Fibro plus other diagnosis

[emd123]

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If you have a reliable low risk patient with a diagnosis that you normal would consider treating with an opiate, yet they have been given the diagnosis of "fibromyalgia" by another doctor, in your opinion does that make opiates contraindicated in that patient?

 

[Aether2000]

Fibromyalgia is not a disease but simply is a moniker for unknown etiology widespread chronic pain. It may coexist with other pain conditions and is not mutually exclusive. There is little or no high quality clinical evidence that widespread global pain does not respond to opioids, and there is little high quality clinical evidence that it does respond to opioids. There exist in the medical literature opinions, reviews of low quality papers, speculation, and highly emotionally charged irrational discussions about the appropriate and inappropriate treatment for this ill defined condition that really get us nowhere. It is a confounding diagnosis that is frequently employed by physicians as a euphemism or code word for "I think this patient is nuts" or "I do not possess the training, skills, or interest in making or pursing the differential diagnosis or treatment for this condition".

Observations about chronic widespread pain:
- whatever the etiology, it results in hypersensitization to real or perceived pain
- concurrent treatment of other pain generators is very problematic given the tendency towards hypersensitization responses.
- most of the time, a medically accepted valid diagnosis of the cause of chronic widespread pain is not determined
- many of these patients are self absorbed in their pain and lack the tools to focus externally
- it ultimately doesn't matter if you successfully treat a focal pain generator: the remainder of their pain will soon overwhelm any transient successes achieved.

 

[Ducttape]

clearly, fibromyalgia was initially a diagnosis of exclusion. unfortunately, over time, it is becoming a diagnosis of inclusion, as more and more criteria are thrown around. like algos says, oftentimes it becomes a situation in which there is no medically accepted valid diagnosis (in fact, a psychological diagnosis is probably much more appropriate)

the vast majority of individuals diagnosed with fibromyalgia have extraordinarily poor coping skills and underlying psychological issues that are frequently left unaddressed.

this becomes a self-fulfilling never ending pain process.


now combine opioid therapy on top of this, with tolerance, dependence, alterations of chronic hormone levels, changes in mood/hyperalgesia syndrome, whatever you may think bad that occurs with chronic opioid therapy, and you have a disaster begging to happen.

 

[lobelsteve]

Counterpoint:

I have labelled hundreds with FMS as the criteria in 2010 were changed to allow a WPI and a SSS to make the Dx meaningless.

FMS is the easiest thing we treat:

Choose: Lyrica, Savella, or Cymbalta.
Add: Skelaxin, Robaxin, or Flexeril.
If they are enrolled in aquatic or formal classes for PT or cardio, I add in Tramadol.
If they are in HEP or nothing else works I add in Naltrexone 5mg compounded.

They can get topical creams du jour and a TENS.
They can go to counseling.

There is no other treatment. Period. Period. Period.

It's a 5 min consult as long as they have had underlying medical Dx excluded.

I treat FMS as a distinct entity separate from all other conditions that the patient may have. So if they are post-lami, RA, or comorbid lung CA- I have no problems using opiates for the other condition knowing it has no effect on the FMS. The patient is counseled on this at the time I Rx opiates. I give them articles on decreased mu sensitivity and that the guidelines do not support opiates for FMS. If they can understand that there are two things wrong and one does notget better with the opiates, I am fine with that. They also know that opiates do not treat their HTN, DM, or underlying lung CA.

 

[Ducttape]

Counterpoint:

I have labelled hundreds with FMS as the criteria in 2010 were changed to allow a WPI and a SSS to make the Dx meaningless.

FMS is the easiest thing we treat:

Choose: Lyrica, Savella, or Cymbalta.
Add: Skelaxin, Robaxin, or Flexeril.
If they are enrolled in aquatic or formal classes for PT or cardio, I add in Tramadol.
If they are in HEP or nothing else works I add in Naltrexone 5mg compounded.

They can get topical creams du jour and a TENS.
They can go to counseling.

There is no other treatment. Period. Period. Period.

It's a 5 min consult as long as they have had underlying medical Dx excluded.

I treat FMS as a distinct entity separate from all other conditions that the patient may have. So if they are post-lami, RA, or comorbid lung CA- I have no problems using opiates for the other condition knowing it has no effect on the FMS. The patient is counseled on this at the time I Rx opiates. I give them articles on decreased mu sensitivity and that the guidelines do not support opiates for FMS. If they can understand that there are two things wrong and one does notget better with the opiates, I am fine with that. They also know that opiates do not treat their HTN, DM, or underlying lung CA.

the problem is that patients will not for the most part buy into the bold part. i have "caught" several legacy patients state that their long term opioids are either not helping with their fibro pain, or state that their other pain state has gotten worse so they need more and later slip up that they expect the fibro pain to get better with opioid increases.

Or, frequently, they will state that "but doc, its so hard telling the difference from my fibro pain and my chronic (insert pain condition here)."


ergo, for someone (myself) who really does not recommend opioids for chronic nonmalignant pain states for the vast majority of people, its an easy decision to avoid opioids.

 

[clubdeac]

Counterpoint:

I have labelled hundreds with FMS as the criteria in 2010 were changed to allow a WPI and a SSS to make the Dx meaningless.

FMS is the easiest thing we treat:

Choose: Lyrica, Savella, or Cymbalta.
Add: Skelaxin, Robaxin, or Flexeril.
If they are enrolled in aquatic or formal classes for PT or cardio, I add in Tramadol.
If they are in HEP or nothing else works I add in Naltrexone 5mg compounded.

They can get topical creams du jour and a TENS.
They can go to counseling.

There is no other treatment. Period. Period. Period.

It's a 5 min consult as long as they have had underlying medical Dx excluded.

I treat FMS as a distinct entity separate from all other conditions that the patient may have. So if they are post-lami, RA, or comorbid lung CA- I have no problems using opiates for the other condition knowing it has no effect on the FMS. The patient is counseled on this at the time I Rx opiates. I give them articles on decreased mu sensitivity and that the guidelines do not support opiates for FMS. If they can understand that there are two things wrong and one does notget better with the opiates, I am fine with that. They also know that opiates do not treat their HTN, DM, or underlying lung CA.

Excellent summary Steve. However I have offered these treatments and laid out a thorough treatment plan and the patient still counters with "but doc what ya gonna do for my pain?" It's completely unbelievable. And what about nucynta. Should this be added to your algorithm?

 

[lobelsteve]

Excellent summary Steve. However I have offered these treatments and laid out a thorough treatment plan and the patient still counters with "but doc what ya gonna do for my pain?" It's completely unbelievable. And what about nucynta. Should this be added to your algorithm?

If they cannot understand what I am telling them, there are other doctors.

No Nucynta for FMS. Schedule 2 (despite lack of mu binding).

1/50th in animal studies published
1/17th in human studies unpublished

for mu binding affinity compared to morphine.

So it is a little weaker than codeine from that standpoint.

 

[SSdoc33]

FMS is the easiest thing we treat:

QUOTE]

wrong.

FMS is a time sink and frustrating to treat.

the treatment options may be clear, but getting the patients to buy in is not. i give them my spiel, but if i let them, they'd keep firing away questions for a half an hour. how is that "easy"? what the patients need is some good mental health care, and i am not the right doctor for that.

 

[lobelsteve]

FMS is the easiest thing we treat:

QUOTE]

wrong.

FMS is a time sink and frustrating to treat.

the treatment options may be clear, but getting the patients to buy in is not. i give them my spiel, but if i let them, they'd keep firing away questions for a half an hour. how is that "easy"? what the patients need is some good mental health care, and i am not the right doctor for that.

You have to lose the attitude and attack with what you will and will not do. If they feel they need something that you will not do, then you cut them off from their woe is me speech and redirect. One redirect per patient, then I get up and walk towards the door. It's that simple, "choose one from column A and one from column B and tell the nurse, I'll write the TENS and aquatic referral while she is getting you check out."

 

[SSdoc33]

You have to lose the attitude and attack with what you will and will not do. If they feel they need something that you will not do, then you cut them off from their woe is me speech and redirect. One redirect per patient, then I get up and walk towards the door. It's that simple, "choose one from column A and one from column B and tell the nurse, I'll write the TENS and aquatic referral while she is getting you check out."

Right. That's your spiel. Fms patients don't want that. They want someone to listen to them moan. I'm with you, Ill lay it out for them and be direct. Never heard anyone say that treating FMS is the easiest thing they do,tho

 

[painstop]

Two new patient fibros in a row this morning...man those patients just drain me. Easily take twice as long as a typical lumbar radiculopathy new patient because I have to explain all the ways they should approach this problem without making them "feel" like head cases or drug addicts using opiates to escape reality (please note the quotation marks).

 

[clubdeac]

I find a lot of times these patients just want someone to listen. If you're caring and show genuine interest, they're content if they can see you every few months just to vent. I try a little of this and a little of that and even if it doesn't work they aren't that disappointed as long as there's something else we can try and they feel they are being listened to.

 

[clubdeac]

Steve or anyone else who is familiar with this, when prescribing 5mg compounded naltrexone, can the patient be one opiates or will that precipitate withdrawal? I'm thinking of trying this with one of my whole-body pain patients but she is already on 75mcg fentanyl by her pcp. Any thoughts?

 

[SeniorWrangler]

I was going to reply but Steve already said it. The only thing I'd add is that many studies have shown that graded exercise is really effective for fibromyalgia, and in my own experience that's the only thing that really gets people better, all the other modalities just take the edge off somewhat.

I personally think it's really important to help fibro patients understand what they have and what they need to get better; until they get that, they tend to keep searching and seeing different specialists and they can get in a lot of trouble getting inappropriate meds or procedures. I also think that procedures tend not to work very well in patients with poorly controlled fibro, and in fact can be counterproductive, but I will consider them in well-controlled fibro patients who are physically active and have a clear indication for such.

Steve or anyone else who is familiar with this, when prescribing 5mg compounded naltrexone, can the patient be one opiates or will that precipitate withdrawal? I'm thinking of trying this with one of my whole-body pain patients but she is already on 75mcg fentanyl by her pcp. Any thoughts?

Interesting question, but I can't find any literature to speak to it either way. There are only a few topical neltrexone studies and they all excluded patients on chronic opioids as far as I can tell. Opioid withdrawal isn't dangerous, so you could have the patient try it judiciously on unbroken skin if you think they could handle it. Are you using it for pruritus or other indication?

 

[melancholy]

i think learning how to manage fibromyalgia itself is difficult but can be done with proper education and addressing co-morbidities including mood and sleep disorders. patients have a tendency to have overactivity pain and lose confidence in exercise. other thing to consider is that given the hypersensitivity, they can have flareups induced by other pain generators and vice versa. once fibromyalgia symptoms are under better control, patients can better differentiate a distinct separate pain generator whether it is a new lumbar radiculopathy, SI joint pain, and even a myofascial trigger point. there are occasional patients who have these diagnosable other pain generators who may benefit from low dose opioids with careful monitoring and find that it helps to manage their separate pain generator and secondarily their fibromyalgia pain. opioids are never first line for fibromyalgia patients, but i do find cases where they are helpful for managing patients that have multiple diagnoses. i do agree with steve on adding in your favorite neuropathic agent, occ muscle relaxant, and a pool program to boot.

 

[mille125]

Counterpoint:

I have labelled hundreds with FMS as the criteria in 2010 were changed to allow a WPI and a SSS to make the Dx meaningless.

FMS is the easiest thing we treat:

Choose: Lyrica, Savella, or Cymbalta.
Add: Skelaxin, Robaxin, or Flexeril.
If they are enrolled in aquatic or formal classes for PT or cardio, I add in Tramadol.
If they are in HEP or nothing else works I add in Naltrexone 5mg compounded.

They can get topical creams du jour and a TENS.
They can go to counseling.

There is no other treatment. Period. Period. Period.

It's a 5 min consult as long as they have had underlying medical Dx excluded.

I treat FMS as a distinct entity separate from all other conditions that the patient may have. So if they are post-lami, RA, or comorbid lung CA- I have no problems using opiates for the other condition knowing it has no effect on the FMS. The patient is counseled on this at the time I Rx opiates. I give them articles on decreased mu sensitivity and that the guidelines do not support opiates for FMS. If they can understand that there are two things wrong and one does notget better with the opiates, I am fine with that. They also know that opiates do not treat their HTN, DM, or underlying lung CA.

Gabapentin, tizanidine and nortriptyline should also be in the "choose" category. They do work well for fibro despite what the drug rep marketing machine will have you believe.

 

[Aether2000]

I suppose so. Working well in pain medicine means a 1.5-2 point. VAS reduction...not much clinical improvement but enough to keep statisticians happy. Sometimes that is as good as it gets.

 

[EdPierce]

i think the worst is when these FMS patients bring their sob stories and complaints to surgeons, and the surgeons dont really get that its a supratentorial process. So they find some type of vague objective finding (OA, inflammation, scar tissue, abnormal emg) to justify surgery. Then they operate, chronic pain ensues and another chapter is added to the sob story, and they come to your clinic now feeling like they "deserve" opiates since they "had to have surgery" "no my joint was really bad totally gone (from a 35 year old guy).

we have to be skeptical of their side complaints, this is just a hypersensitive person in general. How legitimate is this complaint? These complaints are likely nothing, but get operated on, and opiates follow.

 

[epidural man]

Since the question was - do you treat with opioids for ANOTHER pain condition in someone with FMS - not, how do you treat fibromyalgia...I agree with Steve, who said that he would, in some painful conditions treat with opioids.

I agree with that, however, would not choose a pure mu agonist. I really like Nucynta and bupernorphine in this context (or really any context that i'm thinking about using opioids).

I also agree with ya'all that supportive listening is the key.

I also find I need to get these patients to sleep. That is difficult sometimes. I will try them all (meds), including ambien. I think if they can sleep, life for them is much better.

On the topic of Nucynta, I have yet to find anyone get hyperalgesic on it. I have yet to find anyone seem to abuse the drug. I have yet to find anyones pain get worse on it (although plenty say it doesn't work). There have been a ton of strange side effects when starting it however (although I often question the validity of the patient's complaint and wonder if they just want their oxycodone back). Also, we have yet to find HPA axis supression on the stuff.