Provider News Summer 2016 - Fibromyalgia

Fibromyalgia pain control in primary care

By Shepard Greene, MD, Chief Psychiatrist, Shasta County HHSA

With the growing concern of Rx opioid/heroin abuse and addiction across the country, and pundits advocating for various solutions, I’ve opted to briefly touch upon a common patient presentation.“Doc, I’m sore all over … I’m not sleeping … I’ve got no energy … I can’t concentrate … I’m anxious … my husband’s starting to get annoyed with me … I saw a therapist for a while but that didn’t help … My other doctor put me on Lexapro and then Abilify and then Brintellix and then wanted me to try something else, but …”

You opt to obtain the obligatory labs to include a CBC, comprehensive chem panel, TSH, ESR, ANA, RA and the results were unrevealing.  You start thinking about Lyme titers, Parvo and anything else that you can think of prior to asking for a rheumatology consultation.  The friendly response from your colleague thanking you for the referral of “this most interesting patient” suggested a diagnosis of fibromyalgia high on the differential.  Now what?

As of yet, there are no official treatment guidelines from the American College of Rheumatology, but there is a consensus of expert opinions regarding a multimodal approach that includes medication, cognitive behavioral therapy and lifestyle changes that include exercise.

Please refrain from the use of opiates; quite simply, they don’t work and may eventually exacerbate fibromyalgia.  SNRIs to include venlafaxine (Effexor XR), desvenlafaxine (Pristiq) or duloxetine (Cymbalta) in combination with alpha 2 delta ligands such as gabapentin (Neurontin) or pregabalin (Lyrica) may help.  How? By modulating hypothetically malfunctioning spinal cord/brain circuits.  The antidepressants may activate the descending inhibitory pathways that reduce the activity of nociceptive pain neurons.  The alpha 2 delta ligands may diminish excessive neuronal activity by modulating voltage sensitive calcium channels.

Should you or your patients still feel strongly about using tramadol (Ultram), caution is warranted.  Most if not all your patients with fibromyalgia will also be using an antidepressant.  Many of the antidepressants will inhibit the metabolism of tramadol and in turn precipitate seizures or induce a serotonin syndrome.  There is really no role for the use of hydrocodone, oxycodone, methadone, fentanyl, etc. in fibromyalgia. Research shows opiates are of little benefit to most people with fibromyalgia and may cause greater pain sensitivity or make pain persist. Perhaps we can make a difference in our community by educating our patients regarding multiple approaches to pain management, while still empathizing with their unfortunate maladies.

Emphasize the role of staying active as the primary treatment modality.  Recommend joining a Tai Chi or yoga club or any other activity that may appeal to your patients. De-emphasize the role of medication, but continue to prescribe alternatives to opiates as necessary. Lower your patients’ expectations by realistically explaining that symptoms will only be reduced by approximately 25-50%.  Encourage participation in support/therapy groups, as they will need to learn to live with their symptoms rather than expecting a cure. Fibromyalgia patients may benefit from visiting this page.