Fibromyalgia Opinions

[ntubebate]

patients should not be posting on these boards...

but anyway, this patient who (like the above poster mentioned) has the most condescending post of them all is the perfect example of why one should not prescribe opioid therapy for fibromyalgia, myofascial pain... she is already on fentanyl and despite that is still crying in pain...now some doctors will enable her and in 1.5 years from now she is going to be on 150mcg of fenatyl and 10mg oxycodone qid and she will STILL be crying in pain....then what are you going to do???? are you going to a) say I have to refer you to pain mgt b/c as I cant do anymore...b)well lets try changing you to actiq or dilaudid for breakthru, c) lets increase fentanyl to 200mcg, d)uh, lets try putting you on oxycontin, d) please stop coming to me, find another doctor because now I am scared


folks do not prescribe opiods for fibromyalgia

Firstly, this "folks" can does and will continue to prescribe opioids for FMS. However, in the patient mentioned above I would (as always is the case with me) give a trial of Dolophine with Vicodin HP q4-6HRS PRN with instructions NTE 3 tabs QD. Would titrate the Dolophine as high as 40mg qd. At that point I personally feel we have given a more than adquate trial of opioid analgesia. If the patient is, as you put it, still crying in pain. I am sorry. We've proven that for this patient opioids are not the solution. If they are affording her the ability to better function, I'm fine with continuing them. Otherwise, we're going to taper and we're going to do it in less than three months.

Not all my FMS patients take opioids. I would say a decent portion take Vicodin at a low dosage PRN. A small precentage of those will eventually be tried on strong round the clock opioid therapy and of that small precentage an even smaller portion will stay on chronic strong opioid therapy. I actually looked today at some stats and I average 1 in 4 patients who are tried on strong, round the clock opioid therapy who actually stay on such treatment. Almost all of my FMS patients on strong round the clock opioid therapy have an additional pain diagnosis (OA, DDD, DJD, MPS, ect ect ect...)

My records for treatment are FAR FAR FAR better now that we have Ultram ER. I'm find that Ultram ER properly titrated with PRN Vicodin for BT pain works better than anything I've seen. (That is, when it is combined with either Lyrica or Cymbalta).

I guess what I'm trying to say is FIRST get your FMS patients on Cymbalta. Then add on Lyrica if pain is not improving. Then hit the Ultram ER. Once you've maxed out doses there, throw in a TCA (or not if you aren't familiar with mixing antidepressants) and given them something for sleep... THEN you can worry about prescribing an opioid.

ntubebate

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[deleted87716]

I guess what I'm trying to say is FIRST get your FMS patients on Cymbalta. Then add on Lyrica if pain is not improving. Then hit the Ultram ER. Once you've maxed out doses there, throw in a TCA (or not if you aren't familiar with mixing antidepressants) and given them something for sleep... THEN you can worry about prescribing an opioid.

Actually, that sounds a lot like what I do.

 

[jsaul]

Firstly, this "folks" can does and will continue to prescribe opioids for FMS. However, in the patient mentioned above I would (as always is the case with me) give a trial of Dolophine with Vicodin HP q4-6HRS PRN with instructions NTE 3 tabs QD. Would titrate the Dolophine as high as 40mg qd. At that point I personally feel we have given a more than adquate trial of opioid analgesia. If the patient is, as you put it, still crying in pain. I am sorry. We've proven that for this patient opioids are not the solution. If they are affording her the ability to better function, I'm fine with continuing them. Otherwise, we're going to taper and we're going to do it in less than three months.

Not all my FMS patients take opioids. I would say a decent portion take Vicodin at a low dosage PRN. A small precentage of those will eventually be tried on strong round the clock opioid therapy and of that small precentage an even smaller portion will stay on chronic strong opioid therapy. I actually looked today at some stats and I average 1 in 4 patients who are tried on strong, round the clock opioid therapy who actually stay on such treatment. Almost all of my FMS patients on strong round the clock opioid therapy have an additional pain diagnosis (OA, DDD, DJD, MPS, ect ect ect...)

My records for treatment are FAR FAR FAR better now that we have Ultram ER. I'm find that Ultram ER properly titrated with PRN Vicodin for BT pain works better than anything I've seen. (That is, when it is combined with either Lyrica or Cymbalta).

I guess what I'm trying to say is FIRST get your FMS patients on Cymbalta. Then add on Lyrica if pain is not improving. Then hit the Ultram ER. Once you've maxed out doses there, throw in a TCA (or not if you aren't familiar with mixing antidepressants) and given them something for sleep... THEN you can worry about prescribing an opioid.

ntubebate

are you telling me that you presecribe vicodin q4hrs prn along with methadone 10mg qid????is that what you do?? i would advise you to rethink your strategy on opiods and fibromyalgia in general.

kentw is far more rational and scientific in his strategy

 

[ntubebate]

are you telling me that you presecribe vicodin q4hrs prn along with methadone 10mg qid????is that what you do?? i would advise you to rethink your strategy on opiods and fibromyalgia in general.

kentw is far more rational and scientific in his strategy

I think at this point I've given up on trying to explain what I do.

ntubebate

 

[jsaul]

I think at this point I've given up on trying to explain what I do.

ntubebate

as you should because you are practicing outside the norms of medicine, practicing rogue medicine in regards to this condition...

please for your sake and the sake of these people who will become hopelessy dependent on high doses of narcoticsor even worse become addicted. You are putting your fibromyalgia patients in a precarious situation once you "abandon" them when their dependency for opioids become higher than a dose you are comfortable with.

 

[signomi]

This reminds me of the patient I had to wake up a few nights ago so she could tell me about the 10/10 pain she kept telling the nurse to call the doctor about. This lady's pain doc had her on this regimen for fibromyalgia(I nearly stroked out): oxycontin 80mg BID, lortab 5/500 2 po q4hr prn (you bet your butt she got every single dose!), methadone 30mg BID and for this "acute fibromyalgia flare" requiring hospitalization he added nubain every 6hr. Well the nubain wasn't good enough for her! He then gave her dilaudid 4mg IV q4hr.
Sweet weeping Jesus.

 

[Disciple]

1. 6G of APAP daily
2. Oxycontin and Methadone
3. Acute flare of FM?
4. IV Dilaudid


WTF...

 

[deleted6669]

This reminds me of the patient I had to wake up a few nights ago so she could tell me about the 10/10 pain she kept telling the nurse to call the doctor about. This lady's pain doc had her on this regimen for fibromyalgia(I nearly stroked out): oxycontin 80mg BID, lortab 5/500 2 po q4hr prn (you bet your butt she got every single dose!), methadone 30mg BID and for this "acute fibromyalgia flare" requiring hospitalization he added nubain every 6hr. Well the nubain wasn't good enough for her! He then gave her dilaudid 4mg IV q4hr.
Sweet weeping Jesus.

nubain is an agonist/antagonist...not a great choice in a lady who uses daily narcs to this extent....
sounds like end stage fibromyalgia requiring trigger point transplant from a cadaver donor.....

 

[Faebinder]

This reminds me of the patient I had to wake up a few nights ago so she could tell me about the 10/10 pain she kept telling the nurse to call the doctor about. This lady's pain doc had her on this regimen for fibromyalgia(I nearly stroked out): oxycontin 80mg BID, lortab 5/500 2 po q4hr prn (you bet your butt she got every single dose!), methadone 30mg BID and for this "acute fibromyalgia flare" requiring hospitalization he added nubain every 6hr. Well the nubain wasn't good enough for her! He then gave her dilaudid 4mg IV q4hr.
Sweet weeping Jesus.

Sounds like a drug seeker.

 

[McDoctor]

This reminds me of the patient I had to wake up a few nights ago so she could tell me about the 10/10 pain she kept telling the nurse to call the doctor about. This lady's pain doc had her on this regimen for fibromyalgia(I nearly stroked out): oxycontin 80mg BID, lortab 5/500 2 po q4hr prn (you bet your butt she got every single dose!), methadone 30mg BID and for this "acute fibromyalgia flare" requiring hospitalization he added nubain every 6hr. Well the nubain wasn't good enough for her! He then gave her dilaudid 4mg IV q4hr.
Sweet weeping Jesus.

This doesn't make any sense. Unless this doc was trying to punish her by putting her into withdrawal every six hours.

 

[deleted87716]

Sounds like a drug seeker.

Ya think?

 

[Faebinder]

Ya think?

Well I had more to say but what's the use.... would you really tell a patient on the phone to go **** themselves and to come back at a normal hour for their usual dose of garbage that they have addicted themselves to?

No...

So.... It's back to the usual... send them to the ER and have the EMTALA pay for it...

Luckily I am the lightest sleeper you'll ever see and crap like this doesn't phase me.

 

[jsaul]

ntubate might have to put her on a pca of iv dilaudid or how about epidural opioids or even better lets go intrathecal....

ntubate's moniker is very apporiate

 

[jsaul]

Well I had more to say but what's the use.... would you really tell a patient on the phone to go **** themselves and to come back at a normal hour for their usual dose of garbage that they have addicted themselves to?

No...

So.... It's back to the usual... send them to the ER and have the EMTALA pay for it...

Luckily I am the lightest sleeper you'll ever see and crap like this doesn't phase me.

unfortunately some doctors who love to prescribe opioids for the wrong patients enable these patient's addiction

 

[Faebinder]

Opioid doc survey in pubmed.

 

[Whodathunkit]

This reminds me of the patient I had to wake up a few nights ago so she could tell me about the 10/10 pain she kept telling the nurse to call the doctor about. This lady's pain doc had her on this regimen for fibromyalgia(I nearly stroked out): oxycontin 80mg BID, lortab 5/500 2 po q4hr prn (you bet your butt she got every single dose!), methadone 30mg BID and for this "acute fibromyalgia flare" requiring hospitalization he added nubain every 6hr. Well the nubain wasn't good enough for her! He then gave her dilaudid 4mg IV q4hr.
Sweet weeping Jesus.

That's no pain doc. That's a drug dealer.

I wonder if she paid upfront for her clinic appointments? Only high falutin patients(or those with super great insurance) get that type of treatment.

She'd get a quick referral for opiate detox from me.

 

[jsaul]

you are right,... with that cocktail of meds-- it is a narcotics dealer and not a doctor

 

[Spouse]

Y'all are funny. Three pages of talking down to whiny, drug seeking patients and I am the condescending one.

Also, I am not just a patient. My husband is matching this year, I am matching in dietetics. I actually do have just a tiny, fraction of the knowledge y'all do.

No, I do not have FMS. I told my story to show how quickly 'hard to figure out' patients are given a fibro diagnosis. Just b/c the doctors' want to label us with something-so they can medicate us and get us out of their office. Somehow, they never seem to teach the art of saying "I am sorry. I don't know what is wrong with you. Let me refer you to..." I have never had that said to me, but I have had NUMEROUS diagnoses.

What is *really* wrong with me is I have ligament damage in my back/hips causing or allowing my SI to posteriorly rotate. The chiros/PTs worsened it with US heat, massage, and tons of stretching. Those tight muscles that were treated were actually the only thing holding me together. By stretching me, I was made worse. But, I blindly followed the recommendations-through the pain-hoping to finally feel better. I never did.

I am getting treatment from an awesome PT and PMR doc. My PMR was actually smart and humble enough to learn from the PT. All of his patients that he sent to this guy came back well in half the time. He made an appointment, and basically the PT taught him everything. With my PT I am now doing tons of glute strengthening exercises to get my muscles strong enough to do the work of my shot ligaments. In the meantime-it hurts like hell. For two years I have been essentially dislocated-my tissues, muscles, fascia whatever are trashed. It is very, very painful to try to rehab this area. I hope none of you have to go through it. Honestly. At this point, I am totally seeking drugs. I need anything that can get me through my day. And you know what? That is ok. Sometimes people really are in pain. My pain sucks especially b/c it isn't crazy severe, but it is constant. Fentanyl, ultram, amitriptyline, neurontin-all help, but they can't take it completely away. I am typing this while sitting on an icepack!

Some of you sound so cynical about patients who are in pain. Of course we are drug seeking. Some of us hurt. Many of us are psychologically addicted. A day without a pill to help manage the pain terrifies me. Please, try to have some compassion.

 

[Faebinder]

Y'all are funny. Three pages of talking down to whiny, drug seeking patients and I am the condescending one.

Also, I am not just a patient. My husband is matching this year, I am matching in dietetics. I actually do have just a tiny, fraction of the knowledge y'all do.

No, I do not have FMS. I told my story to show how quickly 'hard to figure out' patients are given a fibro diagnosis. Just b/c the doctors' want to label us with something-so they can medicate us and get us out of their office. Somehow, they never seem to teach the art of saying "I am sorry. I don't know what is wrong with you. Let me refer you to..." I have never had that said to me, but I have had NUMEROUS diagnoses.

What is *really* wrong with me is I have ligament damage in my back/hips causing or allowing my SI to posteriorly rotate. The chiros/PTs worsened it with US heat, massage, and tons of stretching. Those tight muscles that were treated were actually the only thing holding me together. By stretching me, I was made worse. But, I blindly followed the recommendations-through the pain-hoping to finally feel better. I never did.

I am getting treatment from an awesome PT and PMR doc. My PMR was actually smart and humble enough to learn from the PT. All of his patients that he sent to this guy came back well in half the time. He made an appointment, and basically the PT taught him everything. With my PT I am now doing tons of glute strengthening exercises to get my muscles strong enough to do the work of my shot ligaments. In the meantime-it hurts like hell. For two years I have been essentially dislocated-my tissues, muscles, fascia whatever are trashed. It is very, very painful to try to rehab this area. I hope none of you have to go through it. Honestly. At this point, I am totally seeking drugs. I need anything that can get me through my day. And you know what? That is ok. Sometimes people really are in pain. My pain sucks especially b/c it isn't crazy severe, but it is constant. Fentanyl, ultram, amitriptyline, neurontin-all help, but they can't take it completely away. I am typing this while sitting on an icepack!

Some of you sound so cynical about patients who are in pain. Of course we are drug seeking. Some of us hurt. Many of us are psychologically addicted. A day without a pill to help manage the pain terrifies me. Please, try to have some compassion.

Just don't call your primary doc at 12 midnight from the ER because you forgot to get a refill. It's not his fault you forgot to come by in a normal hour for your monthly prescription. Good luck with your condition and God bless you (Yes many of us are cynical but few are heartless).

 

[mindmatters]

I was diagnosed with fibromyalgia in 1984... the dark ages. I'm grateful that the M.D. who diagnosed me also had it or I may have spent years seeking help. Since then, I have worked full time in the psych field. I've never had a psych diagnoses nor have I had many pain/fatigue-free days. I'm one of the lucky ones.

Others aren't so fortunate and have a much harder time controlling their symptoms. They may or may not have a psych diagnosis. Just because one has a comorbid depression or other psych diagnosis does not make fibromyalgia a psychiatric problem. In my experience, it's the chicken or the egg scenario for so many of these patients. Depression often results from being misunderstood and treated badly by the medical profession for far too long before a diagnosis is obtained and proper treatment initiated.

For the sake of the patients seeking help who must pass through your "care," I hope time will teach you some much needed lessons about compassion in medicine that may lead to more accurate diagnoses and appropriate treatment.

 

[Sharon Hanson]

I was diagnosed with fibromyalgia in 1984... the dark ages. I'm grateful that the M.D. who diagnosed me also had it or I may have spent years seeking help. Since then, I have worked full time in the psych field. I've never had a psych diagnoses nor have I had many pain/fatigue-free days. I'm one of the lucky ones.

Others aren't so fortunate and have a much harder time controlling their symptoms. They may or may not have a psych diagnosis. Just because one has a comorbid depression or other psych diagnosis does not make fibromyalgia a psychiatric problem. In my experience, it's the chicken or the egg scenario for so many of these patients. Depression often results from being misunderstood and treated badly by the medical profession for far too long before a diagnosis is obtained and proper treatment initiated.

For the sake of the patients seeking help who must pass through your "care," I hope time will teach you some much needed lessons about compassion in medicine that may lead to more accurate diagnoses and appropriate treatment.

Thank you for your post. We could all learn a lesson in humility from you and would be better off for it. I do wonder seeing where we are not taught about biotoxin illnesses such as mold exposure, lyme disease, pfiesteria and the many other biotoxin illnesses out there that present as FM, CFS and MS how many of these patients could be cured. Heck we don't even look for this. And I heard if you have a certain genotype specifically an HLA-DR marker that you will not get well with just antibiotics but will need toxin binding drugs to get well. I have also heard that metals can cause some of the same problems and present as FM, CFS and MS too but these things are covered up to protect Big Pharma and big corporations. Another area of toxic poisoning is aspartame. Just wondering why we never question what we are taught after all conflicts of interest are occurring all the time in our field.

 

[Sharon Hanson]

it gets better with therapy and ssri's.....it's a psych d/o as far as I am concerned. when folks in the er say" I have fibromyalgia" I list it in their pmh as a psych d/o.

Well I can disagree with this statement as I have my own personal experience. After a biopsy thay put a metal marker in my breast. I am highly allergic to nickel and nickel was part of the composition of the marker. Over a period of five years I became totally disabled with the symptoms progressively getting worse. Before I was diagnosed with Fibromyalgia due to a biotoxin disease I was diagnosed with Secondary Adrenal Insufficiency which by the way is a bonafide medical diagnosis.

Before I found an MD who understood biotoxin disease and metals I was getting sicker and sicker. The side of the biopsy was the only side I had pain. So what was my diagnosis? Fibromyalgio due to a biotoxin disease caused by mold in my breast.

The thing that makes me mad is that there is a five minute test you can do that will tell you if you have a biotoxin disease and the test is standing up in court and was jointly fine tuned by a Dr. at the EPA and Richie Shoemaker, MD. I was immediately put on antifungal drugs and given toxin binding drugs to get the toxins out of my body. The toxins are dead but I'm told they cause the most problems. I'll be lucky if I make a full recovery but five years come on. Why did it take so long. Hundreds of people have been cured of biotoxin disease and I'll bet at least 50% of people with Fibromyalgia have Lyme disease but cannot get a diagnosis. Lyme disease is a biotoxin disease and is misdiagnosed as Fibromyalgia all the time. Please people you can help a lot of patients suffering from these dibilitating disease if only you will read up on this disease of the 21st century. www.chronicneurotoxins.com

Sharon

 

[doc02]

Let's let the physicians with fibromyalgia take care of the patients with fibromyalgia. They'd both be in the room at separate corners going "AIEEEE, DON'T TOUCH ME IT HURTS ALL OVER!!!"

 

[Tired]

Well I can disagree with this statement as I have my own personal experience. After a biopsy thay put a metal marker in my breast. I am highly allergic to nickel and nickel was part of the composition of the marker. Over a period of five years I became totally disabled with the symptoms progressively getting worse. Before I was diagnosed with Fibromyalgia due to a biotoxin disease I was diagnosed with Secondary Adrenal Insufficiency which by the way is a bonafide medical diagnosis.

This is the funniest post I've read in a long time. I particularly enjoy the pseudo-medical terminology. Biotoxin disease. "Mold in my breast". Hillarious.

Also fun is the "I'm highly allergic to nickel but had a nickel implant for five years without dying." So what happens when you get change at McDonalds, and they hand you a nickel? Do you fall back, hissing and bearing your claws? "Get that thing away from me! I could die, you fool!"

Just a tip: if you have to qualify your story with "and that's a bonafide medical diagnosis", everyone pretty much knows you're FOS.

 

[Sharon Hanson]

This is the funniest post I've read in a long time. I particularly enjoy the pseudo-medical terminology. Biotoxin disease. "Mold in my breast". Hillarious.

Also fun is the "I'm highly allergic to nickel but had a nickel implant for five years without dying." So what happens when you get change at McDonalds, and they hand you a nickel? Do you fall back, hissing and bearing your claws? "Get that thing away from me! I could die, you fool!"

Just a tip: if you have to qualify your story with "and that's a bonafide medical diagnosis", everyone pretty much knows you're FOS.

Look it up asswhole. Nickel allergy can be a delayed hypersensitity. Also fungi in the body are not a new concept. Where have you been? It's well known that women who have problems with their breast implants sometimes have black mold all over them upon explants. And biotoxin disease is not new science either it's just they don't teach it in medical school. Do some research you ***** before you come back to me and say my post is a joke. Do you recall the pfiesteria outbreak in Maryland? Hundreds were sick and thanks to one country doctor many were cured. Biotoxin disease (Lyme disease is the best example) is going to be with us for a long time so as long as you ignore it your patients will never get any better. But hey most people aren't helped by us anyway we poison them more with all the wonderful drugs Big Pharma pushes us to give our patients.

 

[doc02]

Thank you for opening my eyes to the aspartimine conspiracy, Sharon. You have saved my life!!

 

[Sharon Hanson]

Thank you for opening my eyes to the aspartimine conspiracy, Sharon. You have saved my life!!

You're welcome doc02. Tell me why it's not recommended for MS patients?

 

[Tired]

Look it up asswhole. Nickel allergy can be a delayed hypersensitity. Also fungi in the body are not a new concept. Where have you been? It's well known that women who have problems with their breast implants sometimes have black mold all over them upon explants. And biotoxin disease is not new science either it's just they don't teach it in medical school. Do some research you ***** before you come back to me and say my post is a joke. Do you recall the pfiesteria outbreak in Maryland? Hundreds were sick and thanks to one country doctor many were cured. Biotoxin disease (Lyme disease is the best example) is going to be with us for a long time so as long as you ignore it your patients will never get any better. But hey most people aren't helped by us anyway we poison them more with all the wonderful drugs Big Pharma pushes us to give our patients.

I can just see all the other fat white women stuck in unhappy marriages, sitting at their computers, taking a break from their sixth Krispy Kreme of the day, going "Woohoo!! You tell that arrogant doctor, Sharon!"

Anyway, you're really funny, and your post was great to read. You really made my day. But no, I won't give you any more Vicodin, so stop asking.

 

[Sharon Hanson]

I can just see all the other fat white women stuck in unhappy marriages, sitting at their computers, taking a break from their sixth Krispy Kreme of the day, going "Woohoo!! You tell that arrogant doctor, Sharon!"

Anyway, you're really funny, and your post was great to read. You really made my day. But no, I won't give you any more Vicodin, so stop asking.

You too. You made my day and you make me laugh as well. You are so naive it's cute. As I sit here taking 20 supplements for my non-existant disease none of which includes Vicodin. I'll think of you when I go after corruption waste and abuse in the medical field. That's the mission my friend. I am getting well though and I thank my lucky stars I left doctors like you behind.

 

[doc02]

Wow, you take 20 supplements? I take 34! Wanna trade lists?

 

[Tired]

As I sit here taking 20 supplements for my non-existant disease . . .

I'd say that sums up this thread nicely.

 

[Old_Mil]

.

 

[LearningAlways]

Wow I guess nobody would ever have guessed how this thread would turn out by reading the title...Honestly, when I read that title and saw that the thread had 3 pages, I had no idea this was how the evolution of a 3 page conversation of Fibromyalgia would end up...

Seriously though, I hate to add more questions at the risk of hijacking the thread, but it looks to me like any meaningful discussion has flatlined anyway so maybe this will help revive it. I apologize if these questions are too basic, but the reason I'm asking questions instead of taking a quote from the three brilliant pages of civilized discussion is that I'm not very familiar with the subject. I also think that if the answers to somewhat basic questions can be agreed upon it might be easier for everyone to move on into the more advanced treatment options.

For those of you who diagnose Fibromyalgia, do you also diagnose Chronic Fatigue Syndrome, or Chronic Lyme Disease and if so, how do you differentiate between those diagnoses?

Also, for those of you who do not diagnose fibromyalgia, what if anything do you diagnose? Do you actually tell the patient that you don't know what is wrong with them and refer them to whatever specialist you feel might be appropriate or do you actually tell them that there is nothing wrong with them, and then come on here and tell us about how you tell them you don't know what's wrong with them?

For all -

Do you feel that the characteristics of fibromyalgia might actually be related to some other underlying condition that just goes undetected. Would you support any form of trial and error approach to treatment?

Also, what is everyone's opinion on whether or not psychiatric diseases can cause physical manifestations; and what about the other way around? Does anyone have an opinion on which is more likely or does anyone believe that only one or the other is possible?

 

[The Janitor]

Also, what is everyone's opinion on whether or not psychiatric diseases can cause physical manifestations; and what about the other way around? Does anyone have an opinion on which is more likely or does anyone believe that only one or the other is possible?

What is it with steel wool? Is it steel? Or is it wool?

 

[Ypo.]

As I understand it, the etiology is unknown. At my school, we were taught the various theories, but no explanation was given for the tissue texture changes, probably because none have yet been found.

This is from UpToDate, and it pretty accurately reflects what we were taught about the histological changes:


As for the psychological issues, the research that suggests altered pain processing, sleep abnormalities, hypothalamic-pituitary hyperactivity, all of which can cause depression. I do not believe that the depression causes the pain. I tend to think it's the other way around.

I can't imagine how some doctors still feel FM is a made-up illness. I've never had an attending who didn't believe it was an actual illness.

My anecdotal thoughts on this are that stress or psychologic illness lead to posturing which lead to tender points and muscle pain and stiffness. Treating the depression and prescribing exercise to strengthen and balances muscles seems to lead to an improvement because you eliminate the factors that trigger the cycle.

I totally believe that these people really are in pain and I have palpated muscle tightness as well. I just think that most of the pain is a result of their psych issues causing bad posturing and lack of physical activity. Have you ever gotten yelled at by someone and then developed tension in your neck and shoulders because of it? I think FM patients are like this, but to a higher degree than the average person.

Interestingly, I have met quite a few patients with the diagnosis of FM who have not had comborbid depression or other psych issues.

If I were a patient, I would do everything in my power to avoid the diagnosis of FM or chronic fatigue syndrome, simply because of how many doctors view those patients.

 

[McDoctor]

Wow I guess nobody would ever have guessed how this thread would turn out by reading the title...Honestly, when I read that title and saw that the thread had 3 pages, I had no idea this was how the evolution of a 3 page conversation of Fibromyalgia would end up...

Seriously though, I hate to add more questions at the risk of hijacking the thread, but it looks to me like any meaningful discussion has flatlined anyway so maybe this will help revive it. I apologize if these questions are too basic, but the reason I'm asking questions instead of taking a quote from the three brilliant pages of civilized discussion is that I'm not very familiar with the subject. I also think that if the answers to somewhat basic questions can be agreed upon it might be easier for everyone to move on into the more advanced treatment options.

For those of you who diagnose Fibromyalgia, do you also diagnose Chronic Fatigue Syndrome, or Chronic Lyme Disease and if so, how do you differentiate between those diagnoses?

Also, for those of you who do not diagnose fibromyalgia, what if anything do you diagnose? Do you actually tell the patient that you don't know what is wrong with them and refer them to whatever specialist you feel might be appropriate or do you actually tell them that there is nothing wrong with them, and then come on here and tell us about how you tell them you don't know what's wrong with them?

For all -

Do you feel that the characteristics of fibromyalgia might actually be related to some other underlying condition that just goes undetected. Would you support any form of trial and error approach to treatment?

Also, what is everyone's opinion on whether or not psychiatric diseases can cause physical manifestations; and what about the other way around? Does anyone have an opinion on which is more likely or does anyone believe that only one or the other is possible?

The ACR (American College of Rheumatology) has established diagnostic criteria for Fibromyalgia, and recognize it as a clinical entity. This is not the case with "Chronic Fatigue Syndrome", or "Chronic Lyme Disease". So Fibromyalgia has much more validity than the other two syndromes you mention, in my opinion.

Many patients will have medically unexplained symptoms that lack a unifying diagnosis. Some of these patients will have a serious underlying disease beyond my scope of practice or recognition. Most will simply have normal aches and pains of life and nothing more. I usually offer symptomatic medications and am clear about the inexact, and imperfect, nature of medical diagnosis. Specialist evaluation is always an option.

I almost never tell a patient with persistent symptoms, particularly if they cause some degree of disability, that there is nothing wrong with them. On the other hand, many patients are otherwise healthy and have minor symptoms and simply need reassurance. It's a fine line to walk.

 

[moonshade13]

hello all here is my view. I have fibromyalgia I do not take any pain meds ( vicdion, ultram ect) I am on lyrica, lunesta and one other I can not spell.
I do think some people use fibro as an excuse to get pain meds or out of work. I do have my bad days but just push on and also get massages from my husband. any questions please ask. I do know some doctors look and roll there eyes at me but I knew they would until the drug seekers quit using fribro as a quick fix.
Also I have never heard of endstage fibro so can I ask what is that? I know I will have this for the rest of my life but I can handle it .


sorry for the rant

 

[Starflower713]

I was diagnosed in 1993 and do not have an underlying psychiatric condtion. I had a shoulder injury that started as a regional myofascial pain disorder that went untreated. It spiraled into fibromyalgia. I have been treated with the standard protocol of anti-depressants with little or no benefit and huge side effects. I do feel it is possible that there is an underlying neurotoxin involved, but few if any doctors even consider this and don't know how to test for it. I think there are people out there who are suffering from neurotoxins that puts them at risk for other conditions such as fibro, chronic fatigue, etc. I do ocassionaly suffer from depression, but is usually the result of undertreated pain and not a primary condition. I am blessed that I have a wonderful physician that has palpated my muscles and believes that I do suffer with chronic pain/fibromyalgia. I see a massage therapist twice a week and that is how I stay functional. She can confirm that my muscles do not feel normal. There are many trigger points, taut bands, adhesions, etc.

 

[montessori2md]

Is this turning up on google or something? It's like a house party, there are so many random people showing up in here?

To the offended guests: I'm not "in" medicine yet, but as a teacher, I can tell you that as uncivil as it is, sometimes you need to vent about the annoying people in your life, and it is best to vent to your peers, rather than patients (or in my case, random complaining parents).


That is, just because people type sarcastic doesn't mean they are incapable of compassion (or at least courtesy) in a professional setting.

 

[Ligament]

There are many "career" fibromyalgia patients that love their diagnosis dearly and love talking about it all over the internet.

Is this turning up on google or something? It's like a house party, there are so many random people showing up in here?

To the offended guests: I'm not "in" medicine yet, but as a teacher, I can tell you that as uncivil as it is, sometimes you need to vent about the annoying people in your life, and it is best to vent to your peers, rather than patients (or in my case, random complaining parents).


That is, just because people type sarcastic doesn't mean they are incapable of compassion (or at least courtesy) in a professional setting.

 

[Ypo.]

I was diagnosed in 1993 and do not have an underlying psychiatric condtion. I had a shoulder injury that started as a regional myofascial pain disorder that went untreated. It spiraled into fibromyalgia. I have been treated with the standard protocol of anti-depressants with little or no benefit and huge side effects. I do feel it is possible that there is an underlying neurotoxin involved, but few if any doctors even consider this and don't know how to test for it. I think there are people out there who are suffering from neurotoxins that puts them at risk for other conditions such as fibro, chronic fatigue, etc. I do ocassionaly suffer from depression, but is usually the result of undertreated pain and not a primary condition. I am blessed that I have a wonderful physician that has palpated my muscles and believes that I do suffer with chronic pain/fibromyalgia. I see a massage therapist twice a week and that is how I stay functional. She can confirm that my muscles do not feel normal. There are many trigger points, taut bands, adhesions, etc.

Do you exercise regularly? (also a treatment for FM).

Smoke? (correlated with FM).

Just curious.

It sounds like you more want sympathy from your doctor than anything else. That's cool. Most of us give that.

 

[Bleurberry]

Real or not, psych issue or not, has anyone EVER met a fibromyalgia patient without another psych diagnosis of some sort?

It's difficult for patients who have a chronic ailment and aren't having their quality of life improved after having being evaluated and addressed by countless health care professionals. Reading the literature on fibromyalgic disorders, it's hard to understand why the research and treatment modalities haven't surfaced in a more mainstream way, as effective as they can be.
I think the exception, both PM&R programs and Osteopathic Medical curriculum, address the situation.

 

[Bleurberry]

There are many "career" fibromyalgia patients that love their diagnosis dearly and love talking about it all over the internet.

As an attending board-certified pain physician in Seattle,
why the public disdain toward fibromyalgia?

Curious of your view on this.

Thanks

 

[Tired]

Reading the literature on fibromyalgic disorders, it's hard to understand why the research and treatment modalities haven't surfaced in a more mainstream way, as effective as they can be.

Isn't it obvious?

1) Most physicians do not believe that fibromyalgia is a true physical disorder. They believe that it is somatization arising from an underlying psychiatric disorder.

2) There is no real evidence that the disease even exists. Its diagnosis relies entirely on patient-reported symptoms, with no objective standards for diagnosis.

3) The "effectiveness" you cite is really small, short-term improvements in subjective symptoms that rarely last, and rarely improve patients' functional status.

 

[Substance]

As far as I have read into the issue, it all seems very subjective. The whole "trigger point" thing doesn't explain anything. While I am not denying that these patients are experiencing some sort of pain syndrome, for the medical profession to label it as fibromyalgia makes it appear as a definite syndrome to which we know the answers. For all we know, it could be referred pain from a visceral source...

Here's my story:

Late-sixties-aged woman comes into the ER with upper back pain - around the trapezius - just like her fibromyalgia which she was diagnosed with a few years ago, except now its more nagging than before. She explained that it always got worse when she exercised, and was better when she rested for a while. This time it happened while she was cooking supper.

Her family history is pretty benign, and aside from a little bout of gout once in the past, and the aforementioned fibromyalgia, she's been ok too. However, she's slightly hypotensive and tachycardic on physical.

We did an ECG: It showed STelevations inferolaterally. So we started the standard acute treatment...her pain improved not long after.

Cath showed triple-vessel-disease. She went in for CABG soon after that.

Post-op she had no "fibromyalgia" pain. On follow up, also no pain like she had been experiencing for years before. She stated she was never this pain free in years.

It was likely that her pain was due to angina and not fibromyalgia; I sure hope that this kind of mistake is not made often.

 

[McDoctor]

Isn't it obvious?

1) Most physicians do not believe that fibromyalgia is a true physical disorder. They believe that it is somatization arising from an underlying psychiatric disorder.

Is this statement based on any actual data?

2) There is no real evidence that the disease even exists. Its diagnosis relies entirely on patient-reported symptoms, with no objective standards for diagnosis.

The same would hold true for migraine headaches. I also assume you'd be willing to diagnose Alzheimer's dementia without doing a brain biopsy. Sinusitis without a CT scan. etc...

 

[Tired]

Is this statement based on any actual data?

In general the diagnosis of a psychiatric disorder requires ruling out actual physical/medical causes. Since there are no objective findings in the diagnosis of fibro other than patient-reported symptoms, your question is kind of backward.

The same would hold true for migraine headaches. I also assume you'd be willing to diagnose Alzheimer's dementia without doing a brain biopsy. Sinusitis without a CT scan. etc...

I'm not talking about how we diagnose this "disease", I'm questioning the very existence of the disorder itself. But regardless, yes, there are other disorders where patient-reported symptoms are the backbone of the diagnosis. The difference, of course, is that response to medication is an important part of the diagnostic process. If a person with migraines doesn't respond to treatment, then the diagnosis itself is in question.

Fibromyalgia, on the other hand, is a disease with no specific objective findings, no supportive imaging or laboratory studies, and no particularly effective treatments. But I'm supposed to believe it exists why? Because there are a lot of internet support groups? Nonsense.

 

[epidural man]

interesting discussion.

Has anyone looked at this article and tried to apply its wisdom?

Cohen SP, Verdolin MH, Chang AS, Kurihara C, Morlando BJ, Mao J.The intravenous ketamine test predicts subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients.
J Pain. 2006 Jun;7(6):391-8.


One reason methadone could be so useful in these patients is its NMDA receptor antagonism (see above article.)

Someone who sees a lot of fibromyalgia patients should really try a randomized trial with memantine, a newer generation NMDA receptor antagonist. Not only will you get to publish a cool article, it may actually work.

 

[medicocebra]

I'm questioning the very existence of the disorder itself. But regardless, yes, there are other disorders where patient-reported symptoms are the backbone of the diagnosis. The difference, of course, is that response to medication is an important part of the diagnostic process. If a person with migraines doesn't respond to treatment, then the diagnosis itself is in question.

Fibromyalgia, on the other hand, is a disease with no specific objective findings, no supportive imaging or laboratory studies, and no particularly effective treatments. But I'm supposed to believe it exists why? Because there are a lot of internet support groups? Nonsense.

Interesting. This line of reasoning is the same one I use when I am arguing with people about the existence of God. Substitute Fibromyalgia and disorder with God, etc. and you get my meaning. Some things you just have to take on faith. For now, you are just going to have to take on faith that Fibromyalgia exists and it hurts. Just because you haven't found the cause doesn't mean a damn thing. When I was young, they said the same thing to us about menstrual cramps. Those didn't exist either. Here we are, thirty years later and we are still telling women that something is all in their head.

Even now, there are urologists that don't believe interstitial cystitis exists but the breakthroughs are coming fast and furious about that disease. Wait for the results of the studies at the University of Maryland.

I snuck into this forum to see what the young doctors are saying. All I can say to the smugness and lack of empathy is wait. Your time is coming, you won't be young forever and someday a part of your body is going to hurt from that day forward. Then you will know.

Now I am a senior citizen and I don't have time for some baby doctor to tell me that the pain is all in my head. My head is about the only place I don't have pain. I think this part of the newer version of the Hippocratic Oath says it all, ". . . will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient."

I've had Fibromyalgia for over thirty years. So I have been through life and my body's ups and downs. The only thing that has remained constant in the last thirty years has been the Fibromyalgia. It comes and goes, the weather affects it, it feels like the achiness of the flu and those trigger points light up like a Christmas tree whenever I am having an attack of it. Fortunately my doctor has grown old with me. When I have pain, he gives me pain medicine. It really is that simple. You give a pill to an addict, they get high; you give a pill to someone in pain, they get relief.

Now you doctors should be reading more about those chronic pain patients. It just rips at the heart. Those people want nothing but their lives. There are all kinds of forums and blogs. I was reading one today by a woman named lilianna. Good blog, very informative and interesting. Go find it and read, there is always time to learn more.

Ilene

 

[racerx]

Interesting. This line of reasoning is the same one I use when I am arguing with people about the existence of God. Substitute Fibromyalgia and disorder with God, etc. and you get my meaning. Some things you just have to take on faith. For now, you are just going to have to take on faith that Fibromyalgia exists and it hurts. Just because you haven't found the cause doesn't mean a damn thing. When I was young, they said the same thing to us about menstrual cramps. Those didn't exist either. Here we are, thirty years later and we are still telling women that something is all in their head.

Just playing devil's advocate, so let's not get into a theology discussion.

Sure, I get your meaning. Let's play it the other way though. If you expect me to believe that fibromyalgia is real based on the same level and quality of evidence as the existence of God, then I expect you to believe in God. Are you willing to do that? Probably not. Sure, you may give lip service to believing, but in your heart? No. So while I may give lip service and treat FMy as a rheumatic disease, I can still believe in my heart that it is mainly a psychiatric based issue, versus a rheumatic disease.

I tend to believe fibromyalgia is a real syndrome based in a real physical disruption in the neurotransmitter / receptor balance with 5HT and NE. I believe it is not a coincidence that TCA's and a few newer antidepressants work for some pain syndromes in fibromyalgia. It is my personal belief that Fibromyalgia is a psychiatric issue, based on a physical disruption in neurotransmitters. So, while it is a real disease, it is potentially quite literally, all in your head.