Excerpts From Our Book
Dr. Michael McNett's Treatment Protocol
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My Approach to Fibromyalgia by Michael McNett, M.D. When approaching a patient with fibromyalgia, my first responsibility is to make sure that they actually have FMS. I commonly see patients misdiagnosed with fibromyalgia who actually have diffuse myofascial pain syndrome, polymyalgia rheumatica, or a variety of other diseases. The history, physical, and initial lab tests often help to establish whether the patient actually has another condition or whether another illness (hypothyroidism, rheumatoid arthritis, etc.) is contributing to their problem. Once the diagnosis is confirmed, our clinic offers a multidisciplinary approach; this has been shown in numerous studies to be the best form of treatment. Our program includes the following components:
In this article, I will detail how I provide optimal management of a patient’s medications. Medication management is very complex and must be structured to each individual – I could write an entire book about this subject alone. In general, medical management has three aspects:
Sleep agents are important in fibromyalgia, since poor sleep not only turns a person’s night into a nightmare, but it also contributes to fatigue during the day, undermines job performance, hurts relationships by making the person irritable – I could go on and on. Sedating antidepressants are the first line here, since they’re not addictive, improve sleep quality, are inexpensive and welltolerated. I don’t like tricyclic antidepressants like amitriptyline (Elavil), nortriptyline (Pamelor) or cyclobenzaprine (Flexeril) because they cause a nasty increase in brain fog in the majority of patients treated with them – something fibromyalgia patients struggle with anyway. I also don’t like benzodiazepines (the Valium/Klonopin class) because they’re potentially addictive, don’t increase deep sleep, and interfere with the stress response (the “HPA axis”). In general, I haven’t had much success with muscle relaxants. They don’t relax trigger points, and they tend to be too sedating for most of my patients to tolerate. Sometimes they can be useful to help with sleep. I also rarely prescribe arthritis medication. The recent controversy over heart problems with COX-II inhibitors (Vioxx, et. al.) has cast doubts on their use. The other major class is a group of aspirin-related compounds known as nonsteroidal anti-inflammatory agents (NSAIDs). First of all, they don’t work very well for most fibromyalgia patients. Secondly, they interfere with platelets in the blood, which prevents clotting. Thirdly, they cause ulcers. (And the last thing you need with a bleeding ulcer is a drug interfering with clotting!) Every three years we kill as many people in the US with NSAIDs as died in the entire Vietnam War. Certainly, these medications should only be used in people who get a major benefit from them, and most fibro patients don’t. Anticonvulsants (drugs used to treat epilepsy) can be very helpful for fibromyalgia pain. An easy way to understand how they work is to think of them as making nerves less irritable. This is how they prevent seizures. Since they also make pain nerves less irritable, they can help fibromyalgia pain, as well. Since many of these medications work in different ways, a patient may have to try several before deciding on the best one for them. Pain medications are important in fibromyalgia. Studies have shown that fibromyalgia patients truly are suffering:
As a result, I consider it cruel not to provide pain relief. Acetaminophen (Tylenol) can be used if it works, but many patients need something stronger. Tramadol (Ultram) is a virtually nonaddictive opiate (narcotic) medication that I have used with great success in my patients; if necessary, it can be made more effective by taking dextramethorphan (a common cough suppressant) along with it. If absolutely necessary—and only as a last resort—I’ll use stronger opiates such as codeine, hydrocodone, oxycodone, methadone, or morphine. For me to prescribe these, the patient must be taking the other, non-addictive medications listed previously and must be participating in the multidisciplinary aspects of our program. The fatigue of fibromyalgia can be intense and even crippling. It can cost a person their job or prevent them from doing simple housework. If it’s severe, stimulants can be used, though they’re controversial. The nutritional supplements malic acid and ginseng are mildly beneficial. Caffeine and over-the-counter decongestants help some people, though they often have side effects. Some antidepressants and anticonvulsants have stimulant properties and are generally well-tolerated. Modafenil (Provigil) is a stronger stimulant which tends not to cause the hypertension and irregular heartbeats that can occur with amphetamines, which I generally avoid. Treating other medical conditions associated with fibromyalgia is important to a patient’s life, as well. These conditions include migraines, myofascial pain syndrome, sleep apnea, depression, anxiety (including panic disorder), irritable bowel, irritable bladder, vulvovaginitis, restless legs, and sicca syndrome (dry eyes and mouth). While a full discussion of these treatments is beyond the scope of this paper, suffice it to say that there are a number of medications available to treat each of these conditions, and patients should not settle for being told that there’s nothing that can be done for them. Treating underlying causes is difficult, since we know so little about what causes fibromyalgia. Still, some treatments show promise at improving overall fibromyalgia symptoms. It is my belief that, by studying how these treatments may be producing their benefit, they could lead us to a breakthrough in understanding what causes fibromyalgia. It should be noted that some of these conditions are viewed as alternative medicine by many doctors. I have reviewed them in detail and fully believe that there is good scientific evidence for them and that they will be accepted by the medical community once rigorous scientific studies had documented their benefit. Our clinic is in the process of setting up a research foundation to perform these studies. Because fibromyalgia is a condition which may have a number of underlying causes, one or more of these therapies may need to be used in a specific individual. Since these treatments and/or conditions are detailed elsewhere in this book, I’ll simply list them here:
In summary, there is a tremendous amount that can be done to help fibromyalgia patients. Proper use of medications as well as the other aspects of our multidisciplinary program has provided a substantial benefit in the large majority of our patients—many of whom had been told by their other doctors that there was no more help for them. We even have a significant number of people who are in complete remission. Fibromyalgia patients are suffering, and there’s a lot that can be done to improve them. Never give up hope.
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