By Dr. Jacob Teitelbaum, Hive Advisor
Fibromyalgia pain afflicts an estimated 6-12 million Americans. Unfortunately, most physicians are not well trained in pain management, and fibromyalgia is no exception. The most effective way to limit fibromyalgia pain is to eliminate the underlying causes of the pain, while using medications only as temporary Band-Aids.
There is a horrible genetic disease which is uniformly fatal, leaving people horribly deformed and crippled. In this disease, people are born without any pain system, and therefore without any ability to feel pain. You may think this would be wonderful. It is not! As children, if they fall off a roof and break a leg, they have no pain and still try to walk — causing further damage. If their hand is on a hot stove or in a fire, they don’t know it until they smell something burning.
The message: Although chronic pain can be devastating, it serves a critical function. Pain is a critical warning system for your body. It tells you when you need to avoid something, or some activity, or to pay attention to something so that you don’t cause damage to yourself. In addition, it tells you when your body is not getting something that it needs, such as sleep, nutrients or oxygen. To simply mask the pain with medication would be like covering up the “low oil” warning light on your dashboard because it was annoying you. Therefore, in addition to teaching you how to turn off the pain signal, we will also help you understand what it is that the pain is trying to tell you that your body needs.
Chronic pain is the exception, as it causes more harm than good. So when the underlying problems that need attention have been addressed, it is very important to turn off, or mask, any pain that still persists.
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So how do I turn off the pain signal?
To turn off pain you need to give your body what it needs and eliminate what is damaging or toxic to your body. One of the most common types of pain in fibromyalgia is myofascial, or muscle, pain. If your muscles do not have adequate nutrients, optimal hormone levels, or enough sleep for tissue repair, they will get stuck in the shortened position and cause pain. Underlying infections can also cause muscles to hurt and/or get stuck in the shortened position (consider the achiness accompanying the flu).
Our research team did a study in which we applied these principles to people with fibromyalgia. We found that hypothalamic dysfunction is common in these patients. The hypothalamus is a small but major control center in the brain that controls sleep and hormonal function. It also contributes to disordered sleep and widespread hormonal deficiencies. Our study showed that after two years of treatment, the average improvement in quality of life was 90 percent and pain decreased by an average of over 50 percent. Most of the benefit was seen within 100 days of treatment and after three months the majority of patients no longer even qualified for the diagnosis of fibromyalgia!
An editorial in the Journal of the American Academy of Pain Management noted that our treatment protocol was an “excellent and highly effective part of the standard of practice for the treatment of fibromyalgia and myofascial pain syndrome. Once you are treating the underlying causes of the pain, it is very reasonable to use natural and prescription therapies to mask the pain until it subsides.
So how do I treat the underlying problems causing the pain?
There are usually five key areas that need to be treated to eliminate muscle/myofascial pain. It helps to remember the acronym “S.H.I.N.E.,” which stands for:
1. Sleep: Get adequate sleep, preferably eight to nine hours a night. Sleep replenishes the body’s energy and heals its muscles. Inadequate sleep will leave you exhausted and in pain.
2. Hormonal support: Get tested for hormone deficiency and treated if needed. Hormone deficiencies can contribute to fibromyalgia and chronic fatigue syndrome.
3. Infections: Get treatment when symptoms of infections occur. The lack of restorative sleep in CFS/fibromyalgia leads to dysfunctional immune systems. Underlying viral, bacterial, bowel, sinus and yeast infections are common and can be a contributing cause or result of CFS/fibromyalgia.
4. Nutritional Support: Optimal nutritional supplementation is essential. Many nutrients can be depleted as a result of CFS/fibromyalgia. B-12, magnesium, acetyl L-carnitine and glutathione, as well as your basic A, B, C and D vitamins need to be supplemented at a level that your average over the counter multivitamin cannot provide.
5. Exercise: Exercise as able. After 10 weeks on the four steps above, you will be able to slowly increase your exercise without being wiped out the next day!
6. Pain Therapies from Comprehensive Medicine
Comprehensive (or integrative) medicine combines the best of holistic and pharmaceutical treatments to create a therapy plan. The wonderful thing it is that it gives you a full tool kit to deal with your problems. Using comprehensive medicine, almost everyone can find a “shoe that fits” so you can get your life and health back!
Many natural therapies can be very helpful for pain. My three favorite pain-relieving herbals are willow bark, Boswellia, and cherry. While going after and eliminating the underlying causes of the pain, it is also perfectly reasonable to use pain medications for temporary relief. The toxicity of chronic pain is far greater than the toxicity of these medications. The main problem is that these medications can cause side effects, especially when started at high dose. It is reasonable to start with a higher dose if needed to get pain free quickly, but if the side effects become problematic, immediately lower the dose to the level that is comfortable (even if this is simply one-half tablet daily at bedtime). As your body adapts to the side effects over a week or two, the dose can then be raised. Starting at too high a dose, without stopping and retrying at a lower dose in the face of side effects, is the major reason why people do not tolerate medications for pain that otherwise would be very helpful.
Three new medications have been FDA approved for fibromyalgia pain: Lyrica, Cymbalta and Minalcipran. However these are not the most effective pain medications for fibromyalgia — simply the most expensive. Below I have listed the medications I recommend be tried for fibromyalgia pain in the order that I find them to be the most effective. Medications can often be combined, and it is reasonable to use a non-sedating medication like Cymbalta (antidepressant) or Skelaxin during the day in combination with a sedating medication like Neurontin or Lyrica at bedtime.
Prescription Medications for Fibromyalgia and the Order in Which to Try Them
Below is the order in which I recommend adding pain medications in fibromyalgia. It may take six weeks to see a medication’s full effect, but usually you’ll have a good sense of whether it is going to help by three weeks of use. Though it may take a high dose of a single medication (which may cause unacceptable side effects) to be effective, often combining a low dose of several medications will allow effectiveness without the side effects. Do not combine medications within a single group below, but rather add one from each group as you go along (and review with your physician to ensure you are using them correctly).
Topical medications for small areas of especially severe pain:
For small areas of especially problematic pain, begin with one or both of these topical treatments. Give them two weeks to work, and they can be very effective — with virtually no side effects. I like to use the two of these together.
1. The Nerve Pain gel or cream from ITC compounding pharmacy (physicians can call a prescription in to 888-349-5453). Apply a pea sized amount to up to four areas 2-3 times a day and give it two weeks to work.
2. Lidoderm patches (by prescription from standard pharmacies). This patch contains a cousin to Novocain called “lidocaine” and can be applied over painful areas. You can use 2-4 patches simultaneously over different areas.
1. I usually begin with a combination of both Skelaxin (metaxalone) — a nonsedating muscle relaxant that helps in about half of those with fibromyalgia; and Ultram (tramadol) — a medication that raises both serotonin and endorphins. If pain persists or side effects prevent the medications use, I then add one medication at a time from the next group (and continue to each subsequent group in the list).
2. GABA-stimulating medications: Neurontin (gabapentin) or Gabitril (tiagabine).
3. Serotonin and norepinephrine raising medications: Cymbalta (duloxetine), Effexor (venlefaxine), or Savella (Minalcipran).
4. Medication with a GABA structure: Lyrica (pregabalin).
5. Tricyclic antidepressants (the first two are especially helpful for nerve/burning pain or pelvic pain syndromes, especially when combined with Neurontin or Lyrica): Elavil (amitriptyline), Doxepin (sinequan) — use if the Elavil is too sedating or causes other problematic side effects, or Flexeril (cyclobenzaprine).
6. NMDA antagonists: Klonopin (clonazepam) — addictive like valium and helpful at bedtime for restless leg syndrome or severe muscle pain that interferes with sleep, or Namenda (memantine).
7. Codeine/narcotic family medications. These can be helpful but can also be addictive and therefore I prefer using the other medications discussed. Nonetheless, these medications are sometimes necessary in a small percent of fibromyalgia patients, and I believe taking them is much less toxic for patients than being in severe pain.
8. Other medications that can help fibromyalgia pain (though usually not needed): Zanaflex, Topamax, Permex, and Celebrex.
In the last 30 years, I have personally treated over 3,000 patients with fibromyalgia and other chronic pain conditions. I can count on my fingers how many were not able to get adequate pain relief. This has also been the experience of many other pain specialists that combine natural and prescription pain therapies while using techniques to eliminate trigger points and the underlying causes of muscle pain.
This article was republished with permission from the author.