Commonly Used Medicines in the Treatment of CFIDS, Chronic Myofascial Pain, and Fibromyalgia
This is an informational guide only and is not meant to take the place of medical treatment or discussion of your therapy with your health care provider or pharmacist. These are not complete listings of the drugs in each particular category. Please carefully read the information that comes with your medicines.
Analgesics:
Acetaminophen (Brand Name: Tylenol): Acetaminophen is a centrally acting analgesic and antipyretic agent. It is effective for the relief of mild pain and fever, and is often paired with an opiate for increased analgesic effect. Has no effect on inflammation.
Side Effects: Generally well tolerated. Mild stomach discomfort may occur.
Contraindications and Possible Long Term Effects: Heavy alcohol use, pre-existing liver disease; patients taking acetaminophen long term should have their liver function monitored as their doctor sees fit.
Non-steroidal anti-inflammatory drugs: (Ibuprophen, Naproxen Sodium, Aspirin, Diclofinac, Mobic, Celebrex- this is not a complete list; discuss with your doctor): NSAIDs is a nonsteroidal anti-inflammatory drug (NSAID) that exhibits anti-inflammatory, analgesic, and antipyretic activities. They are effective for the relief of mild-to-moderate pain and fever. They are also occasionally paired with an opiate for increased analgesic effect.
Side Effects: bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine. These are more common with longer-term usage but even short-term usage is not risk free. There is also a higher risk of heart-related effects, such as hypertension. Cox-2 inhibitors are NSAIDs that have less gastrointestinal effects, but their risk of heart-related effects is higher. Kidney problems are a risk with long term usage of any NSAID. People who already have stomach, heart, or kidney problems should be very careful about taking NSAIDs, especially long term. Discuss with your doctor.
Comments: There is no evidence of inflammation in fibromyalgia. More powerful pain relievers actually are usually safer and more effective. CFIDS has some issues with inflammation, particularly the sore throat, swollen and/or tender lymph glands and the mild intermittent fever that many CFIDS patients experience and therefore NSAIDs might be a better PRN (a term for “as needed”) option for CFIDS then FM.
Central Acting Binary Analgesics, or Centrally Acting Analgesics (Tramadol, Ultram, Ultram ER): Sometimes combined with acetaminophen, these medicines work on both opioid receptors and different receptors. Since patients with CFIDS and FM have less opioid receptors than normal, these may provide relief when even strong opiates do not. They can also be used in conjunction with opioids. They are considered less potentially addictive then opioids, which have a <1% addiction rate when used for chronic pain, and so doctors may feel more comfortable about prescribing it. This medicine works better when taken regularly instead of PRN and therefore is not a good “breakthrough pain” medicine. It has some potential effectiveness as a migraine preventative.
Side Effects: Most common are dizziness, nausea, fatigue, constipation, and headache. Most of these will disappear if used longer term. If this medicine is going to be used long-term, a proactive bowel regimen should be started co-currently with the drug to avoid problems with constipation (stool softeners, fiber, mild laxatives if necessary, etc.)
Drug interactions: Possible interactions with SSRI’s/SNRI’s/MAOI’s that could caused increased risk of serotonin syndrome. Possible interactions with carbamazepine, quinidine, St. John's Wort, Digitoxin, Warfarin and tricyclic antidepressants to varying degrees. Discuss with your doctor.
Opioids (codeine, hydrocodone, oxycodone, morphine, etc): Also called narcotic pain reliever (opiate-type), they act on certain centers in the brain to give you pain relief. These are prescribed for moderate to severe pain, and can be used PRN or on a regular basis. They are often combined with acetaminophen for additional analgesic relief. They can be administed orally, through a patch, or through an IV.
Side Effects: The most common are light-headedness, dizziness, sedation, nausea, vomiting, sweating, flushing, dysphoria, euphoria, dry mouth, and constipation. Many of these effects are lessened by a gradual increase in dosing, taking the medicine with food, taking it along with an antihistamine or antiemetic (Benadryl, Phenegran, Zofran), and most of these effects will disappear if the medicine is used for a longer period of time. The most common problem with long-term use is constipation and if this medicine is going to be used long-term, a proactive bowel regimen should be started co-currently with the drug to avoid problems with constipation (stool softeners, fiber, mild laxatives if necessary, etc.) Respiratory depression is a less common risk and is increased by using the drug co-currently with other central nervous system depressors (sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers and alcohol).
Contraindications and possible long term effects: Possibly, previous addiction history with opioids. If the medicine is an acetaminophen/opioid mix, the precautions with acetaminophen apply. There is the possibility that long term opioid use could have effects on the hormonal system- check with your doctor to see if this is an issue and how this would be monitored.
Comments: There is a small, usually drastically overstated, risk of addiction. Studies consistently show that less than 1% of chronic pain patients become addicted to pain medicine. Many of these people had other risk factors towards addiction. This risk, however small, usually makes health care providers consider opiates as the “last resort” drug. Some do not believe these are effective in CFIDS and FM patients because their pain is more neuro-endocrine based and not musculo-skeletal, and also because patients with these conditions are lacking the normal amount of opioid receptors in the body. Others believe that simply means that a more aggressive dosing pattern may be needed. Many patients who could otherwise be helped are scared away from these medicines because of the media hype, excessively strict regulation, and outdated attitudes. Suicide due to untreated chronic pain is also a risk, and 70% of suicides have untreated chronic pain as a factor. In many ways they are the safest of all of the analgesics, even ones offered over the counter such as ibuprophen. CFIDS and FM patients have the same rights to pain management as patients who suffer from other pain conditions. Be aware that if you are put on these medicines, you are likely to become physically tolerant (so if you quit the medicine you need to do it slowly- most medicines you take long term have a physical tolerance aspect) and in a flare, an emergency or an acute care situation, you may not get adequate pain relief because the health care provider feels you are already on “enough pain medicine”.
Methadone: A mu agonist; a synthetic opioid analgesic with multiple actions qualitatively similar to those of morphine. It is a longer-acting pain medication that is considered extremely safe, and like CABA’s, is considered less addictive then opioids.
Side Effects: Must be titrated up slowly. Most common are dizziness, nausea, fatigue, constipation, and headache. Most of these will disappear if used longer term. If this medicine is going to be used long-term, a proactive bowel regimen should be started co-currently with the drug to avoid problems with constipation (stool softeners, fiber, mild laxatives if necessary, etc.)
Contraindications and med interactions: Known allergy to methadone, acute respiratory depression or distress.
Anti-seizure medicines: (Neurontin, Lyrica, Depakote, Topamax): These medicines are used for the management of neuropathic pain, management of fibromyalgia pain, and migraine prevention. Lyrica was the first FDA approved medicine for fibromyalgia, and is structurally very similar to Neurontin. Lyrica and Neurontin are also prescribed off-label for CFIDS pain, sleep, and headaches. Depakote and Topamax are used more for migraine prevention, and are also mood stabilizers, so may be used in the treatment of atypical depression or bipolar disorder. These medicines can also improve cognitive function for some patients.
Most common side effects of Neurontin and Lyrica are dizziness, somnolence, dry mouth, edema, blurred vision, weight gain, and "thinking abnormal" (primarily difficulty with concentration/attention). Weight gain is much less common with Neurontin then Lyrica. Many of the fatigue-based side effects improve after the first few weeks.
Most common side effects of Depakote are alopecia (hair loss), nausea and vomiting, weight gain, sleepiness and depression.
Most common side effects of Topamax are paresthesia (sensation of tingling, prickling, or numbness), fatigue, nausea, anorexia, dizziness, difficulty with memory, diarrhea, weight decrease, difficulty with concentration/attention, and somnolence.
Comments: Mood destabilization is always a risk with these medicines. Although they, as a whole, help anxiety and depression, these are drugs that affect the brain and therefore there is a low risk of adverse mood effects. If a woman is of childbearing age, she should take these medicines with 1-4 mg of folic acid daily due to the increased risk of neural tube defects. Most of the side effects (except weight-related ones) will go away with longer-term use. Depakote has a long term risk of causing metabolic disorders and polycystic ovarian syndrome (PCOS) which can affect the metabolic system and fertility.
Anti-Depressants
Tricyclics (amitriptyline, nortriptyline, doxepin, etc.): These are anti-depressants that work on norepinephrine and serotonin, which are believed to affect pain levels, sleep, and mood in CFIDS/FM patients. At dosage lower than the dosage used for depression, they are used for pain relief and sleep. They can also be used at higher doses to treat depression as well or to provide help with sleep for patients with a high tolerance to sedation, and they have different side effects then the SSRI/SNRI medicines. They are often used for depression when a patient cannot tolerate or has not responded to a trial of SSRI/SNRI’s.
Side Effects: Drowsiness, dizziness, dry mouth, blurred vision, constipation, fast heartbeat, nausea, vomiting, loss of appetite, changes in taste, weight gain, tiredness, or trouble urinating may occur. Can increase dysautonomia symptoms. If this medicine is going to be used long-term, a proactive bowel regimen should be started co-currently with the drug to avoid problems with constipation (stool softeners, fiber, mild laxatives if necessary, etc.). Amitriptyline in particular can cause neurological symptoms such as lack of balance, more frequent falls, dizziness, and difficulty with motor skills. Since this can sometimes be mistaken for early stage multiple sclerosis, it is important that anyone exhibiting these symptoms who is on amitriptyline take that into consideration if a neurological evaluation is being considered.
Contraindications and Drug Interactions: Cannot be used with MAOI inhibitors. There should be at least a two week spacing between stopping an MAOI and going on a tricyclic.
Comments: There is some evidence that these medicines are more problematic for CFIDS patients then FM patients. People who have both CFIDS and FM need to be aware of this. Mood destabilization is always a risk when taking an antidepressant and any signs of worsening depression or of other strange behavior (irritability, hyperactivity, inflated mood, etc) should be immediately reported to your doctor.
Selective serotonin reuptake inhibitor (SSRI) (Prozac, Zoloft, Paxil, etc.): These work by inhibition of CNS neuronal uptake of serotonin (5HT). Studies at clinically relevant doses in man have demonstrated that sertraline blocks the uptake of serotonin into human platelets. In vitro studies in animals also suggest that sertraline is a potent and selective inhibitor of neuronal serotonin reuptake and has only very weak effects on norepinephrine and dopamine neuronal reuptake. These are prescribed for depression and anxiety disorders (social anxiety, OCD), PTSD, PMDD, adjunct therapy for bipolar disorder, and are believed to help somewhat with chronic pain and to regulate sleep. They are less effective for pain then SNRI or tricyclics.
Side Effects: Nausea, vomiting, dry mouth, sleepiness, sleeplessness, agitation, akathesia (inner restlessness combined with some psychological effects such as anxiety, emotional instability, etc.), sexual dysfunction, appetite suppression or increased appetite.
Contraindications and Drug Interactions: Multiple drug interactions. Please check with your doctor or pharmacist. Careful monitoring is necessary when using these medicines on a bipolar patient because anti-depressants can cause “switching” into mania. SSRI’s increase the risk of persistent pulmonary hypertension in newborns (although it is still extremely low). Pregnant women should discuss continuing SSRI’s with their doctors and consider weaning off the medicine a few weeks before delivery. May cause a worsening of depression.
Comments: DO NOT quit these medicines abruptly unless you are specifically directed to do so by your doctor.
Serotonin-norepinephrine reuptake inhibitor type (SNRI) (Effexor, Cymbalta): These medicines work by restoring the balance of natural substances (neurotransmitters such as serotonin and norepinephrine) in the brain. They are used to treat major depression, bipolar depression, and anxiety disorders. They have also been used in the management of chronic pain and neuropathic pain. Cymbalta is the second drug to get FDA approval for the treatment of fibromyalgia.
Side Effects: Nausea, vomiting, dry mouth, sleepiness, sleeplessness, agitation, akathesia (inner restlessness combined with some psychological effects such as anxiety, emotional instability, etc.), sexual dysfunction, appetite suppression or increased appetite.
Contraindications and Drug Interactions: Multiple drug interactions. Please check with your doctor or pharmacist. Careful monitoring is necessary when using these medicines on a bipolar patient because anti-depressants can cause “switching” into mania. SNRI’s increase the risk of persistent pulmonary hypertension in newborns (although it is still extremely low). Pregnant women should discuss continuing SNRI’s with their doctors and consider weaning off the medicine a few weeks before delivery. May cause a worsening of depression.
Comments: DO NOT quit these medicines abruptly unless you are specifically directed to do so by your doctor.
Atypical anti-depressants: (Wellbutrin, Trazadone, nefazodone): These medicines are used for the treatment of depression and anxiety disorder. They are often used when a patient has not responded to SSRI/SNRI treatment and may also be used for sleep (Trazadone) or for quitting nicotine (Wellbutrin).
Side Effects: Nausea, vomiting, diarrhea, drowsiness, dizziness, tiredness, blurred vision, changes in weight, headache, muscle ache/pain, akathesia, dry mouth, bad taste in the mouth, stuffy nose, constipation, or change in sexual interest/ability.
Contraindications and Drug Interactions: Multiple drug interactions. Please check with your doctor or pharmacist. Careful monitoring is necessary when using these medicines on a bipolar patient because anti-depressants can cause “switching” into mania. Possible contraindications with heart disease (e.g., irregular heartbeat), liver disease, kidney disease, blood pressure problems.
Comments: DO NOT quit these medicines abruptly unless you are specifically directed to do so by your doctor.
Sleep Medications:
Antihistamines (Benadryl, Vistaril, Dramamine, Unisom): These medicines can be used for mild sleep dysfunction, particularly sleep-onset insomnia. They are used in the treatment of allergies and can sometimes be used as mild anti-anxiety medicines (particularly Vistaril) and anti-emetics. The non-drowsy antihistimines (Claritin, Zyrtec, etc.) do not have these effects and are only recommended for the treatment of allergies. Many of these medicines are over the counter (OTC). Using them with an opioid medicine can both increase efficiency of the medicine and help with accompanying nausea. They can also be used for dizziness related to motion. They work by blocking the release of histamines by the body. Histamines are related to symptoms of nausea and allergy symptoms.
Side Effects: Drowsiness, headache, fatigue, dry mouth.
Contraindications and drug interactions: May increase the effects of sedatives or other sedating medicines. Discuss with your doctor.
Benzodiazepines (Klonopin, Atavin, Valium, Xanax): These medicines depress and relax the central nervous system. They are used to treat sleep dysfunction, particularly sleep onset insomnia, acute panic/anxiety symptoms, and muscle spasms or trigger point spasms. Klonopin also has anti-seizure properties and has some of the pain relieving effects as the other anti-seizure medicines. They can also help treat allodynia (painful response to non-painful stimulus).
Side Effects: Drowsiness, ataxia (difficulty with gait), depression, slurred speech, vivid dreams, dizziness, rebound depression or anxiety (a worsening of the original symptoms during or after dosage).
Contraindications and Drug Interactions: Sensitivity to benzodiazepines and certain types of glaucoma. Can increase the effects of other sedating drugs if you are easily sedated, possibly causing respiratory depression. Discuss possible interactions with your doctor or pharmacist. These meds are considered a potentially addictive substance. Physical dependency with longer-term regular use- do not stop these drugs abruptly.
Hypnotics (Ambien, Lunesta): These drugs are used for the treatment of insomnia. They are known for extremely rapid effects. There are controlled release versions that help with sleep maintenance.
Side Effects: The most common side effects of Lunesta are viral infection, dry mouth, dizziness, hallucinations, infection, rash, and unpleasant taste. The most common side effects of Ambien are dizziness, drowsiness, headache, nausea and vomiting. Ambien seems to have a greater potential effect on mood compared to Lunesta. Both are considered safe for pregnancy, which gives them an edge over benzodiazepines for sleep-onset insomnia during pregnancy.
Contraindications and Drug Interactions: Numerous potential drug interactions. Please check with your doctor or pharmacist. Addiction potential. Physical dependency- do not stop these drugs abruptly
Muscle Relaxers (Skelaxin, Flexeril, Soma):
These are medicines which act on the central nervous system (CNS) to relax muscles. These drugs are often prescribed to reduce pain and soreness associated with sprains, strains, or other types of muscle injury. They are used for muscle spasms that often accompany fibromyalgia, for chronic myofascial pain, and other muscle-related chronic pain (ex. TMJ). Their efficiency in fibromyalgia treatment is debatable because of the source of pain in fibromyalgia. However, it can help accompanying CMP, which can lessen the overall pain of the patient.
Side Effects: Drowsiness, dizziness, headache, nausea, and nervousness. Soma has sedative properties, particularly when used with CNS depressors, opioids, or tricyclics. It works on the central nervous system and may be particularly effective for allodynia.
Contraindications and Drug Interactions: Acute intermittent porphyria or a hypersensitivity reaction to a carbamate such as meprobamate. Impaired kidney or liver function can be an issue with long-term regular use of Skelaxin.
Comments: Soma, while effective for several fibromyalgia and CFIDS symptoms, is considered potentially addictive. One book on fibromyalgia accuses patients of addiction who simply ask to try the drug while on an analgesic such as opioids or CABA’s. Although most cases of addiction occurred in people who already had addiction issues with drugs or alcohol, other muscle relaxers should probably be tried first to avoid the suspicion of drug seeking behavior, particularly if you need analgesic therapy.
Central Nervous System Stimulants/Medicines for Fatigue (Provigil, Ritalin, Strattera, Adderall, etc.):
These are medicines prescribed to help severe fatigue and cognitive issues (more commonly prescribed for CFIDS, but they are prescribed for FM fatigue as well).
Side Effects: Provigil is generally well tolerated. The side effects were mild and consisted of headache, nausea, nervousness, rhinitis, diarrhea, back pain, anxiety, insomnia, dizziness, and dyspepsia.
For the CNS stimulants the side effects are nervousness and insomnia (usually prevented or helped by dose adjustment and timing of dose), hypersensitivity, nausea, diarrhea, arthralgia (pain in the joints without swelling or redness) anxiety, dizziness, and dyspepsia.
Contraindications and Drug Interactions: None of these drugs should be taken within two weeks of an MAOI inhibitor. They may interact with tricyclics, some anti-convulsants, anti-coagulants, and medicines for hypertension. Could bring on mania in someone with bipolar.
Information taken from RxList.Com; WebMD; Chronic Fatigue Syndrome for Dummies, Lisman and Dougherty 2007; Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Guide, Starlanyl and Copeland, 1996.
Copyright Sara Stewart, 2008
