TREATMENT OF FIBROMYALGIA
By Prof. Robert Bennett M.D., FRCP, FACP
If you are reading this you probably have a common syndrome of chronic musculoskeletal pain called Fibromyalgia. This chronic pain state is now appreciated to be caused by abnormalities of sensory processing within the spinal cord and brain. As such you will usually experience a bewildering (both to you and your doctor) array of bodily and psychological problems that can seldom be “cured”. However, armed with both patience and knowledge, many Fibromyalgia patients can be helped to live with less pain and be more productive. In my own evolving experience of dealing with this problem, I can identify seven aspects of management that are of importance for your doctor to successfully manage your Fibromyalgia.
My Advice to Doctors who care for Fibromyalgia Patients
1. Realise that FM patients are going to be a chronic challenge.
2. Be non-judgmental and prepared to be an advocate.
3. Understand the pathophysiological basis for symptoms.
4. Analyse and treat pain complaints in a systemic approach.
5. Recognise and treat psychological problems at an early stage.
6. Recognise associated syndromes of disordered sensory processing.
7. Involve all FM patients in a program of stretching and gentle aerobic exercise.
Treatment of Pain in Fibromyalgia
Pain is the primary over-riding problem for most of you. Many of the problems you experience are largely a secondary consequence of having chronic pain. When pain is even partly relieved, Fibromyalgia patients experience a significant improvement in psychological distress, cognitive abilities, sleep and functional capacity. A total elimination of pain is currently not possible in the majority of Fibromyalgia patients. However, worthwhile improvements can nearly always be achieved by a careful systematic analysis of the pain complaints. As a generalisation, Fibromyalgia-related pain can be divided into general pain (i.e. the chronic background pain experience) and focal pain (i.e. the intensification of pain in a specific region – usually aggravated by movement). The latter is probably a potent driving force in the generation of central sensitisation. Attempts to break the pain cycle, to enable patients to be more functional are especially important. In general, most FM patients do not derive a great deal of benefit from NSAID preparations or acetaminophen, although NSAIDs are very useful in the treatment of associated joint pain problems such as Osteoarthritis.
* General Pain
The use of NSAIDs (e.g. ibuprofen, aspirin, etc.) is usually disappointing; it is unusual for FM patients to experience more than a 20% relief of their pain, but many consider this to be worthwhile. Narcotics (codeine, and oxycodone (OxyContin/OxyNorm)) often provide a worthwhile relief of pain. In most patients, concerns about addiction, dependency and tolerance are ill founded. Ultram (Tramadol, Zydol, Tramacet) and Ultracet (Tramadol + Tylenol) (not available in UK), are the most useful pain medications in many patients. They both have the advantages of having a low abuse potential and is not a prostaglandin inhibitor; Tramadol reduces the epileptogenic (seizure) threshold and it should not be used in patients with seizure disorders. Currently, opiates are the most effective medications for managing most chronic pain states (Friedman OP 1990, Portenoy 1996). Their use is often condemned out of ignorance regarding their propensity to cause addiction, physical dependence and tolerance (Melzack 1990, Portenoy et al 1997, Wall 1997).
While physical dependence (defined as a withdrawal syndrome on abrupt discontinuation) is inevitable, this should not be equated with addiction (Portenoy 1996). Addiction is a dysfunctional state occurring as a result of the unrestrained use of a drug for its mind-altering properties; manipulation of the medical system and the acquisition of narcotics from non-medical sources are common accompaniments. Addiction should not be confused with "pseudo-addiction". This is a drug-seeking behaviour generated by attempts to obtain appropriate pain relief in the face of under-treatment of pain. Opiates should never be the first choice for pain relief in Fibromyalgia, but they should not be withheld if less powerful analgesics have failed. In my experience many Fibromyalgia patients want to try opioid medications, but then give up on them due to unacceptable side effects, such as mental fog, increased tiredness, dizziness, constipation and itching.
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