Detailed guides to painful problems, treatments & more

Vitamin D for Pain

Is it safe and reasonable for chronic pain patients to take higher doses of Vitamin D? And just how high is safe?

Paul Ingraham • 25m read
Photograph of shiny, brightly lit vitamin D gel capsules close up.

Vitamin D deficiency (or milder insufficency) is probably more common than once suspected. It’s tough to get enough D from food alone, and many people don’t get enough from sun either. Although a 2016 New England Journal of Medicine article made headlines debunking hype about a vitamin D deficiency “pandemic,” even their estimates are “of concern”: 6% of the population, more than 1 in 20 people.1 Walk down a busy street in Canada, Russia, or the UK — there’s more deficiency in the north, and in the cloudiest and smoggiest places2 — and you’ll pass someone with vitamin D deficiency every few seconds.

That’s the low estimate: other experts have declared that there is a pandemic of vitamin D deficiency (or at least that it’s extremely common) even in otherwise completely healthy people.34

An important debate about the actual prevalence and value of supplementation rages on. But most of the controversy is about healthy patients — are healthy people deficient? Do healthy people need to take vitamin D? Probably not — a major 2018 scientific review concluded that supplementing vitamin D was basically useless for preventing falls/fractures and does not increase bone density or “maintain or improve musculoskeletal health.”5 It seemed quite definitive, but of course the debate rages on.

But what about people who actually have health problems? That’s a different kettle of fish! And people in chronic pain are a particularly special case. Vitamin D may be the single most promising of all nutritional supplements for chronic pain (which isn’t say much — most supplements are kind of terrible).

The link between hypovitaminosis D and pain

Vitamin D deficiency is suspiciously common in people with chronic pain,6789 maybe because it actually causes it or at least makes it worse.10 It is probably more common in patients with specific kinds of chronic pain, most notably fibromyalgia,11 which is a common misdiagnosis.12 The symptoms that cause the diagnostic confusion include:

About the bone aching

Bone aching is often mistaken for muscle aches simply because people don’t expect their bloody bones to ache. The pain is a symptom of osteomalacia specifically, which is kind of like an evil twin of growing pains: bone weakening caused by malfunctioning bone building biology, not the same thing as osteoporosis.13 The Mayo Clinic describes osteomalacia symptoms like so: “The dull, aching pain associated with osteomalacia most commonly affects the lower back, pelvis, hips, legs and ribs. The pain may be worse at night, or when you’re putting weight on affected bones.” Thus, vitamin D deficiency may be a partial explanation for the extremely common phenomenon of morning back pain.

I think it’s possible that bone aching can occur even when osteomalacia is mild.14

About the muscle aching

The connection between bone health and vitamin D is familiar to most people, but muscle is more obscure. Vitamin D actually has plenty to do with muscle, both muscle pain1516 and dysfunction (weakness).1718 This may be why some experts believe it is particularly prevalent in people with a lot of “trigger points” (muscle knots). Although the nature of trigger points is unclear and controversial, the role of vitamin D might actually be one of the keys to understanding them.

Vitamin D and statins

Probably due to the aching symptoms of D deficiency, vitamin D has been floated as a treatment for another kind of aching: the notorious muscle soreness side effect of statins (the cholesterol-lowering drugs). However, D supplementation did not ease that symptom in a 2023 study by Hlatky et al.19 Interesting that the researchers didn’t mention Gupta et al., who reported in 2017 that statins didn’t cause muscle pain in the first place…when people didn’t know what they were taking! Whether or not this side effect is a genuine phenomenon remains controversial.2021

Vitamin B12 is quite similar

Vitamin B12 deficiency is practically a clinical clone of D deficiency: there’s major symptom overlap, it’s surprisingly common, and testing is not as reliable as you would think. But B12 symptoms tend to be more neurological in character (more tingling, more strange sensations), and it is often more ominous and difficult to treat. See Misconceptions about a B12 deficiency.

Who should be concerned?

You are more likely to have a vitamin D deficiency if several of these points describe you:

If there’s only one supplement you’re taking for your health and your diet is decent, it should probably be vitamin D.

Herman Gill, editor (Vitamin D reference page)

Does taking vitamin D treat pain? Unknown! Maybe?

We know that vitamin D deficiency and pain are probably related — see above — but that doesn’t necessarily mean that taking vitamin D is going to actually help the pain. There’s almost certainly not a benefit for any kind of pain patient, which is hardly surprising — there are many different kinds of pain, and it would be shocking if vitamin D was good for all or even most of them — and a pair of reviews in 2015 and 2016 both show this clearly.2324 (Although one of them did actually detect a slight benefit. Just sayin’!) Both reviews mainly just expose the sad state of the evidence regarding the specific kinds of chronic pain that might be more likely to benefit, such as fibromyalgia. The only studies of treating that condition with vitamin D are actually quite clearly positive.2526

But “more study needed” in a big way! Beyond these scraps of evidence, for now there is only educated guessing and clinical experience.

Vitamin D is probably only one of many common factors in pain

Nothing’s ever simple and chronic pain least of all: it’s usually caused by a sinister stew of factors that eat away at people for many years. Trying to solve the problem by fixing one thing — if indeed vitamin D is even a problem — may be about as feasible as trying to fix a broken engine with just one tool. Vitamin D deficiency may contribute to a chronic pain disaster over time, but by the time you’re actually in trouble the problem may be much more complicated than just vitamin D deficiency.

That’s a bleak warning not to put too much hope into vitamin D. But there are still reasons for optimism!

Vitamin D may be the most common and manageable factor in pain: the case for presumptive treatment

The only thing worse than chronic pain with six causes is … seven causes. Obviously. Anything you can do to simplify the pain equation is a good idea, and you can certainly take vitamin D. (Just consult with a doctor first, please.)

Vitamin D deficiency can be fixed. It may be tough to get enough from diet and sunshine, but supplementation is cheap, safe, and effective, so it’s an ideal candidate for presumptive treatment: going ahead and treating based on the presumption of vitamin D deficiency even if it has not been established with blood tests. By all means do that too, of course! But if a lot of healthy people take this stuff “just in case,” it’s hardly radical for pain patients to give it a shot. There’s just not much downside to this one … and chronic pain is a major bummer. So talk to your doctor, get tested, and get supplementing — it could be a big deal for you.

Why not a vitamin D rich diet?

Because you’d have to eat a lot of fish.

It’s hard to get a meaningful amount of vitamin D from food. For pain patients, who are trying to make absolutely sure they are getting enough vitamin D, food is just not a rich enough source. Supplements and sunshine should be your main sources, but of course that doesn’t mean you shouldn’t also try to get as much as you can from food. Salmon is the best source — there’s about 600 IU in 6 ounces of salmon — followed by mackerel, tuna and other fatty fish. (Cod liver oil, if you can stand taking it, is so vitamin D rich that it’s almost like taking a vitamin D supplement.) Other than that, the foods with the most vitamin D are:

Fruits, veggies, and grains have almost no vitamin D.

How to take vitamin D supplements

Although vitamin D supplements are cheap and easy and safe, they don’t always actually do the job. The vitamin D we can absorb through the gut is a little more awkward to “work with” than the kind we make from exposure to ultraviolet radiation. Here are some tips to make it work as well as possible:

Dosage: how much Vitamin D should you take?

There’s a more detailed discussion of dosage safety below, but here’s the bottom line in two points:

  1. There’s a large margin of safety in vitamin D dosing. You can double what’s recommended to healthy people in most countries without coming anywhere close to a safety concern.28
  2. But “megadosing” is silly — don’t do that!

Supplement or sunshine?

Sunshine is preferable … if you can get it. The body is good at making vitamin D from sunshine, and even modest exposure can easily replace days of oral supplementation. Unfortunately, it’s just about impossible to get enough exposure in higher latitudes for large chunks of each year. Some tips and guidelines:

The Vitamin D Council website has a very detailed page about sun exposure (and much more).

What about tanning beds?

If they are used with the goal of resolving a vitamin D deficiency, tanning beds can be considered a kind of photobiomodulation therapy (PBMT), along with cold lasers, far infrared radiation, and so on — exploiting the putative biological effects of electromagnetic radiation. But some experts are calling for a ban on tanning beds because of serious safety concerns, and it will probably happen eventually. Until it does, the option presents chronic pain patients with a tough dilemma. Unsurprisingly, their priorities have been ignored in the debate.

Tanning definitely produces vitamin D, but not as well or reliably as natural sunlight. And it’s well-established that tanning lamps are full-blown carcinogenic, no question — just like the sun, or possibly worse.29 And so it may not be worth the risks, and at the very least it’s critical to limit your dosage. Above all, do not use tanning beds to tan! If you use them at all, use them in moderation.

The main public health issue with tanning beds is not that they are much more dangerous than sunshine, but that people use them to overdose on UV (and even get addicted to them). It’s way too easy to get too much UV in a tanning bed, especially when used with the goal of tanning (where “too much” is almost the point).

Of course, it is possible to control the dosage and use tanning beds temporarily for shorter durations, thus hopefully reducing the risks while still being stimulated to produce large doses of completely bio-available vitamin D. This is called “safe tanning,” and some experts think it’s a myth. However, their arguments boil down to “better safe than sorry” rather than resting on hard evidence that it’s actually dangerous. There are three good points to consider though:

  1. They may be more dangerous than has yet been confirmed (but no one’s totally sure of that yet).
  2. Vitamin D supplementation mostly work just fine.
  3. Quality control and standardization of tanning beds are sketchy. Many tanning beds are not actually as good as sunshine anyway (different kind of ultraviolet), and it’s impossible for customers to know what they’re actually getting — which is a standard problem with virtually all consumer medical hardware.30

All of that should be a deal-breaker for almost everyone. But it’s not necessarily a deal-breaker for chronic pain patients.

Maybe chronic pain patients should take the risk

Tanning beds are not safe (definitely true), but neither is sunshine (also definitely true), and the stakes with chronic pain and vitamin D deficiency are extremely high (all too true). For chronic pain patients whose lives are being ruined, the limited risks of careful UV exposure in a tanning bed may “pale” in comparison to the greater danger of the pain.

If you prefer to play it safe, stick to supplementing. If you are in rough shape and desperate to rule out vitamin D deficiency as decisively as possible, do some tanning but follow these rules of thumb to minimize the risk:


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A more detailed look at dosing safety: are higher dosages of Vitamin D really safe?

I’m not talking about megadoses over 20000 IU per day. That’s just silliness: although it’s probably not dangerous, it might be, and it’s not necessary. This is more about the kind of dose you can easily find for sale in drugstores: 5000 IU capsules are quite common. Dr. Harriet Hall has reasonable concerns about that:

A Walmart ad in my local newspaper trumpets “75% of all Americans don’t get enough Vitamin D” and offers to sell me Maximum Strength Vitamin D3, 5000 IU capsules to “promote bone, colon and breast health.” Meanwhile, the Institute of Medicine (IOM) tells me that “the majority of Americans and Canadians are receiving adequate amounts of … vitamin D” and that no one should take more than 4000 IU a day. Apparently Walmart and the IOM aren’t talking to each other.

Indeed, the official recommended dosage for adults is 600 IU per day, with a tolerable upper intake level for D for adults of 4000 IU.31 If we’re going to break those rules, there had better be a compelling rationale and evidence of safety. I have looked very hard at these questions repeatedly over the years.

The first reason to break the rule is a good one: it is probably wrong due to a “serious calculation error,” reported by two groups of researchers.32

In any case — even if there was no error — the Walmart shopper looking at a sale on 5000 IU vitamin D capsules thinking it might help them with some vague symptoms like fatigue is a completely different critter than the chronic pain patient wondering if, perhaps, their vitamin D deficiency could be a factor in their horrible problem. Is the average person deficient? Do they need 5000 IU per day? Probably not. That is what the IOM guidelines are concerned with.

But the pain patient might. The geometry of risk and benefit is different for pain patients.

Fortunately, there is a wide margin of safety error with vitamin D dosing, especially with relatively short term usage. There is no question that truly excessive vitamin D can be dangerous,33 nor any question that it takes a lot, sustained for long periods. Even megadoses of 50,000 IU/day have failed to cause any trouble, and when supplement baron Gary Null overdosed on vitamin D in his own contaminated product — talk about poetic justice — he was taking upwards of two million IU per day. That nearly killed him, but it still didn’t, and we’re talking about a dose five hundred times larger than the IoM’s upper limit — such a ridiculous number that I’m really only bringing it up as a fun example. Here’s a summary of the safety evidence from Heaney:

Both the intoxication literature and the recent controlled dosing studies have been reanalyzed by Hathcock et al. These authors show that essentially no cases of confirmed intoxication have been reported at serum 25(OH)D levels below 500 nmol/L. Correspondingly, the oral intakes needed to produce such levels are in excess of 20,000 IU/day in otherwise healthy adults and, more usually, above 50,000 IU/day. These findings led Hathcock et al. to select 10,000 IU/day as the tolerable upper intake level (TUIL, or UL), with considerable confidence.

I also discussed the toxicity issue briefly with Dr. Hall (quoted above). She agreed that anything under 50,000 IU is unlikely to be toxic (and again that would be especially true for temporary supplementation for deficient patients).

Anything up to 5000 IU is still comfortably within the margins of safety for short term supplementation (several weeks to a few months). There is zero evidence of risks up to that dosage, and the IOM just substracted 20% from that just in case.34 Meanwhile, others are still vigorously arguing that their 7000 IU may be both safe and actually necessary for anyone deficient.35


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

Related Reading

Appendix: Does vitamin D prevent colds/flu? About those hopeful headlines

Probably not — not to any meaningful degree. But it also a small potential side benefit to supplementation that already makes sense for chronic pain patients for other reasons.

Vitamin D deficiency is probably associated with frequent cold/flu, and some studies have shown that it can reduce infection frequency and severity, especially in people with more greater deficiency. An early 2017 review of 25 studies had a classic damned-with-faint-praise conclusion.36 If you only read the abstract, you’d think it was good news, because apparently D supplementation “reduced the risk of acute respiratory tract infection.” Unfortunately, the abstract doesn’t say how much it was reduced. The media reported only the appearance of great news, of course, while an editorial in the same issue by Mark Bolland and Alison Avenell quietly pointed out the boring truth:

The primary result is a reduction from 42% to 40% in the proportion of participants experiencing at least one acute respiratory tract infection. It seems unlikely that the general population would consider a 2% absolute risk reduction sufficient justification to take supplements.

Could there be a more potent effect for pain patients? There’s a small possibility. Pain patients may be more likely to be more severely deficient: the population that seems to get the greatest protective effect. Or there could be something about pain patients that makes them more vulnerable to infection, which could improve if the extra D helps the pain problem. But this is just speculation, of course.

What’s new in this article?

Eleven updates have been logged for this article since publication (2010). All updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

2023 — Added a tiny new section about vitamin D as a possible therapy for statin-associated muscle soreness. Also removed the position statement on vitamin D and COVID. It was more interesting in 2020, but since then the relationship between vitamin D and COVID has become a big nothing burger, and it’s beyond the scope of this article in any case.

2022 — Science update, citing Bolland and Bislev on the (undetectable) value of vitamin D supplementation for healthy patients.

2020 — Added a statement about vitamin D and COVID-19.

2017 — Significant removal of obsolete content, plus revision and updating of dosing and safety information.

2017 — New section: “Does Vitamin D prevent colds/flu?” Not really, no, contrary to recent headlines.

2017 — Safety update. Sterner and more detailed warnings about the risks of tanning beds, and the dilemma they present to chronic pain patients.

2017 — Major udpate. Four new short practical sections about how to get more vitamin D: food sources, supplementation tips, sunshine versus supplementing, and all about tanning beds.

2016 — Major update. Total renovation of this article continues with many additions and changes today: several citations and footnotes, some important new key points, some less important but interesting tangents, more specific recommendations, and a lot of reorganizing to continue making the page more useful to readers.

2016 — Added fun little footnote about the cloudiest places on Earth. I live in one of them …

2016 — Major update. All new introduction explaining and exploring the link between vitamin D deficiency and chronic pain, with a much greater focus on being of service to readers. Includes discussion of the recent controversy over whether or not vitamin D deficiency is a “pandemic.”

2016 — Significant science update. Added a significant new citation (Wu, plus some older ones, and upgraded the article to use popup footnotes instead of inline links.

2010 — Publication.


  1. Manson JE, Patsy M B, Rosen CJ, Taylor CL. Vitamin D Deficiency — Is There Really a Pandemic? N Engl J Med. 2016 Nov 10;375(19):1817–1820. PubMed 27959647 ❐


    The claim that large proportions of North American and other populations are deficient in vitamin D is based on misinterpretation and misapplication of the Institute of Medicine reference values for nutrients — misunderstandings that can adversely affect patient care.

  2. See this beautiful satellite imagery of averaged global cloud cover, or this more utilitarian annual sunshine hours map.
  3. Vieth R, Bischoff-Ferrari H, Boucher BJ, et al. The urgent need to recommend an intake of vitamin D that is effective. Am J Clin Nutr. 2007 Mar;85(3):649–50. PubMed 17344484 ❐ PainSci Bibliography 55037 ❐
  4. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008 Apr;87(4):1080S–6S. PubMed 18400738 ❐ PainSci Bibliography 55028 ❐

    In one of the world’s most respected medical journals, Vitamin D activist Michael Holick writes, “Vitamin D deficiency is now recognized as a pandemic” and recommends that, “in the absence of adequate sun exposure, at least 800-1000 IU vitamin D3/d may be needed to achieve this in children and adults,” which is higher than historical upper limits.

  5. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018 11;6(11):847–858. PubMed 30293909 ❐

    From the abstract:

    “Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health.”

    The debate rages on. Obviously “musculoskeletal health” is very broad, and that’s probably an unnecessary overstatement that cannot be fully supported by the evidence, but it’s certainly substantially true for the musculoskeletal health benefits commonly associated with vitamin D.

    Many readers might wonder about prevention of sarcopenia (muscle loss with age, the muscle equivalent of osteopenia), but this is also very much in doubt. The assumption has been that vitamin D prevents falls by preventing sarcopenia, so if vitamin D does not prevent falls, then it probably doesn’t prevent sarcopenia… and there is also evidence that casts doubt on that more directly (see Bislev): “Available evidence does not support a beneficial effect of vitamin D supplementation on muscle health.” Or even worse! “Vitamin D may have adverse effects on muscle health.”

  6. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc. 2003 Dec;78(12):1463–70. PubMed 14661675 ❐ PainSci Bibliography 55011 ❐

    What is the prevalence of hypovitaminosis D in patients with nonspecific musculoskeletal pain syndrome? It’s quite striking, according to this important 2003 paper. Researchers did a cross-sectional study of 150 patients to find out and concluded (rather dramatically, emphasis mine) that “all patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex.”

    Even watered down, these results would be of considerable interest to pain patients.

  7. Atherton K, Berry DJ, Parsons T, et al. Vitamin D and chronic widespread pain in a white middle-aged British population: evidence from a cross-sectional population survey. Ann Rheum Dis. 2009 Jun;68(6):817–22. PubMed 18697776 ❐

    This UK study of more than six thousands Scottish and Welsh patients found an association between chronic widespread pain and vitamin D status in women. It could be partially explained by differences in lifestyle or social factors, but not fully. This data did not show the same connection in men.

  8. McBeth J, Pye SR, O’Neill TW, et al. Musculoskeletal pain is associated with very low levels of vitamin D in men: results from the European Male Ageing Study. Ann Rheum Dis. 2010 Aug;69(8):1448–52. PubMed 20498201 ❐

    This study found a modest but clear link between vitamin D deficiency and chronic pain. Researchers looked at 3000 older men. About 250 (8%) of them were suffering from chronic, widespread pain, and they had at least a 20% greater chance of having low vitamin D, less than 15ng/ml — the low end of “enough” Vitamin D. A weaker connection was also found in men with less pain. As with all studies like this, all it can tell us is that there is a connection, not what kind of connection: D deficiency might cause pain, or it might just be another side effect of the real causes of pain. Nevertheless, this is one of the best studies of its kind ever done, and the authors concluded: “These findings have implications at a population level for the long-term health of individuals with musculoskeletal pain.”

  9. Hsiao MY, Hung CY, Chang KV, Han DS, Wang TG. Is Serum Hypovitaminosis D Associated with Chronic Widespread Pain Including Fibromyalgia? A Meta-analysis of Observational Studies. Pain Physician. 2015;18(5):E877–87. PubMed 26431141 ❐

    This is a review of a dozen studies of the link between vitamin D and chronic widespread pain. They identified a “crude association” between them which was “likely to remain after adjusting confounding factors.”

    (One of the best such studies, McCabe et al. published a year after this review, failed to find a clear independent link: it weakened after the elimination of obese and depressed subjects, which are known risk factors for chronic pain.)

  10. It’s also possible that it’s simply associated with other known risk factors for pain, such as obesity and depression, which is what McCabe et al. found: a clear link until they factored out obese and depressed patients. It’s a very complicated puzzle.
  11. Karras S, Rapti E, Matsoukas S, Kotsa K. Vitamin D in Fibromyalgia: A Causative or Confounding Biological Interplay? Nutrients. 2016 Jun;8(6). PubMed 27271665 ❐ PainSci Bibliography 53667 ❐ “Overall, although a cause and effect relationship has not been proven yet, available evidence indicates, that vitamin D is a vital bioregulator of pain pathways involved in FM pathogenesis. …  Hypovitaminosis D may be a risk factor for FM and a way of worsening the symptoms through central and peripheral pathways. The exact mechanisms however, by which vitamin D may be related with FM remain unclear.”
  12. Fibromyalgia is overdiagnosed in general, thanks to its many non-specific symptoms (among other things, see Walitt). But in the case of vitamin D deficiency, the link may be so strong that it’s truly difficult to meaningfully separate them.
  13. Osteoporosis is an erosion of bone that has already been built. Osteomalacia is a failure to build it in the first place.
  14. I don’t know if that’s true, but I am fascinated by the idea that the human nervous system might be capable of detecting and raising an alarm about such a subtle problem; it’s also possible that we are more capable of it when pathologically sensitized for other reasons, such as fibromyalgia. If you’re skeptical, that’s reasonable, but bear in mind that it’s a known phenomenon that we will get strong cravings to eat bizarre things as a response to mineral deficiencies.
  15. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc. 2003 Dec;78(12):1457–9. PubMed 14661673 ❐ PainSci Bibliography 55029 ❐

    In this editorial for Mayo Clinic Proceedings, Holick explains that “Vitamin D deficiency causes muscle weakness and muscle aches and pains in both children and adults.” In reference to Plotnikoff et al., who studied the relationship between D and pain directly and produced quite dramatic data, “The association between nonspecific musculoskeletal pain and vitamin D deficiency was suspected because of a higher prevalence of these symptoms during winter than summer. The study patients ranged in age from 10 to 65 years, and all had symptoms of vitamin D deficiency. Of the more than 90% of patients who were medically evaluated for persistent musculoskeletal pain 1 year or more before screening, none had been tested previously for vitamin D deficiency.”

  16. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc. 2003 Dec;78(12):1463–70. PubMed 14661675 ❐ PainSci Bibliography 55011 ❐

    What is the prevalence of hypovitaminosis D in patients with nonspecific musculoskeletal pain syndrome? It’s quite striking, according to this important 2003 paper. Researchers did a cross-sectional study of 150 patients to find out and concluded (rather dramatically, emphasis mine) that “all patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex.”

    Even watered down, these results would be of considerable interest to pain patients.

  17. Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003 May;89(5):552–72. PubMed 12720576 ❐ “ … vitamin D insufficiency can lead to a disturbed muscle function.”
  18. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692. PubMed 19797342 ❐ PainSci Bibliography 55598 ❐

    Can taking vitamin D prevent falls? Apparently so: these researchers set out to “test the efficacy of supplemental vitamin D … in preventing falls among older individuals” and found that a “high dose” (700-1000 IU a day) actually reduced falling by a whopping 19%. That’s quite a substantial effect! It’s also a rare example of research actually confirming that vitamin supplementation does something helpful — most similar research in the last decade has come up quite empty-handed.

    More to the point for how does vitamin D reduce falls? The authors explain: “Vitamin D has direct effects on muscle strength modulated by specific vitamin D receptors present in human muscle tissue.” Muscles like vitamin D, and “these benefits translated into a reduction in falls.”


  19. Hlatky MA, Gonzalez PE, Manson JE, et al. {Statin-Associated Muscle Symptoms Among New Statin Users Randomly Assigned to Vitamin D or Placebo}. JAMA Cardiology. 2023 01;8(1):74–80. PainSci Bibliography 51241 ❐
  20. Gupta A, Thompson D, Whitehouse A, et al. Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase. Lancet. 2017 Jun;389(10088):2473–2481. PubMed 28476288 ❐

    This study was designed to test the existence of the phenomenon of statin myalgia. Taking statins did not increase pain in patients when they were unaware that they were taking them. This suggests that statin myalgia is something people get because they are afraid of it, not because it’s a real side effect. As the authors concluded:

    These analyses illustrate the so-called nocebo effect, with an excess rate of muscle-related AE reports only when patients and their doctors were aware that statin therapy was being used and not when its use was blinded. These results will help assure both physicians and patients that most AEs associated with statins are not causally related to use of the drug and should help counter the adverse effect on public health of exaggerated claims about statin-related side-effects.

  21. Cholesterol Treatment Trialists' Collaboration. Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials. Lancet. 2022 Aug. PubMed 36049498 ❐

    This is an enormous review of nineteen placebo controlled tests of the side effects of statins, following over 30,000 patients for about 4 years on average. A data set like that makes a typical little musculoskeletal medicine study look like a shack in the shadow of the Burj Khalifa.

    There was no major difference in the rates of muscle pain and weakness in statins versus placebo. They saw a modest signal in the first year, and for more intensive statin therapy: slightly more myopathy with statins, and mostly mild. Only about 1 in 15 cases of allegedly statin-induced myopathy reported by patients were actually related to statins, according to this data, and those were pretty tame. The researchers concluded:

    “Statin therapy caused a small excess of mostly mild muscle pain. Most (>90%) of all reports of muscle symptoms by participants allocated statin therapy were not due to the statin. The small risks of muscle symptoms are much lower than the known cardiovascular benefits.”

    This statin evidence cuts both ways: it undermines the Legend of Statin Associated Myopathy, but it also confirms that there is indeed an unpleasant side effect. Even a 5% risk of very mild-but-chronic muscle pain might seem unacceptable to many people. One in twenty is not “rare,” and no amount of chronic pain is cool. So even as it fights excessive hype about SAM, it’s not particularly reassuring either.

    For a more detailed report on this paper, see “Sign me up for mild muscle pain? The statins dilemma.

  22. Cashman KD, Wallace JM, Horigan G, et al. Estimation of the dietary requirement for vitamin D in free-living adults >=64 y of age. Am J Clin Nutr. 2009 May;89(5):1366–74. PubMed 19297462 ❐ PainSci Bibliography 54807 ❐

    There’s limited evidence for how much vitamin D older adults need in their diet. This study was a test of over 200 men and women over the age of 64. It found that the vast majority of adults need 320-2000 IU per day during the winter, depending how much sun they got in the summer. This paper does not discuss the safe upper limits of supplementation dosages.

  23. Straube S, Derry S, Straube C, Moore RA. Vitamin D for the treatment of chronic painful conditions in adults. Cochrane Database Syst Rev. 2015 May;(5):CD007771. PubMed 25946084 ❐ “…a large beneficial effect of vitamin D across different chronic painful conditions is unlikely. Whether vitamin D can have beneficial effects in specific chronic painful conditions needs further investigation.”
  24. Wu Z, Malihi Z, Stewart AW, Lawes CM, Scragg R. Effect of Vitamin D Supplementation on Pain: A Systematic Review and Meta-analysis. Pain Physician. 2016;19(7):415–27. PubMed 27676659 ❐ PainSci Bibliography 53675 ❐

    There are good reasons (including some evidence, e.g. see Schreuder) to hope that vitamin D supplementation is valuable for some kinds of pain patients, but it remains speculative. This is the first “major” meta-analysis of trials, but arguably it’s premature: just not enough data to meta-analyze meaningfully. Although 19 studies and 3,436 participants might seem like plenty, that includes studies of a wide variety of conditions — too wide, everything from fibromyalgia to osteoarthritis to migraine. It would be surprising if any treatment had a consistent effect on such different problems! This isn’t just a “limitation” of the meta-analysis, it’s a sucking chest wound. Although the authors did compare results in two meaningful categories (regional pain versus widespread pain), there were still too many different kinds of conditions within those categories. (Diabetic neuropathy definitely does not work the same way as rheumatoid arthritis.)

    Despite this major flaw, Vitamin D still seemed to work on average, at least a little bit. They detected a small improvement, about a half point (on a 10-point pain scale). Would you bother taking a pain-killer for a 5% improvement? Probably not: that is a classic example of a clinically trivial benefit, the bare minimum required for better-than-nothing, but still right at the edge of giving-a-crap, and of detectability. But it probably worked better for some patients, and not at all for others.

    Also completely missing from this study is any hint of whether more is better. Or whether D2 or D3 is better. Or whether a longer course of supplementation is better. Or whether any improvement was related to blood serum D levels.

    The main thing this study tells us is that the evidence is far too limited and still can’t really tell us the value of vitamin D for any specific kind of pain patient.

    This is the same conclusion reached by Straube et al. in 2016.

  25. Schreuder F, Bernsen RMD, van der Wouden JC. Vitamin D supplementation for nonspecific musculoskeletal pain in non-Western immigrants: a randomized controlled trial. Ann Fam Med. 2012;10(6):547–55. PubMed 23149532 ❐ PainSci Bibliography 54533 ❐

    This test of the effect of Vitamin D supplementation on nonspecific chronic musculoskeletal pain showed that pain modestly improved within 6 weeks. Musculoskeletal strength (stair climbing ability) also improved somewhat. See a thorough analysis of this study by Dr. Steven Leavitt for [now defunct]: “a most remarkable aspect of this study is that, even though patients probably received fundamentally inadequate vitamin D supplementation and for a relatively brief period of time, there were still strongly beneficial outcomes … significant enough to realize meaningful differences in everyday clinical practice.”

  26. Wepner F, Scheuer R, Schuetz-Wieser B, et al. Effects of vitamin D on patients with fibromyalgia syndrome: A randomized placebo-controlled trial. Pain. 2014 Feb;155(2):261–8. PubMed 24438771 ❐ “Optimization of calcifediol levels in FMS had a positive effect on the perception of pain. This economical therapy with a low side effect profile may well be considered in patients with FMS.”
  27. Mulligan GB, Licata A. Taking vitamin D with the largest meal improves absorption and results in higher serum levels of 25-hydroxyvitamin D. J Bone Miner Res. 2010 Apr;25(4):928–30. PubMed 20200983 ❐
  28. Cranney A, Horsley T, O’Donnell S, et al. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep). 2007 Aug;(158):1–235. PubMed 18088161 ❐ PainSci Bibliography 54893 ❐

    Although mainly about bone health, I cite this paper on primarily for information on the safety of vitamin D supplementation. It is reassuring: it isn’t easy to take too much D (short of megadosing). The report concludes that dosing of “vitamin D above current reference intakes was generally well tolerated. There was a non-significant increase in the risk of hypercalcemia and hypercalciuria with vitamin D relative to placebo, and these events did not appear clinically significant.”

  29. Woo DK, Eide MJ. Tanning beds, skin cancer, and vitamin D: An examination of the scientific evidence and public health implications. Dermatol Ther. 2010;23(1):61–71. PubMed 20136909 ❐


    Indoor tanning has become increasingly popular over the past decades, despite evidence of an increased risk of melanoma and, possibly, nonmelanoma skin cancer. Tanning bed proponents cite the health benefits of vitamin D to support indoor tanning, including concerns that reduced vitamin D levels or certain vitamin D receptor polymorphisms may be associated with increased incidence of various cancers, including cutaneous melanoma. However, most tanning devices primarily emit ultraviolet A, which is relatively ineffective in stimulating vitamin D synthesis. Health benefits can be fully dissociated from the ultraviolet exposure risks with vitamin D supplementation, although optimal levels remain to be established. Indoor tanning represents an avoidable risk factor for skin cancer, and education of the general public as well as the enactment and stricter enforcement of indoor tanning legislation are a public health imperative.

  30. Is your far infrared sauna, which cost as much as a car, actually producing radiation in a very specific wavelength as advertised, or is it spilling over into the near infrared and microwave? Is your cold laser therapy gadget actually a laser, or just a red diode? If you have any doubt that truly fraudulent medical gadgets exist, do a little reading on the topic of scammy products on Amazon.
  31. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010. These numbers are summarized nicely by the NIH, National Institutes of Health, Office of Dietary Supplements, in their Vitamin D Fact Sheet.
  32. Heaney R, Garland C, Baggerly C, French C, Gorham E. Letter to Veugelers, P.J. and Ekwaru, J.P., A statistical error in the estimation of the recommended dietary allowance for vitamin D. Nutrients 2014, 6, 4472-4475; doi:10.3390/nu6104472. Nutrients. 2015 Mar;7(3):1688–90. PubMed 25763527 ❐ PainSci Bibliography 52986 ❐
  33. Durup D, Jørgensen HL, Christensen J, et al. A Reverse J-Shaped Association of All-Cause Mortality with Serum 25-Hydroxyvitamin D in General Practice: The CopD Study. J Clin Endocrinol Metab. 2012 Aug;97(8):2644–52. PubMed 22573406 ❐

    “I think the message is pretty clear: think twice before you megadose.” — Alex Hutchinson (Sweat Science). Amen. The low-to-nil risks of “high” doses of D may be justified by the evidence for the specific case of patients with chronic pain. But “mega” doses? Not sure that was ever a good idea for anyone.

  34. Vitamin D Fact Sheet for Health Professionals, op cit.:

    While symptoms of toxicity are unlikely at daily intakes below 10,000 IU/day, the FNB pointed to emerging science from national survey data, observational studies, and clinical trials suggesting that even lower vitamin D intakes and serum 25(OH)D levels might have adverse health effects over time. The FNB concluded that serum 25(OH)D levels above approximately 125–150 nmol/L (50–60 ng/mL) should be avoided, as even lower serum levels (approximately 75–120 nmol/L or 30–48 ng/mL) are associated with increases in all-cause mortality, greater risk of cancer at some sites like the pancreas, greater risk of cardiovascular events, and more falls and fractures among the elderly. The FNB committee cited research which found that vitamin D intakes of 5,000 IU/day achieved serum 25(OH)D concentrations between 100–150 nmol/L (40–60 ng/mL), but no greater. Applying an uncertainty factor of 20% to this intake value gave a UL of 4,000 IU which the FNB applied to children aged 9 and older and adults, with corresponding lower amounts for younger children.

  35. Heaney 2015, op. cit.

    Thus, we confirm the findings of these investigators with regard to the published RDA for vitamin and we call for the IOM and all public health authorities concerned with transmitting accurate nutritional information to the public to designate, as the RDA, a value of approximately 7000 IU per day from all sources. We note that this conclusion applies specifically to the IOM’s designation of 20 ng/mL as the lower bound of adequacy, and that higher values, such as that of the Endocrine Society and GRH, would mandate the higher RDA values cited above.

    With regard to possible safety concerns related to such a recommendation, we note that: (a) as the figure shows, the mean 25(OH)D and the upper bound of the 95% probability range for the supplemental intake of 3875 IU/day are less than 50 ng/mL and 100 ng/mL, respectively; (b) the correctly calculated RDA is well below the cutaneous production of vitamin D from summer sun [5]; and (c) the total, all-source intake of 7000 IU/day is below the no observed adverse effect level (NOAEL) of both the IOM and the Endocrine Society, below the tolerable upper intake level (UL) of the Endocrine Society, and well within the safe range delineated by Hathcock et al. [6], who had generated that range using the IOM’s method of hazard identification.

  36. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017 Feb;356:i6583. PubMed 28202713 ❐


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