When a Pain Patient Insists on Alternative Treatments Alone
Question: A 45-year-old woman has an old cervical neck injury from an automobile accident and now has symptoms of fibromyalgia. She makes an appointment with her primary care physician and tells him that she doesn’t want any prescription drugs; she only wants to try the natural and alternative treatments she has heard about. What course of action should the doctor take at the onset and later on if the initial measures fail?
Answer: One of the challenges clinicians often face is when a patient comes in with preconceived ideas on how he or she wants to be treated. Some patients are sure that only strong painkillers will help, and they resist going to physical therapy, working on their sleep hygiene, or walking regularly. Other patients are interested only in natural and alternative treatments while resisting medication treatment. And yet others are convinced the only thing that will help is a specific diagnosis followed by surgery.
Fibromyalgia is a chronic, long-term disorder of central nervous system pain processing, whose symptoms often include not only widespread myofascial pain and tenderness, but also fatigue, sleep problems, temporomandibular joint disorder pain, irritable bowel syndrome, headaches, anxiety, and depression. First, of course, comes confirmation of the diagnosis, which requires widespread pain for at least 3 months, associated with fatigue, awakening unrefreshed, and cognitive symptoms. Traditionally, diagnosis has included finding multiple myofascial tender points. Assuming this has been done, the physician should counsel patients that this complex syndrome is best treated with a combination of approaches. Physical therapy, along with a cardiovascular fitness program, are good first steps. Refer the patient to a physical therapist who is knowledgeable in treating myofascial pain and trigger points. Improving sleep is very important, and this may involve sleep hygiene instructions as well as medications such as low-dose amitriptyline or non-benzodiazepine sleep agents such as zolpidem (Ambien). Cognitive-behavioral therapy, a valuable part of treatment, can teach the patient how to live with this chronic and sometimes unpredictable disorder as well as decreasing negative thinking and finding feasible, enjoyable activities. (However, getting insurance approval for this may be difficult.)
Alternative approaches such as acupuncture, hypnosis, and dietary supplements may help. If the above approaches do not suffice, then it’s time for medications. Many patients find that without medications, they are in too much pain to go to physical therapy or walk more than a few steps. In such cases, it is definitely time for prescription drugs. The FDA has approved several non-opioid drugs for alleviating the pain of fibromyalgia. These include pregabalin (Lyrica), milnacipran (Savella), and duloxetine (Cymbalta). Duloxetine is an antidepressant as well, so it can do double duty. Otherwise, adding an antidepressant can improve the patient’s mood. It has also been my experience that patients who don’t obtain adequate relief from the above combination of treatments may benefit from adding opioids to their regimen. Fibromyalgia is a neuropathic pain syndrome, and in the past it was believed that opioids do not benefit neuropathic pain. However, my clinical experience has shown that many fibromyalgia patients have reduced pain with opioids, so they are worth a trial when all else fails.
Finally, group support can be a great help for obtaining emotional support as well as information. The Fibromyalgia Network, an Arizona-based organization, maintains a list of support groups in all 50 states, and also regularly publishes a newsletter providing updates on treatment and research. You can find the Fibromyalgia Network online.
Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management