As we discussed in earlier articles (7 Types of Fibromyalgia Pain and Natural Pain Relief in FMS), both natural and prescription treatments can be very helpful while you are eliminating the root causes of your pain with the S.H.I.N.E.® protocol. Once the biochemical root causes of the pain have been addressed, structural treatments such as chiropractic manipulation and massage (such as myofascial release) cannot only be helpful, but the treatments will hold for longer and longer until they are no longer needed. As an additional measure, you should address possible ergonomic problems such as uneven hip heights — for instance, make sure that your computer area has proper wrist and elbow support with your feet planted comfortably on the floor.
In addition to addressing the root causes of your pain, the actual pain mechanism can be subdued from many directions. This works better than just using a high dose of one medication, which often causes more toxicity for less benefit. Low doses of several treatments are more likely to be safe and effective for treating fibromyalgia pain.
Below are a few general guidelines for using pain medications:
1. Start with a low dose and work up as tolerated.
If you don't tolerate a medication, it's usually because you started with too high a dose. Fortunately, over time the body will usually adapt to the sedation and other side effects, though not to the pain relief itself.
2. Low doses are better than high doses.
A low dose of several medications tends to work better than a high dose of one (I am purposely repeating this one!).
3. High cost doesn't mean high effectiveness.
The cost of the medication has nothing to do with its effectiveness. Old low-cost medications are often far more effective than very expensive new ones, and with far fewer side effects. More often than not, the cost of a medication simply tells you whether or not it's still under patent protection.
Especially helpful treatments to begin with include:
- Low dose naltrexone 4.5 mg at bedtime. This actually helps suppress the glial cell activation, which plays a role in chronic pain central sensitization while also helping to balance immune function. Higher doses will not work, and several studies have shown this to be effective for fibromyalgia. Give it at least 2 to 3 months to start seeing the effect. It cannot be taken in people taking narcotics. (See Low Dose Naltrexone for more information.)
- Ultram (tramadol) 50-100 mg 2-3 times a day can be very effective for fibromyalgia pain.
- Neurontin (Gabapentin) is very helpful for both sleep and pain as well as restless leg syndrome. I find it has fewer side effects than Lyrica, which can also be helpful, but often is pretty poorly tolerated at doses over 300 mg a day. When used by itself, higher Lyrica doses than this are needed.
- Flexeril (cyclobenzaprine) 2.5 to 5 mg 1-4 times a day.
- For severe local pain, using a mix of medications in a topical cream can be very helpful after 2 to 6 weeks. These medications may include Neurontin, amitriptyline, beclomethasone, lidocaine, and a host of others. Because they are used topically, there are virtually no side effects. But they can be very effective. Your doctor will likely not be familiar with this, but they can call your local compounding pharmacist who can guide them on how to prescribe these. I recommend ITC pharmacy (have your physician call 888-349-5453 and ask for the pharmacist Allen Jolly who can instruct them on using the topical pain creams).
Tylenol can be helpful, but it depletes the critical antioxidant called glutathione. If using acetaminophen/Tylenol chronically, I have people take a sublingual glutathione (I use only one called Clinical Glutathione) 1 tablet 1-2 times daily. For most people (86%), ibuprofen related medications are not helpful for the fibromyalgia pain and have significant side effects.
If these medications aren't effective, I recommend trying these next ones:
- Zanaflex (tizanidine) 4 mg 1/2-1 tablet up to 4 times a day. You should stop it if it causes nightmares. Do not combine it with Cipro antibiotics.
- Namenda (Memantine). I especially suggest using this for chronic severe neuropathic and allodynia pain, or pain not responding to the other treatments.
- Cymbalta (duloxetine). This medication has the benefit of not causing as much sedation as some others, but can cause horrific withdrawal symptoms, and therefore needs to be tapered off slowly after long-term use. Unfortunately, the company does not make a low enough dose to allow proper tapering, and because of its time-released nature the pills cannot be crushed or broken in half. Fortunately, inside the pills there are a number of small pellets that can be obtained by opening the pill carefully, and these can be slowly decreased to allow tapering.
There are numerous other medications that can be quite helpful as well.
Narcotics - the Savior or the Devil?
I find it sad that, societally, the discussion has been framed in these terms. Put simply, narcotics are a helpful and sometimes invaluable tool for treating chronic pain. For those with severe chronic pain, generally the chronic pain is far more toxic than the narcotics.
The concern? The narcotics carry risks just like any other medications. Especially important is the risk of addiction and drug diversion. 15,000 Americans die each year from overdose from prescribed narcotics. To put this in perspective, research shows that over 50,000 Americans die each year from heart attacks, strokes, and bleeding ulcers caused by ibuprofen (Motrin) related medications. Odd that we don't see the news media putting up a fuss over this, and treating people who use Advil as if they are junkies!
The solution? Most often, by treating the root causes of the pain, one simply does not need to use the narcotics. Simple, isn't it? Instead of leaving people in chronic pain, physicians should learn how to properly treat pain. Another solution? When watching yet another sensationalistic TV "news" story on the topic, consider changing the channel.
If you do need narcotics for pain relief, or find that you're part of the 5 to 10% of the population with fibromyalgia whose energy and mental clarity improve on the narcotic (where endorphin deficiency is actually contributing to the fibromyalgia, just as serotonin and dopamine deficiencies can), recognize that these are simply one more tool that can help you. But here are a few tips:
- Excellent work by Dr. Forest Tennant, the editor of Practical Pain Management, has shown that adding in hCG and oxytocin can decrease the dose of narcotics needed (in those with very severe chronic pain who are using high-dose narcotics) by upwards of 30% (see article at Medscape).
- Chronic narcotic use routinely will causes suppression of testosterone, and testosterone deficiency, despite normal blood tests. In both men and women, I recommend adding bioidentical testosterone if they are in the lowest 30 percentile of the normal range, as low testosterone then amplifies the pain.
- Narcotics can cause constipation, so I suggest adding magnesium and other natural treatments to 'keep things moving.'
- Narcotics will cause B vitamin deficiencies, which can sometimes even be severe enough to cause a rash at the corner of your lips. More importantly, B vitamin deficiencies can aggravate pain.
It's a bad sign if you find that you continuously need to escalate your dose of narcotics. If that happens, it's time to look for other ways to relieve your pain. If you can maintain a stable dose (allowing for occasional adjustments during flare ups), then generally the narcotics can be used safely. Please note that your needing narcotics is not a character defect. The whole tenor of the discussion nationally is more of a societal/media problem, and the whole discussion needs to be reframed along the lines of the points I've discussed.
The above is simply the tip of the iceberg of what can be done to get you pain free. Chronic pain is optional!
Jacob Teitelbaum, M.D. is one of the world's leading integrative medical authorities on fibromyalgia and chronic fatigue. He is the lead author of four research studies on their treatments, and has published numerous health & wellness books, including the bestseller on fibromyalgia From Fatigued to Fantastic! and The Fatigue and Fibromyalgia Solution. Dr. Teitelbaum is one of the most frequently quoted fibromyalgia experts in the world and appears often as a guest on news and talk shows nationwide including Good Morning America, The Dr. Oz Show, Oprah & Friends, CNN, and Fox News Health.