Part 3 Treatment
Fibromyalgia has no cure, and treatment is based on a holistic approach that would involve combining multiple disciplines that will together improve one's quality of life. Essentially, when we discuss the treatment or management of fibromyalgia the aspects of pain must be controlled, as well as the vast array of other symptoms. Personally, it's a bit of a juggling act, in trying to not let the pain get out of control while functioning just performing normal daily tasks, and trying to be cognizant of not overdoing it. As for me, the pain when it's bad, seems to take all my focus, and I am easily forgetful about my self-control issues in terms of wanting to set the table and cook dinner, and then not having enough energy to do the dishes and clean up. However, over time and learning some tricks I will get better with self-management. I may be getting take out now and then (just saying!). Then, this will be my husband when I tell him we're getting take-out because he hates eating out as he eats out at work too much. Note the mean eyes!
Seriously, though every person who is suffering from fibromyalgia is obviously different and not just in terms of pain tolerance but also in the line of symptoms they are experiencing. Each individual experiences with fibromyalgia is not a cookie-cutter format. There are all too many symptoms that exist which can affect an individual. This is where a support group would be beneficial as people can share their experiences. This is an important factor, to be considered as treatments will vary drastically from person to person. Therefore, each individual's treatment plan will have to be designed to meet their individual needs. A treatment plan should be formulated together with your physician and your health team. Your input should be considered when this plan is developed. In illustrating this point my physician and his staff (who are wonderful by the way) are aware if I am experiencing a bad flare it is known that I can pop into their office, be seen briefly and he okays what I call the "cocktail" which consists of three shots that include a steroid, Toradol, and Benedryl. It gives me some relief to get some rest and usually, it relieves most of my joint pain and migraine. It is a sense of security may be that I know that I can attend for the cocktail shot should I need it and they know how to deal with me.
According to the Canadian Fibromyalgia Guidance Committee,
"Ideal management includes both non-pharmacologic and pharmacologic treatments in a multimodal approach, with active patient participation fostered by a strong patient-centered locus of control".
A treatment plan should combine both the pharmaceuticals that will be taken as well as the self-care strategies that we previously discussed, such as, massage therapy, acupuncture, yoga, and counseling. When I was newly diagnosed I failed to comprehend that I had a role to play in this illness, besides just being ill. I was initially completely passive and expecting my Doctor to "fix" everything. I slowly then realized after some frustrations that I didn't have to be passive and I should be managing my treatment more actively. I will say that sometimes we're too busy managing life and the illness to realize these things. So, my plan combines many aspects such as an occupational therapist, a chiropractor, a massage therapist, a psychologist, a few specialists, a pain management doctor, a pharmacist, and my family physician. Note that with COVID some aspects are on hold. The best thing I did was get referred to a pain management clinic. I also started with a psychologist quickly to help me navigate my emotions and help me adjust better. I believe that each individual who is dealing with fibromyalgia should be involving a psychologist or a social worker in their care plan as the disorder does involve depression and anxiety.
In regards to treatment, a fibromyalgia patient should be aware of the existence of guidelines for this illness. The Canadian Fibromyalgia Guidance Committee ( CFCG) was established and consisted of health care professionals, a subject matter expert, a patient representative, and a research coordinator. The CFCG developed the guidelines in order to help address the needs of patients care.
"The need for guidance which goes beyond management, and also incorporates diagnosis and the patient trajectory. We have set out to consolidate information published mostly in the last two decades to develop evidence-based recommendations that will have good clinical utility in the day to day management of FM patients".
These guidelines seek to enhance patient care by managing symptoms in order to improve the quality of the individual's life with better functionality. The takeaway here is to manage the symptoms and have pain control mechanisms in place that allows a patient to function and enjoy their life more.
Medication
As we discussed previously the best approach for fibromyalgia is to combine several treatment methods that involve self-care, physical therapy, and counseling. This is basically the guidelines set out by (CFCG) for the treatment of fibromyalgia. In this section we will our discussion about treatment, focusing on medication for fibromyalgia. Currently, in Canada, the only two medications that are officially designated for the treatment of fibromyalgia by Health Canada are duloxetine and pregabalin. http://www.pharmacists.ca/cpha-ca/assets/File/Sample%20chapters/CTC2017_Sample%20Chapter-Fibromyalgia.pdf
"The traditional pharmacologic treatment paradigm begins with the use of simple analgesics and TCA’s. Other pharmacologic treatments including other antidepressants, gabapentinoids, dopaminergic agents, and sleep modifiers are now more commonly used". http://fmguidelines.ca/?page_id=21
The pharmacology aspects of the treatment of fibromyalgia involve the use of analgesics, antidepressants, and various mediations to treat the worst symptoms. Essentially, the treatment of the most annoying symptoms is to improve how an individual feels. Keep in mind, everyone is different and not all things will work the same for everybody. Careful attention to prescribed medication, dosage, interactions, and tracking the effects is important. A physician can slowly modulate the dosage as a person climates to the prescription until relief is noticed.
Analgesics
First, let us talk about pain relievers. Acetaminophen, Tylenol, Aleve, and non-steroid anti-inflammatory drugs are the most popular. Usually, used at low doses temporarily to avoid any other side effects https://arthritis.ca/about-arthritis/arthritis-types-(a-z)/types/fibromyalgia. The non-steroid anti-inflammatory drugs (NSAID) are hard on the stomach and this may lead to the need for another prescription drug to control the acid caused by the NSAID. Also, NSAIDs can not be used for extended periods without causing other side effects. I want to make sure that it is understood that I have no medical training and I am definitely not a Doctor. However, I can explain from personal experience that I did try the basic pain relievers but I did not receive enough relief from them. Especially, during a flare when the pain is severe. So, there is a need for other alternative pain medications.
Opioids
Generally, it is not advised to take narcotics for fibromyalgia, there is a great concern for opioid addiction. However, in many cases, many drugs don't work well for fibromyalgia due to nerve pain. "Opioids showed only small to moderate benefits for improving pain and function" http://nationalpaincentre.mcmaster.ca/opioid/cgop_b01_r04.html. From what I can gather there is a controversy regarding the use of pain medications and addiction concerns.
The Canadian guidelines for safe and effective use of opioids for chronic non-cancer pain found that "one opioid (Tramadol) was effective for fibromyalgia pain and function" http://nationalpaincentre.mcmaster.ca/opioid/cgop_b01_r04.html. There were two studies that support the use and effectiveness of Tramadol to relieve certain pain conditions such as neuropathy, neuralgia, low back pain, and neck pain. Further, another pain condition for which Tramadol would also be effective would be for osteoarthritis and rheumatoid arthritis. Often, the existence of arthritis is a comingled condition with fibromyalgia. Also, the use of Butrans patch (Buprenorphine) does help with pain and it has great reviews. Check out Fibro Mom's personal experience on youtube https://www.youtube.com/watch?v=kukkVWhDBTc&t=26s. In my personal opinion, I am impressed with this medication. As with any medication, there are side effects and interactions so please be careful and ask all the good questions.
Anti-depressants
I was pretty shocked when my family doctor prescribed an anti-depressant for my Fibromyalgia, and even somewhat offended at first. He explained that the medication was very helpful with low-back pain and joint pain. I started on Cymbalta and eventually went off it for a bit. When I went off it for a period I found that my low-back pain became severe. I have to say that Cymbalta is a necessity for me since I did not like Lyrica. However, having Fibromyalgia and taking medication is like being in a bad romance and it is a love and hate relationship. Cymbalta (Duloxetine) and Savella are both utilized in the treatment of Fibromyalgia.
"Antidepressants change the way certain neurotransmitters work in your brain, and the same neurotransmitters are involved in FMS, ME/CFS, and major depressive disorder." https://www.verywellhealth.com/ssrisnri-antidepressants-for-fibromyalgia-and-mecfs-716039
The neurotransmitters involved are serotonin and norepinephrine that send messages to other brain cells. Sleep disturbance and pain processing are some of the biggest issues with Fibromyalgia, and one of those neurotransmitters, serotonin is involved in those two essential body functions. Whereas, norepinephrine, the other neurotransmitter is the stress response mechanism. Essentially, the anti-depressants make the neurotransmitters in your brain perform alternately. The serotonin increase alone decreases pain.
Also, let's discuss muscle relaxers such as cyclobenzaprine,(Flexeril) and Zanaflex, which will help to alleviate some pain, fatigue, and tenderness. This medication is taken at bedtime for better sleep. Again, ensure you ask good questions regarding drug interactions. Medications such as Baclofen, another muscle relaxer, that is used to treat spinal cord injuries, multiple sclerosis, can also be prescribed.
"Bedtime treatment of fibromyalgia patients with low-dose cyclobenzaprine was safe and appears to be effective," says Seth Lederman, MD, president of TONIX Pharmaceuticals, which funded the study" https://www.webmd.com/fibromyalgia/news/20110914/muscle-relaxant-may-help-fibromyalgia-patients#1
Anti-seizure drugs
Lastly, anti-seizure drugs such as Gabapentin (Neurontin)and (Lyrica) pregabalin are utilized for fibromyalgia and chronic pain patients. Gabapentin helps to alleviate nerve pain which is a common symptom. This drug does improve my sleep and lessens my nerve pain to some degree but it does not take it away.
Some, drugs that I can't be without are Ondansetron or Zofran for nausea since I have horrible nausea all the time. It does help me function better. This is my box of drugs that I and every fibromyalgia patient has stashed probably in their nightstand for easy accessibility. Every day, I take at least ten capsules, that is just the maintenance program. That does not include pain drugs for breakthrough pain, nausea, or acid pills for the stomach. I don't like to live like this and I am sure no one does. We will talk about other alternative drug modalities in another blog.
In conclusion, we have discussed so much in regards to treatment and medication. In speaking with so many fibro fighters everyone is always trying to get the right treatment protocol and function the best they can. There is no right or wrong, everybody is different and their pain is unique. I have no medical training, please speak to your medical team including your physicians and pharmacy before changing anything.
I am a fibro fighter and this is my disorder' ed life, messy top knot bun hair, and all. Thank you for following.