As we discussed in earlier articles, both natural and prescription treatments can be very helpful while you are eliminating the root causes of your pain with the SHINE protocol. Once the biochemical root causes of the pain have been addressed, then 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. Also be sure to address ergonomics such as uneven hip heights, and make sure that your computer area has proper risk and elbow support with your feet planted comfortably on the floor.
In addition to addressing the root causes of the 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 cause more toxicity for less benefit. Low doses of several treatments are more likely to be safe and effective for treating fibromyalgia pain.
A few general principles for using pain medications:
- Start with a low dose and work up as tolerated. If you do not tolerate a medication, it is usually because you started with too high the dose. Happily, the body usually will adapt to the sedation and other side effects, but not to the pain relief, over time.
- A low dose of several medications tends to work better than a high dose of one (I am purposely repeating this one!)
- The cost of the medication has nothing to do with its effectiveness. Old low-cost medications often are far more effective than very expensive new ones – with much lower side effects. The cost of the medication simply tells you whether or not it is still under patent.
Especially helpful treatments to begin with include:
- Low dose naltrexone 4.5 milligrams at bedtime. This actually helps suppress the glial cell activation playing 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 the website www.lowdosenaltrexone.org 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 less 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) one tablet one to two times daily. For most people (86%), ibuprofen related medications are not helpful for the fibromyalgia pain and have significant side effects.
If these medications are not effective, I next go with the medications:
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- Zanaflex (tizanidine) 4 mg one half to one tablet up to four times a day. I stop it if it causes nightmares. Do not combine it with Cipro antibiotics.
- Namenda (Memantine)- I am especially likely to use 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, actually teach physicians how to properly treat pain. Another solution? When looking at yet another sensationalistic “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 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 and high-dose narcotics) by upwards of 30% http://www.medscape.com/viewarticle/822093.
- Chronic narcotic use routinely will cause suppression of testosterone and testosterone deficiency, despite normal blood tests. In both men and women, I will add 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 add 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, the B vitamin deficiencies can aggravate pain.
If you find that you need to escalate the dose of narcotics, that is a bad sign, and it is time to look for other ways to relieve the pain. If one can maintain a stable dose (with occasional adjustments during flares), then generally the narcotics can be used safely. 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. It is okay to ignore it until it is.
The above is simply the tip of the iceberg of what can be done to get you pain free. Chronic pain is optional!
Love and blessings,