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Pain

Pain is a major symptom in both FM and CFS/CFIDS/ME, although many don't initially think of CFS/CFIDS/ME as illnesses with pain. Since patients experience many types of pain—such as muscle aches and spasms, fatigue pain in muscles from lactic acid build-up, myofascial pain, multiple joint pain, neuropathy, and headaches, including migraines—therefore, pain is often treated with a combination of medications and/or therapies.

Many patients find they have a hard time getting adequate treatment of their pain and are often met with resistance by their doctors—in particular, primary care physicians. This is often due to not understanding how to use certain medications, misconceptions about dependence versus addiction and/or efforts to avoid scrutiny by regulatory agencies. It may become necessary for patients to seek out doctors who specialize in treating pain, possibly rheumatologists or physiatrists (specialists in physical medicine and rehabilitation) and/or pain management. There are clinics/centers dedicated to pain management which operate as small private practices or as pain management clinics within hospitals.

Home remedies can include use of ice or heat packs. Ice packs help to reduce swelling and slow down the nerve impulses to a localized area of pain, while heat packs help to increase blood flow to a localized area of pain and ease stiffness. The most commonly prescribed treatments are listed below, while it is understood many other medications/ protocols are being used.

  • Over the Counter (OTC) pain relievers—Tylenol (an analgesic using acetaminophen as its active ingredient), Motrin or Advil (nonsteroidal anti-inflammatories that use ibuprofen, as an active ingredient, to reduce pain and inflammation), and/or Aspirin (from a group of drugs called salicylates) which is used to relieve pain and inflammation, but also to treat cardiovascular conditions in some patients. Be careful about checking warnings on each product and observing daily recommended limits, especially for acetaminophen as it may cause liver damage when used at high doses or by someone with abnormal liver function. Also, be aware some of these pain relievers, like acetaminophen, are added to multi-symptom cold formulas and prescription narcotic pain medications.   

  • Topical pain relievers (OTC)—creams and ointments with active ingredients such as camphor, menthol or other oils (like eucalyptus) and /or methyl salicylate which help to reduce localized pain. A few OTC creams contain capsaicin (like Zostrix) which, with repeated applications, is supposed to lower Substance P (a neurotransmitter for pain). The active ingredients in these products still get absorbed into the body and it is possible to use too much.

  • Topical products, by prescription—compounding pharmacies can prepare creams with a variety of medications in them, like anti-inflammatory or anesthetic agents. Lidoderm are transdermal patches which contain lidocaine and used on sites of localized pain.

  • NSAIDS (nonsteroidal anti-inflammatories) by prescription—Mobic (Meloxicam), Naprosyn (naproxen) and Celebrex (Celecoxib). These may cause considerable gastrointestinal upset and bleeding.

  • Muscle relaxants—Zanaflex (tizanidine), Skelaxin (metaxalone), Lioresal (baclofen), and Soma (carisprodol) are the most common ones prescribed. They are used to relieve muscle spasm pain and stiffness, but each works in a slightly different way.

  • GABA (gamma aminobutyric acid) inhibitors—these are medications which change the firing of certain nerve cells in the brain and were initially prescribed to control seizures. Neurontin (gabapentin) was the first such medication used for CFS/CFIDS/ME and FM to help treat neuropathy (nerve pain) while Lyrica (pregabalin), a derivative of gabapentin and manufactured by the same company, was recently approved specifically for FM pain. Lyrica seems to work well for some patients, while others experience too many troublesome side effects, including weight gain. The standard, recommended dosage has been found somewhat too high for many FM patients. Another drug used to control seizures in Europe, Lacosamide, is currently in US clinical trials as another treatment of pain in FM (estimated market date is around 2011). Its mechanism is considerably different from Neurontin and Lyrica by working on the hyperactivity of certain neurons, thus being able to raise the pain threshold, and possibly, without weight gain or sedation.

  • Antidepressants—some of the same antidepressants prescribed to promote sleep have been found to reduce pain in some patients. One of the newer antidepressants, Cymbalta (duloxetine), was recently approved for the treatment of pain in FM and it works by increasing activity of serotonin and norepinephrine, which are thought to affect amount of pain one can feel.

  • Migraines—there are range of medications used to treat migraine headaches. One of the older formulas that might be prescribed is Midrin (isometheptene mucate, dichioraiphenazone, and acetaminophen) which consists of three ingredients—one works on blood vessels, another provides a mild sedative, and the third is a common pain reliever. A newer family of migraine medications is the "triptans" family which includes Imitrex (sumatriptan)—it comes in oral form, nasal spray and as subcutaneous injections. Other related medications are Zomig (zolmitriptan) or Relpax (eletriptan). Extra caution needs to be taken in anyone who has co-existing cardiac problems. It is essential to also understand triptans should not be combined with SSRIs (or other medications that alter serotonin) which according to recent FDA alert can lead to Serotonin Syndrome. Another treatment approach is to try and prevent migraines with the use of beta-blockers (like Inderal) or calcium-channel blockers—verapamil, in particular (which has been studied as an effective prophylaxis of migraines). Other medications used to prevent migraines are some of the anti-seizure medications such as Topamax (topiramate).

  • Non-narcotic pain relievers—Ultram (tramadol) or Ultracet (tramadol with acetaminophen). This medication is considered a cousin of the narcotic family and binds to certain opioid pain receptors and affects the re-uptake of norepinephrine and serotonin. Seizures have been reported in some people using Ultram.

  • Opioid Analgesics—used to relieve moderate to moderately severe pain. Examples of pain medications in this group are Vicodin (acetaminophen and hydrocodone), Tylenol #3 (acetaminophen with codeine), Darvocet-N (propoxyphene), Percocet or Percodan (short-lasting oxycodone with acetaminophen or aspirin), oxycontin (a longer lasting controlled time-released agent) and/or Duragesic (fentanyl transdermal system). Several important warnings need to be made about fentanyl patches and their safety, especially given the incidence of accidental overdose and even death from these. The active ingredient is a powerful, rapid-acting opioid which is absorbed through the skin via a sustained release system. Patches must be used exactly as prescribed, including placement which can affect drug absorption, and extra care should be taken not to damage nor cut them in any way because this could cause the opioid to leak and alter the dose received. Furthermore, numerous lots of fentanyl patches have been voluntarily recalled by different manufacturers due to defects which could cause an incorrect amount of medication to be released and absorbed. All of these aforementioned medications are "controlled substances". Some are classified as Schedule II medications which means patients will need a new prescription for each month that they will be using one of these medications. Methadone, also in this category of medicines, has been gaining more recognition as an option for pain relief and is prescribed in very small amounts by some leading FM specialists. Many of these medications could provide inexpensive, effective pain relief for a number of patients, but often they are not even able to try them. Many inaccuracies and myths surround this family of medications, like fears of patient addiction. The limiting of quantities, if or when they are prescribed, creates inadequate pain relief (as the effects of some last for only about four hours). Asking for better/ longer pain control is often viewed as drug-seeking behavior by the patient. A number of international CFS/CFIDS/ME and FM specialists recommend longer-acting, as opposed to shorter-acting, opioids in order to level off the up and down recurrence of pain.

  • Dry needling and/or injections of trigger points—treatment primarily used in FM where patients' trigger points (points of knotted muscles from which pain often radiates) are isolated and either thin needles are inserted into these points/knots or they are injected with anesthetic agents. The goal is to reduce painful input to the central nervous system.

 
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