 Oct 7)

• Omega 3 fatty acids for intermittent claudication (Cochrane Database Syst Rev 2013 July 4;7 (A. Campbell)-  no effect

• Osteoarthritis of the knee: DMSO and MSM.  MSM provided positive but not definitive evidence of effectiveness.  DMSO demonstrated improvement in half the clinical trials.  (Osteoarthritis Cartilage 2008 Nov p1277)

• Omega 3 fatty acids for inflammatory joint pain:  Meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty supplementation for inflammatory joint pain:  positive outcomes in the meta-analysis, mainly in reduction of NSAID consumption and in reduction of number of minutes of morning stiffness (Pain 2007 May p 129)

• Probiotics reduce abdominal pain, bloating, and flatulence compared to placebo in a systematic review and meta analysis.  The relative risk was 0.79 compared with placebo (note-this is a clinically small improvement) Am J Gastroenterol 2014 Oct; 109(10):1547-61

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POSITIVE SUPPLEMENT RANDOMIZED CONTROLLED TRIALS  FOR PAIN

• Boswellia extract for knee osteoarthritis:  Improved outcomes compared to standard management; both statistical and clinically significant improvements (Minerva Med 2014 Dec;105(6 Suppl 2):9-16);    Boswellia + Curcuma longa in combination improved pain from full thickness rotator cuff tears for one week only during rehab after surgery (Musculoskelet Surg 2015 Sep:99 Suppl 1:43-52).

• Boron reduces the severity of pain in primary dysmenorrhea (Complement Ther Clin Pract 2015 May;21(2);79-83)

• Probiotics reduce pain in irritable bowel syndrome-a meta-analysis of 1793 patients (World J Gastroenterol 2015 Mar 14;21(10):3072-84

• NKCP (extract of natto) in a 4 week treatment for lifestyle diseases (sports) decreases shoulder stiffness, low back pain, and coldness of extremities but not headache  (Int J Gen Med 2015 Jan 20:8;41-6)

• Branched chain amino acids (leucine, isoleucine, valine) reduce pain and muscle damage when used during training for endurance sports (Nutr Hosp2014 Nov 15;31(2):577-89) however a 7 day treatment prior to a marathon did not prevent muscle pain or damage during a marathon (Amino Acids 2014 May; 46(5):1169-76)

• Saccharomyces cerevisiae reduces abdominal pain/discomfort more than placebo for irritable bowel syndrome. However, there was a very large placebo effect of 47% response.  (Dig Liver Dis 2015 Feb 47(2);119-24)

• Coenzyme Q10 50mg twice daily reduces statin induced muscle pain from 3.9 to 2.9 overall with 75% of patients receiving relief (note the reduction in pain is statistically but not clinically significant)  Med Sci Monit 2014 Nov 6;20:2183-8

• Coenzyme Q10 significantly reduced pain from statin induced myopathy from 6.7 to 3.2. (Can J Physiol Pharmacol 2013 Feb;91(2):165-70)

• Saffron 300mg/day reduces pain and soreness induced by exercise (Clin J Sport Med 2015 Mar;25(2);105-12)

• Vitamin E reduces total pain in diabetic neuropathy when combined with lyrica (Pharmacol Rep 2014 Feb 66(1):44-8)

• Instaflex, a combination of glucosamine, MSM, white willow bark extract, ginger root concentrate, boswella serrata extract, turmeric root extract, cayenne, and hyaluronic acid demonstrated clinically significant improvement over placebo (Nutr J 2013 Nov 25; 12(1):154)

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NEGATIVE SUPPLEMENT RANDOMIZED CONTROLLED TRIALS FOR PAIN

• Ginger does not reduce exercise induced muscle pain (Phytother Res 2015 Jun;29(6);887-93)

• Glucosamine does not reduce pain after ACL reconstruction in the knee (Res Sports Med 2015;23(1):14-26)

• Glucosamine/chondroitin has no protective effect nor reduces pain in patients with knee osteoarthritis (Arthritis Rheumatol 2015 Mar 67(3):714-23)

• Glucosamine and chondroitin does not result in clinically significant improvement over placebo in the treatment of OA of the knee (Ann Rheum Dis 2015 May; 74(5):851-8)

• Lactobacillus plantarum 299 did not reduce symptoms of abdominal pain nor quality of life compared with placebo.  Note very large placebo effect.  Nutrition 2014 Oct;30(10):1151-7

• Calcium plus Vitamin D3 does not reduce the frequency or severity of joint pain in postmenopausal women (J Acad Nutr Diet 2013 Oct;113(10):1302-10)

• Vitamin D does not reduce progression of osteoarthritis or joint pain (JAMA 2013 Jan 9;309(2):155-62)

• Oral lecithin (choline) has no effect on post operative pain (Br J Anaesth 2013 Aug:111(2):249-55)

• Creatine supplements do not reduce pain in fibromyalgia (Arthritis Care Res (Hoboken) 2013 Sep;65(9);1449-59)

• Yogurt with active probiotics has no effect on pain, bloating in irritable bowel syndrome (BMC Gastroenterol 2013 Mar 7;13:45)

• Cinnamon is inferior to ibuprofen but better than placebo for menstrual pain (J Clin Diagn Res 2015 Apr;9(4):QC04-7)

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WIDELY USED WITHOUT ANY RELEVANT STUDIES

• Kratom, the leaves of the Mitragyna speciosa tree found in Indonesia and southeast Asia, is available in a capsule or the seeds may be purchased to grow the plant at home.  It thrives in tropical climates but grows very tall, up to 65 feet.  The leaves contain mitragynine, also known as Kratom, that is currently a non-FDA regulated substance available on the internet.  It is used by an estimated 100,000 people in the US and is an opioid narcotic acting on opioid receptors.  It has a moderate dependency attached to its use (Drug Alcohol Depend. 2014 Jun 1;139:132-7) 

• Lettuce (Lactuca sativa) and especially wild lettuce (Lactuca virola) has been used traditionally as an opium substitute due to the milky liquor obtained from the stems of lettuce resembling opium liquor.  However, lettuce has no opium or opioid active ingredient.  Very high doses in mice and rats (30mg/kg) show analgesic, anti-inflammatory, and anticoagulant properties similar to nonsteroidal anti-inflammatory drugs, but without opioid activity.  Lactuca apparently acts on the peripheral bradykinin pathway instead of any central opioid pathway to reduce pain, very much like NSAIDs (Int J Biol Macromol. 2016 Nov;92:820-830.)  Lettuce was traditionally prepared by drying the stems and leaves, preparing a tea from the product.  Other ways to prepare lettuce was simmering in a pot with water and sugar, then reducing it to form a thick syrup.  Modern uses include using it in a vaporizor or vaping.  

• In Kenya, a variety of plants are used in traditional medicine for the treatment of joint pain.  These are used by local shaman and have no studies to support their use: Pavetta crassipes K. Schum, Strychnos henningsii Gilg., Carissa spinarum L., Fagaropsis hildebrandtii (Engl.) Milve-Redh. and Zanthoxylum chalybeum Engl. Acacia mellifera (Vahl) Benth., Amaranthus albus L., Balanites glabra Mildbr. & Schltr., Grewia fallax K. Schum., Lactuca capensis, Launaea cornuta (Oliv. & Hiern) O. Jeffrey, Lippia kituiensis Vatke, Pappea capensis Eckl. & Zeyh. and Pennisetum glaucum (L.) R. Br.