The growing use of alternative medicines such as minerals, vitamins, and herbals in the world warrants a more comprehensive understanding of these agents by the medical community. It is important for the pain practitioner to recognize certain facts regarding these supplements. For example, there are about 1,300 g of calcium in a 70-kg adult and the mineral magnesium activates approximately 300 enzyme systems in the human body; most of these systems involved in energy metabolism (Kaye and Grogono 2000). Aside from these, the pain practitioner must appreciate the effect of these supplements on such functions on a regular basis as well as during various operative procedures. As demonstrated in this chapter, the use of these compounds may prove beneficial for some patients, but result in alterations in normal physiologic functions in others, thus potentially resulting in deleterious consequences. Moreover, in our own survey, in patients undergoing operative surgery, including interventional pain procedures, approximately one in three patients takes some form of herbal supplement although 70% of these patients did not admit to its use during routine questioning (Kaye et al. 2004). For this reason, these agents, in addition to all other medications taken by the patient, should be screened for by medical practitioners vigorously, in particular pain practitioners, as some of these compounds may interact with chosen anesthetics during the stages of anesthesia or can affect treatment or even worse cause harm to the patient. In this regard, education of patients regarding the serious potential supplement-supplement and drug-supplement interactions should be an integral component of pain assessment and ongoing pain management. Currently the American Society of Anesthesiologists (ASA) suggests that all herbal medications should be discontinued 2-3 weeks before an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he or she should be urged to bring the container so that the pain practitioner/anesthesiologist can review the contents of the herb or preparation (Kaye et al. 2004).

Due to current lax regulations in some countries, some of these agents are poorly categorized and standardized, thus resulting in a high risk of adverse effects when used by an uninformed or misinformed public. Within the last few decades, hundreds of deaths have been linked to the use of these agents, specifically the herbals. Given that the FDA considers herbals as foods and that this industry has developed into a multibillion dollar business, it is imperative for the pain practitioner to have a basic understanding of issues related to the over 29,000 supplements and herbal-related agents available without prescription in the United States. Worldwide there are varying levels of scrutiny and protection for consumers. Data also suggest that less than 1% of adverse effects associated with herbals are reported in the United States. In general, whether the patient is taking minerals, vitamins, and/or herbals, one thing is for certain: an open line of communication between pain physician and patient should exist regarding all of these agents. This communication is essential to ensure quality patient treatment, a stable and secure rapport, and a properly informed and educated general public. Though only recently being taught in many medical schools, pain practitioners will be well advised to gain a solid foundation in this most important and relevant topic.

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