Fibromyalgia: Conventional Treatment

Patients and physicians unfamiliar with fibromyalgia are rightfully a bit shocked when they learn the average fibro patient uses five prescription drugs to make it through her day. Not one of these is “for fibro,” in the sense of a cure, the way penicillin cures a strep throat. The medications don’t even actually treat fibro, the way insulin treats diabetes. At their best, the drugs (sometimes) reduce symptoms.

Doctors face a real challenge when treating fibro:
• First, fibro patients are extremely chemically sensitive, probably related to low levels of stress-buffering serotonin. If anyone is going to experience a side effect from medications, it will be a fibro patient.

• Second, fibro drugs actually have more side effects than most other prescription medicines. I’ve personally sampled them all, and I don’t regard myself as particularly chemically sensitive, but all things considered I would have preferred sampling a selection of Cote du Rhone wines. The thought of taking five of these drugs simultaneously (which I did not attempt) curls my toes.

There are three FDA-approved drugs for fibromyalgia. Two of them, Savella and Cymbalta, were originally developed as antidepressants, but were later found to have fibro pain-relieving benefits. Physiologically, they do “correct” the basic defect occurring in fibromyalgia–low levels of the brain chemicals serotonin and norepinephrine–and work for about half the women who try them. The other half are stymied by nausea, headaches, palpitations, and sweating.

The third FDA-approved med–the one you see in TV ads–is Lyrica, one of several in a class of anti-epilepsy drugs that some years ago was found to have pain-reducing qualities. Lyrica works for about a third of my patients who try it, the other two-thirds abandoning it for side effects of dizziness, brain fog, double vision, and weight gain.

Everything else prescribed for fibromyalgia falls under the heading “FDA off-label” which translates to “Let’s try this one and see what happens.”

• Painkillers The acetaminophen family (Tylenol, etc.): useless. The NSAID family (ibuprofen): useless. The tramadol family (Ultram): can be helpful. The opioid family (Vicodin, OxyContin): helpful, but see my comments at the end of this article.

• Muscle relaxants (Flexeril, Skelaxin, Soma): marginally helpful, but cause drowsiness, dry mouth, and other side effects.

• Sleeping pills (Ambien, Lunesta, etc.): helpful because deeper sleep reduces fibro pain.

• Antidepressants (Elavil, Trazodone, Prozac, Effexor, etc): sometimes helpful, but inconsistent and may have unpleasant side effects (dry mouth, drowsiness, brain fog, flat emotions, weight gain).

• Energizers (Provigil, Nuvigil): sometimes helpful in boosting daytime energy and alertness. Side effect is very straightforward: think “too much Starbucks.”

As you may have guessed, when you take five meds the side effects are additive, meaning the drowsiness from medication A is added to the dry mouth of B and the weight gain of C. In the parlance of physicians, the current approach to fibro is called “shotgun therapy with a load of dirty (i.e., side effect-laden) drugs.”

What this really means is that the pharmaceutical industry may not be the best place to look for fibro treatment. Most physicians work with a single toolbox–their prescription pads. Maybe it’s time to look for a different one.

I’m going to close with a topic that is really–and I mean truly–controversial among physicians.

Because fibromyalgia is basically a physiological chronic pain syndrome and not an actual disease, the ideal treatment should be the best available pain medication. And the best available pain medications are the opioid family (Vicodin, Percocet, and the drug that Rush Limbaugh bought in a Denny’s parking lot, OxyContin).

US physicians are extremely reluctant to write prescriptions for opioid medications, fearing addiction (though the addiction rate among chronic pain patients is less than 1%), street re-selling, and so forth. They also fear a variety of government agencies that monitor physicians and their opioid prescription-writing habits.

There’s a gender bias here as well. An orthopedic surgeon might readily prescribe Vicodin to a guy with chronic back pain, but a rheumatologist will virtually never give OxyContin to a woman with fibromyalgia. Dentists, on the other hand, are quite generous with Vicodin, and many patients have told me that their fibro “melted away” after taking a few Vicodin after dental surgery.

Opioid side effects include constipation, which is so universal that variations of opioid drugs are used for chronic diarrhea (Lomotil, paregoric), and brain fog or nausea.

But the opioid issue is heatedly argued among doctors. A few weeks ago, after a fibro meeting, when the topic was the chronic pelvic pain of fibromyalgia, one physician said “I’d rather schedule a hysterectomy on her than write a Vicodin prescription.” If I were one of his patients, I’d keep a watchful eye on my uterus.

You can read more about the opioid controversy here.

Next week: alternative therapies for fibromyalgia, the last article in this lengthy series I promise.

Click here for Part 6.