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Fibromyalgia Has Central Nervous System Origins

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Press Release: American Pain Society, May 16, 2015 – Fibromyalgia is the second most common rheumatic disorder behind osteoarthritis and, though still widely misunderstood, is now considered to be a lifelong central nervous system disorder, which is responsible for amplified pain that shoots through the body in those who suffer from it. Daniel Clauw, M.D., professor of anesthesiology, University of Michigan, analyzed the neurological basis for fibromyalgia in a plenary session address today at the American Pain Society Annual Scientific Meeting.

“Fibromyalgia can be thought of both as a discreet disease and also as a final common pathway of pain centralization and chronification. Most people with this condition have lifelong histories of chronic pain throughout their bodies,” said Clauw. “The condition can be hard to diagnose if one isn’t familiar with classic symptoms because there isn’t a single cause and no outward signs.”

Clauw explained that fibromyalgia pain comes more from the brain and spinal cord than from areas of the body in which someone may experience peripheral pain. The condition is believed to be associated with disturbances in how the brain processes pain and other sensory information. He said physicians should suspect fibromyalgia in patients with multifocal (mostly musculoskeletal) pain that is not fully explained by injury or inflammation.

“Because pain pathways throughout the body are amplified in fibromyalgia patients, pain can occur anywhere, so chronic headaches, visceral pain and sensory hyper-responsiveness are common in people with this painful condition,” said Clauw.

“This does not imply that peripheral nociceptive input does not contribute to pain experienced by fibromyalgia patients, but they do feel more pain than normally would be expected from the degree of peripheral input. Persons with fibromyalgia and other pain states characterized by sensitization will experience pain from what those without the condition would describe as touch,” Clauw added.

Due to the central nervous system origins of fibromyalgia pain, Clauw said treatments with opioids or other narcotic analgesics usually are not effective because they do not reduce the activity of neurotransmitters in the brain. “These drugs have never been shown to be effective in fibromyalgia patients, and there is evidence that opioids might even worsen fibromyalgia and other centralized pain states,” he said.

Clauw advises clinicians to integrate pharmacological treatments, such as gabapentinoids, trycyclics and serotonoin reuptake inhibitors, with nonpharmacological approaches like cognitive behavioral therapy, exercise and stress reduction.

“Sometimes the magnitude of treatment response for simple and inexpensive non-drug therapies exceeds that for pharmaceuticals,” said Clauw. “The greatest benefit is improved function, which should be the main treatment goal for any chronic pain condition. The majority of patients with fibromyalgia can see improvement in their symptoms and lead normal lives with the right medications and extensive use of non-drug therapies.”

About the American Pain Society
Based in Chicago, the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering. APS is the professional home for investigators involved in all aspects of pain research including basic, translational, clinical and health services research to obtain the support and inspiration they need to flourish professionally. APS strongly advocates expansion of high quality pain research to help advance science to achieve effective and responsible pain relief. For more information on APS, visit

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32 thoughts on “Fibromyalgia Has Central Nervous System Origins”

  1. kandi_jar says:

    Although I have had some sensitivities and joint pain growing up, it didn’t stop
    me from being a very healthy active child, teen, adult until I was hospitalized for suspected
    Meningitis.. I say suspected because tests could never confirm, I had been on antibiotics for strep
    during this.. But after I did my full treatment I had in so much pain and so exhausted I could barely move.. For someone who walked everywhere her whole life.. Suddenly I couldn’t walk a block. Took 2 years to diagnose fibromyalgia.. And another year and a half to realize I also had some inflammatory arthritis.
    For those doctors who believe pain killers don’t work… I have tried Prozac, Effexor, Amitriptyline, Cymbalta, gabapentin, Lyrica, Celebrex,Vioxx before it was discontinued.. And a few others I can’t remember.. All resulted in my gaining 60 pounds.. Making me depressed and becoming sedentary.. Only tramadol, t3’s, and tramacet have helped me regain a little more function and I am now able to work part time… When I don’t take these I can’t function. I also take, malic acid, magnesium, vit d3, flax oil, serapeptase, vit c, iron ( I’m anemic) dhea, Alcar, ribose, Tumeric, and a few I’m probably forgetting… NONE of the natural stuff had helped the way pain killers and anti inflammatories have.. I keep taking them to maintain what health I have and for other health issues. When doctors continue to treat patients as drug seeking, or say natural products work just as well.. It’s because they really don’t get it.

    1. Stila says:

      I agree with you 100 percent.I have been were you are. Without Tramadol I would be confined to bed,and was ,until I received this medication. I too tried all you had been on ,to no avail.The pain is real. I am never below a 10 on a scale of 1 to 10. No one listens! I do believe that the thyroid is a part of the big picture. I hope you all get better and know you are not alone.

    2. o36m15k11 says:

      Hello I have had chronic pain for a few years and it has just gotten worse I also have a lot of other stuff going on. The pain I feel and the stiffness in the morning was ridiculous I always say no one should feel this way well I would be lost without Tramadol myself it really helps muy pain also baclofen helps my stiffness. I am also allergic to all muscle relaxer but baclofen. I am working on trying to get a diagnosis it helped reading all the post on here because I am getting so frustrated with the doctors but hearing int has taken some of you years to get the diagnosis it makes me feel better because I don’t feel like its just me they don’t want to deal with or find the cause of my symptoms. The fatigue I get is awfully I cant even keep eyes open and often I get headache light bothers me and some days I just have to lay down for awhile sometimes all day cause I am just sick. I am also on 800 mg Ibuprofen and 300 mg Gabapentin. I hope it won’t take me years to get a diagnosis.

    3. IanH says:

      description of FM from the cns viewpoint. Of course FM affects the CNS and sensitization is part of the problem. However we need to get past this superficial description of FM. The current paper by Sonya Marshall-Gradisnik et al in Australia is what is needed for FM too.

      I don’t doubt that the SNPs in the TRP genes will explain some, if not all of FM, not just the 40% who satisfy the ME/CFS diagnostic criteria. The texts by Bernd Nilius on TRP SNPs has me convinced that FM is a variant of ME/CFS, both illnesses being genetic and channelopathies.

      While it is possible that prolonged trauma can trigger the condition/symptoms of FM, these circumstances are not strictly the cause. You have to have the genes!

      In addition it can be the reverse, that FM for many years can cause spinal and neuro-muscular deterioration. Prolonged pain can induce a lot of muscle and epi-joint tension as well as microvascular changes which results in stenosis and further painful sources. This is why it is so important for people with FM to exercise appropriately, to minimize this deterioration.

    4. JamesFugedy says:

      In the Harvard study published in 2006, 5 20-minute transcranial direct current stimulation (tDCS) treatments reduced fibromyalgia 50%. The 2012 review at the Medical University of South Carolina deemed tDCS a first line treatment for fibromyalgia, because of its efficacy and absence of side effects. The cost was considered the sole drawback, but the subsequent availability of tDCS for self-administration has eliminated that. Besides pain reduction, tDCS improves cognitive function and reduces fatigue. tDCS provides relief for the other central pain syndromes, including complex regional pain syndrome, phantom limb pain and migraine headache. tDCS is also effective for treatment-resistant depression.

      1. says:

        I am a Nurse Practitioner with FM for 25 years now. AT first I functioned and did not want to consider a dx of FM. The massage was helping a lot as long as I got them 2 x a week.The headaches were the worse part of my disease at the beginning. I also took various muscle relaxers which helped the headaches. One day, about 22 years ago my massage therapist said to me”did you ever think about having FM. I said I do not want to think about having that disease” That is when I started worrying about it since I did know quite a bit about it. From there I ignored it and about 19 years ago my FM got severe, especially the pain. that is win I realized I really had it. But with no insurance , since I was not working, I was put on cortisone for a year plus hydrocodone I improved greatly but I knew I had to find a job so I could get insurance..Then I was diagnosed and tried different FM drugs. I had a horrible reaction to cymbalta called tetney. I will never take that drug again. Since then I developed neuopathy in my feet and legs so I was put on Gabapentin and now am up to 800 mg.I can’t afford ant FM drugs since they are too expensive on medicare. We can barely pay the medical bills. Some weeks all we live on is soup and cereal. Not easy to loose wt on that diet. So now I hear about ICDS which I have no idea what it is. Please explan it to me.

    5. sunshinejw says:

      Where can I find this treatment ? How much it’s it ? Any proof since the Harvard test 2006 study ?

      1. IanH says:

        Yes this study got similar results:

        A randomized placebo-controlled study of noninvasive cortical electrostimulation in the treatment of fibromyalgia patients.

        Hargrove JB, Bennett RM, Simons DG, Smith SJ, Nagpal S, Deering DE

        Pain Med. 2012 Jan;13(1):115-24.

        Pain reductions seem to be in the range 30%-50% with regular treatment. Less severe cases seem to benefit more. There is some loss of effect over time but it seems a worthwhile treatment compared to anything else.

      2. says:

        I totally agree with you. I hate taking any of the medications I’m on but Tramadol is the only med that helps take the edge off my constant pain. My doctor is great but he knows very little as most medical practitioners do when it comes to Fibro. I hate having to go to him each time I need another script for Tramadol just so he can monitor my use as it makes me feel like a drug seeker and I find that I limit myself to taking them so that they last longer putting myself through unnecessary pain. On the same topic of supposed addiction to opioids they have no problem handing out Lyrica and Cymbalta which have the worst cruel withdrawal symptoms possible and they don’t help the pain either. Seriously if Opioids give us some kind of relief let us have them, give me some kind of quality of life

        1. IanH says:

          Firstly no analgesics work well for FM. So the best one can do is get partial relief. There is a lot of variance in response to the drugs. SNRI’s work better for some people and opiates work better for others. Even ibuprophen works for some.

          FM is a chronic illness so the doctor is rightfully concerned about any of these drugs being taken for many years. The problem can be that many doctors consider FM a “so-called” functional illness and are therefore reluctant to give opioids and deem that psycho-actives like SNRI’s are more appropriate. What they should do is consider each case differently and not consider FM to be one homogeneous condition.

          In practice drug shifting can be useful. Take one drug for a while then shift to a different type of drug. Tramadol – Pregabalin – Duloxetine – Amitryptiline. etc

          This is actually better than staying one drug for years.
          Equally it is vital to eventually have exercise and relaxation work for you in order to reduce dependence on analgesics and take them only for more strong bouts of pain, learning to put up with some of the pain for the sake of overall health. Of course people with multiple pathology such spinal stenosis plus FM must consider the arthritic pain as well as it will be amplified by the FM condition.

          Hopefully we will soon know more about the underlying causes and get better medications.

        2. IanH says:

          While this study is not specific for FM it does indicate a relationship between vitamin D blood levels and opiate use for the control of pain. Low levels of Vitamin D are associated with greater use/dose of opiates.

          This suggests that vitamin D modulates pain OR that vitamin D reduces tolerance and habituation.

          1. says:

            I have had fibromyalgia after 3 auto accidents in 4 months! My doctor diagnosed my condition right away! I have tried every natural item that has ever been recommended in the 25 years since my accidents and nothing!!but narcotics have helped!!! I went to a pain clinic for 10 years. They have done studies on chronic pain and narcotic patients and the first one was done with 5000 patients taking narcotic pain meds. Only 7 patients were found to be addicted!!! One doctor did not believe the results!! This doctor did his own study on 10,000 patients, and guess what he came up with?? Only ONE patient was addicted!! I have had pain since my very first period due to endrometriosis so I dealt with that pain for 45 years until a doctor finally said that I needed a historectomy. Before that I took enough extra strength tylenol (8-10) a day to ruin my kidneys I would imagine! Unless you are in my body you or any doctor can tell me what works! Believe me when I say that I have tried every drug mentioned here and has anyone read the side effects of those drugs?? Read them all of you taking them! I never became addicted to oxicodone and it had no tylenol in it. It is a known fact that woman respond to narcotics for pain from fibromyalgia!! The government is more worried about those on street drugs than ordinary people in pain from nothing they have done wrong. They do not care about quality of life for those who have worked hard their entire life and now live in unbearable pain. It is genetic as my mother had it and a cousin is now complaining of pain all over, although she has not been diagnosed as yet. Her mother says that she exercised too much. Cold weather and inland storms also exacerbate the condition! While you doctors are searching for a cure and using drugs with terrible side affects that also cause addiction we with fibromyalgia have no quality of life. How helpful is a doctor that tells a woman who has been let go from her job due to cognitive problems from fibromyalgia, to go back to work!!! Is that doctor going to hire her???? Judy m Hinton I’ve been there!!!!

          2. IanH says:

            to have FM diagnosed straight after accidents because the diagnosis requires a different set of criteria to those for pain after physical trauma.

            It is understandable that the opiates help your pain because, probably much of your pain is arising from spinal compression and stenosis. If you do have FM then the FM will be heightening the pain from these anatomical pain sources. This is a very common confusion even among Rheumatologists, where spinal pain induces or worsens wide-spread pain and some people are diagnosed FM when they should be diagnosed “wide-spread pain arising from spinal injury”.

          3. gordonpt says:

            What if an FMS patient also has Asperger’s Syndrome? As an AS person, they are not as sensitive to applied pressure as a neuro-typical person. In order for pain to register, harder pressure is required. So, although there is body-wide pain from the FMS, perhaps it is not felt as soon as a neuro-typical with FMS. Does this make sense?

          4. binkies136 says:

            I too have fibro and a whole host of other stuff like cervical disk disease,osteoarthritis,…etc,that has been diagnosed by my practioner and is being treated by an Advanced Pain Specialists.I get put to sleep monthly for triple epidurals in my neck,to keep pressure off my brainstem,I take 4 pills x3 times a day and for pain and muscle spasms and then juggle 5 other meds for other issues.With all that being said,I had been denied for SSI 2 times and then waited another year for my hearing – despite all my records and all,I was denied AGAIN!He feels that my fibro hasn’t been properly diagnosed.I have to go to a Rheumatologist AND there’s only ONE that will take my state provided insurance AND that’s ALL the way in Oklahoma City!! I don’t have the money to travel so far and my vehical has been extremely neglected since I had to quit working in 2012.As is,I’m going to have to figure out how to go.The judge and VE(vocational expert) believe that I should be able to work fast food or in a factory,apparently they believe that at low paying jobs,they will let you lay down and take a break whenever you need too!!!WHAT!!!? Every job I have ever worked – I was lucky to get a 15 or lunch/dinner break EVER!!As is,I’m in another Appeal process AGAIN.I just want hot water again and feel secure to pay my bills and not get shut off every time I turn around.My kid has one pair of pants and they have holes,his shoes are growing to small and I can’t do anything about it.That little tiny bit of financial security would make such a difference,to not have to worry about those few things while I lay in bed,trembling uncontrollably in bed.Sometimes I can’t even sit up.
            I strongly suggest you all get set up with a Rheumatologist and the judge made a big deal about me not going to counseling too.I don’t have emotional instability,so why a counselor? I can’t afford to go to one for nothing.Yes,I take anti depressants but,who wouldn’t w/o heat and hot water,in our condition through 2 winters in Oklahoma gotta tell you,a space heater don’t do squat when its THAT cold!Regardless,I hope you the best,be patient.I hope I get mine before another winter hits or we lose my home.

          5. jewelll says:

            I have had fm since 1989 and have been on every assorted medication you can think of. What I now have found works for me is M-Eslon (morphine) 30mg, 3 times per day. 60 mg cymbalta in the am. 7.5 mg of zoplicone, 10 mg amitriptalyne. And I am sleeping nightly all night, my mood is getting better daily, my pain has gone from a 10 to a 3. I think I have found what works for me in having a good quality of life now and hope this may help others.

            So I can’t believe it when these pain specialists go on and on that opiates do not help fibromyalgia suffers. If they had this disease they would be needing opiates as we all suffer greatly with this disease.

          6. Bjcwskar15 says:

            I recommend using an attorney…..when they win your case they will get a percentage but require no money while handling your case and no money if they lose! It’s a lot quicker than going it on your on!!

    6. tailight7 says:

      Would like to learn more about these I just got diagnose 3years ago.

    7. mrshef says:

      Greetings. I honestly believe trama is a factor in fibromyalgia and all its family members. For me it was several head injuries and emotional trama. At 15 I started getting severe migraines that would just come on and last for several weeks, yes weeks, then as fast as it came on, it was gone. At 49 I was given a small dosage of an anti seizure med that after a few years stopped them. I lived in an abusive marriage for 20 years. The physical, emotional and mental abuse was another factor to my current medical conditions. I suffered a head trama after passing out from being ill. My forehead hit the porcelain tp roller. I still have a significant dent in my head. I had a roll over auto accident in which I experienced trama to my body and head.
      My current dx are acid reflux, ibs, cfs, memory loss, cognitive inabilities, fibromyalgia, panic/anxiety issues, depression and myasthenia gravis.
      I’ve decided to ween myself off the Cymbalta, kolonopin, flexeril, ambien, and only take the nexium and welbutrin. I’m blessed to have 3 awesome drs. My pc and rhumitologist are young women recently graduated and very receptive and knowledgeable. My neurologist is good, but doesn’t always listen.
      I know my body better than anyone. I’ve lived in it 59 years.
      Please take these comments under advisement when studying these issues. Thank you for the opportunity to voice myself.

    8. dstambaugh says:

      Tramadol isn’t a narcotic, it’s tagged as such because it can cause dependency. It only makes me unable to sleep, took one pill, that was enough for me.
      My pain started at the age of 14, I’m now 44, just after having Mono. Migraines started 6 months after having Meningitis. I currently get Botox injections for the migraines, and it has really helped. I recently started on LDN, which has helped with the Fibro Fog. Otherwise I take Tylenol and Aleve.

  2. Donna59 says:

    Hi my name is Donna, I’m 55 years old. I was diagnose last year for fibromyalgia. I also have several other health issues like severe sleep apnea, high blood pressure, severe psoriasis and psoriatic arthritis, osteo-arthritis, ulcer & acid reflux disease.

    My belief is my nervous system has alot to do with most of my health problems. I had a hard life growing up, alot of abuse.I never dealth with the abuse until later in my life but by then it had taken a toll on my health.

    Dr. Clauw have you found others with the same type of trauma/abuse with an connection with fibromyalgia? I beleve any type of trauma will bring this fibromyalgia on.

    I would like to hear from others who suffer with this horrible fibromyalgia and what their thoughts are on this.


    1. Petuniaim says:

      Donna, yes, I totally agree that the traumatic and abusive childhood I had was directly related to my fibromyalgia. I was under a great deal of stress and unresolved emotions, beginning with neglect and abandonment as a a baby and toddler followed by abuse through age 16. I was in severe pain by age 13. All of this also led to my perfectionism and type A personality which further stressed my body. Finally at age 32, I got viral pneumonia and literally, I collapsed. I had to quit my job when I was not getting better after 2 months. I laid in bed and thought I was dying. I am now 56 and have gone through many stresses and severe losses in my life. I still struggle each day of my life with pain, fatigue and a multitude of issues.

    2. chris60 says:

      I was diagnosed in about 1997. I was always active, I walked everywhere until then. I was abused growing up. I was moms favorite one to abuse. Someone once told me I probably have post traumatic fibromyalgia. For more than 10 years now, I have had no concentration whatsoever, and I hurt everywhere all the time, I also get little sleep at night. I have constant fatigue and take trazadone, and over the counter supplements for sleep, and gabapentin during the day. I have lost weight more than once over the years, and I hurt worse after weight loss. Altogether with fibromyalgia, I have arthritis, carpal tunnel syndrome in right side, tarsal tunnel syndrome in right side, heel spurs in both heels, and diabetes. I was diagnosed with diabetes in 2007. I am a mess. My doctor attributes every problem (but the tarsal tunnel and carpal tunnel syndrome) to weight and diet and can all be reversed in a month. He does not understand that when I lost 35 pounds, it took more than a month of healthy eating to achieve that goal. He also doesn’t understand that I was much more active when it started, so it’s not due to lack of activity. I have yet to find a doctor that even wants to understand fibromyalgia. I have not worked since 2011,when I was laid off from the job I had for 9 years. My lack of concentration certainly had a bad effect on my job and I have been unable to get a job since. I am trying to qualify for disability, but so far they tell me “there is no reason I can’t go back to the same type of work”. If you can’t concentrate on it, you cannot do your job. I had a desk job. I am at my wits end at this point and am not sure what to do.

    3. myia1013 says:

      I had pain and many sleepless nights rocking on the floor of my bedroom in tears while my family slept. When my daughter was born her pediatricians first greeting was a hug for mom and “how is Mom” I went to tears telling him of my symptoms. He sent me to a doctor friend Dr Carlos Keir This was 1982. Once someone understood He gave me a RX for helping sleep. What a difference in mt life. I am 70 yrs old now and GABAPENTIN is my bff. Just because you can’t see it doesn’t mean it isn’t there. Keep up the research.

      1. namawmills says:

        It took 4 years to diagnose me (My Doctor is very thorough). I take Lyrica 900 mg per day, Soma, oxycodone, Norco, 800 mg ibuprofen (three different pain pills for three different levels of pain). I have never taken so many meds in my life! I am on 1 year unpaid medical leave with no guarantee of my position should I be able to return to work. I have applied for disability and am waiting for a court day. I very rarely sleep at night, my Dr. has given me a sleeping pill but after 2 months it still was not working so he agreed with me and let me stop the pills, if they don’t work you don’t need them. I used to be a back packer and rock climber!! not any more, most days it is hard to get out of bed! I have regular adjustments (chiropractic) regular massages (yes it hurts but I ultimately feel better), and now I use my hot tub (Dr ordered so it is 100% tax deductible so get a prescription for it). I am hoping that with the 3 different therapies I might get some relief. I hope you can feel better soon!

  3. clownman says:

    Hello all Fibromylgia new and current members. I am new. I have had Post-Fibromyalgia for 22 years. Their is much difference in thee types of myalgias. Post is created from Trauma (example car accidents).You do not want to take addictive strong medications if you can avoid it or desire not to.My experience is to take a muscle relaxant at night controlled of coarse.It must be controlled through a very educated practioner in thee field,.though all input is good from everyone.Please check thee backdrop.If you are in a car related accident thee disease can come on right away..It does not mean that it will effect orther family members with pain.Post is entirely different on how a person received thee illness. It can effect them emotionally from thee sufferer having a chronic illness that will never go away.Unless their is a cure someday or a miracle.Good-Luck to all my new fibromyalgia friends,Post.

  4. DougalsMom says:

    Yes, from what I have heard there are a disproportionate number of people with Fibro who were abused. I also think chronic stress in your job or marriage is a contributing factor as well. The best thing I ever did for myself is start taking Ribose twice a day. It has taken a few months, and some adjusting of prescription meds, but I am nearly pain free and on no T3’s, Tramacet/Tramadol etc; not even any Aleve or extra strength Tylenol. I am off Amitryptilene and doubled Cymbalta with Trazadone (200mg) for sleep. No craving for sweets, muscle spasms are less, and I no longer feel like I’m slogging through mud everyday. I am 62 and was diagnosed at 36. I’ve been on disability for 11 years.

  5. scottyojai says:

    Another article praising CBT, exercise, and stress reduction for Fibromyalgia, and claiming that opioids don’t work. What? how can the American Pain society have it all backwards? This is the year 2015, that nonsense was proven wrong years ago. CBT,and exercise will do no good at all and exercise, if it is possible at all, can be dangerous. So, my question is: who IS this American pain society, and who is funding them? I’ll find out and get back to this group….meanwhile, pay attention to where you get your information.

  6. jordaine says:

    It seems to work for many people with autoimmune disorders. Google LDN and/or go to Much success.

  7. kraysabel says:

    Concerning Fibromyalgia pain in which I was diagnosed with for I had all 18 tender points positive. I also have tried all the medications approved for Fibromyalgia only to have allergic reactions to them or no relief whatsoever. I have literally a whole page of medications my doctors tried me on with no relief. I was unable to walk for the pain was so great and just unliveable. I was also unable to move my arms for the pain mimicked my legs. All blood work and even a muscle biopsy turned up negative for inflammatory diseases. It wasn’t until I was finally put on Hydrocodone and Dilaudid that I got some of my life back. Not all pain is taken away but at least now I can get up and do a few things here and there before using my muscles takes its toll and I need to rest. At least now I can live independently having narcotics for pain and am a believer that narcotics do help with Fibromyalgia pain.

  8. Bjcwskar15 says:

    I agree! I would not be able to function with the pain I have with fms if it were not for percocet and morphine through a pain clinic. I’m convinced all fms patients do not have the same level of pain! I have known people that say they have fms and never miss work and attend church and other functions regularly……I used to…..but now I am on disability and have very few “good” days and would have no good days without the regiment prescribed by my pain clinic….I keep watching for someone to come up with a cure so I wont have to continue these meds….but until then…thank God they are prescribed under strict supervision of course.

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