from Fibromyalgia and Chronic Myofascial Pain: A Survival Manual, 2nd Ed; by Devin J. Starlanyl and Mary Ellen Copeland
Australian version
adapted by Moira Smith
Introduction to this versionThis is an Australian version of Devin Starlanyl's useful guide to Fibromyalgia medications, adapted with her permission from the information in the book Fibromyalgia and Chronic Myofascial Pain: A Survival Manual. Devin's FM medications guide is also available here on her website.
Some medications are marketed under different brand names in Australia and the US; some medications available in the US are not available here at all. In this version, all brand names in orange are applicable to Australia. I have retained some frequently mentioned USA NAMES in the text in green.
Medications are one way you can gain some control over your symptoms. They may enable you to handle greater amount of bodywork and exercise, and can be used to restore greater levels of function. Until recently, much of the medical world regarded complaints caused by FMS and CMP as psychological. One result of that attitude is that very few drugs are established as effective in these conditions. Medications developed for other conditions may often prove helpful. Antidepressants have pain-relieving effects independent of changes of mood, for example, and in lower doses than used to treat depression (Fasmer, 1990) and may be effective in reducing pain associated with FMS (Fishbain, 2000).
Medication should never be considered as the only form of pain control. It must be part of a global strategy, with sound nutrition, bodywork, mindwork, lifestyle adjustments, and other non-medicinal options of pain control.
Before adding any new medication, review your current meds with your doctor. Discuss your options. Address all perpetuating factors. For example, you may have been put on Tagamet, Zantac, or Prilosec for heartburn and oesophageal reflux. These can decrease your ability to digest foods, and add to your symptoms in the long run. If you have reflux, look into the possibility that you may have insulin resistance/reactive hypoglycaemia. If you crave carbohydrates and have other symptoms of these conditions, try diet modification. Eliminate excess carbohydrates. Check for possible TrPs in the area around the base of your breastbone. With a change of diet and some myotherapy, you may be able to avoid these expensive medications.
Medications that affect the central nervous system are appropriate for FMS. These medications target insomnia, pain, and fatigue. Pain sensations are amplified by FMS, so if you have TrPs or other instigators, your total pain level may be severe.
FMS patients may react in an unusual manner to medications. Keep careful records of your medicines using a medical use form such as the one in The Fibromyalgia Advocate * . There is no cookbook recipe for prescribing medications for FMS and CMP. A medication that works well for one person can be completely ineffective for another.
It is important that you don't mix non-prescription medications, such as herbal remedies, with your prescription medications without discussing it with your health team first.
Benadryl (diphenhydramine hydrochloride): This sleep
aid/antihistamine is safe to take even during pregnancy. The starting dose is 50 mg, taken
1 hour before bed. About 20 percent of patients are stimulated rather than sedated by
Benadryl. Patients have reported urinary hesitancy on this medication.
The author is referring to pure Benadryl syrup which
is not available in Australia. Here, there are three versions of the
syrup and they all contains other ingredients. Diphenhydramine hydrochloride
is available in Australia as a single ingredient in Unisom Sleepgels.
Calms Forte: This mix of herbs and minerals may be effective to promote sleep. NOT AVAILABLE IN AUSTRALIA
Chromium Picolinate: This may decrease carbocraving. It seems to improve the efficiency of insulin (Striffler, Law, Polansky et al. 1995). Available in Australia in the product "Endocrave".
Coenzyme Q10 is a vitamin-like substance. Some people have found it helps reduce fibrofog. It's an important part of the mitochondrial membrane, but we don't understand its functions.
DHEA (dehydroepiandrosterone) turns into oestrogen and testosterone in your body. High doses (25-50 mg/daily) can trigger heart irregularities, or even a heart attack. (Sahelian and Borken, 1998). Some FMS patients report it helps them feel better.
Digestant Enzymes: If you have problems digesting foods, try taking papain or a natural enzyme combination to help your gastrointestinal system break down foods. In Australia, health food supplements containing digestant enzymes are available (for example Blackmores, Bioglan).
Glucosamine and chondroitin: These may be beneficial in cases of inflammation, bone or cartilage degradation, or problems with ground substance. Glucosamine may cause worsening of symptoms for FMS patients with high levels of hyaluronic acid. Glucosamine is contained in over-the-counter products such as ArthoAid etc. Chondroitin is shark cartilige.
5-Hydroxytryptophan (5-HTP): Your body converts this to serotonin. It easily crosses the blood-brain barrier and effectively increases synthesis of serotonin (Birdsall, 1998).
Human Growth Hormone (HGH, somatotropin): This hormone is converted into insulin-like-growth-factor-1 (IGF-1). There are dangerous implications with OTC use (Ng, Ji, Tan et al.1998). The use of OTC growth hormone is not to be confused with the legitimate FMS research that has uncovered a subset of FMS patients who have low IGF-1. This deficiency occurs in about 30 percent of FMS patients (Bennett, 1998). Replacement treatment for these patients improves some FMS parameters.
Malic acid and magnesium: Malic acid plays a key part in the metabolism of carbohydrates, as well as in the formation of ATP. Magnesium and B6 are needed for malate to work in energy production (Lowe, 2000). One study showed that this combination is safe and may be beneficial in the treatment of FMS (Russell, Michalek, Fletchas et al. Abraham, 1995).
Melatonin: Melatonin is a neurotransmitter that the body changes into serotonin. It may help reduce tender point count and severity of pain as well as improve sleep significantly in FMS patients (Citera, Arias, Maldonado-Cocco et al. 2000). Patients with FMS may have low melatonin secretion during the hours of darkness. This may contribute to poor sleep, fatigue, and enhanced pain (Wikner, Hirsch, Wetterberg et al. 1998). Melatonin in sufficient dosage may inhibit ovulation. Up to one-third of those who try melatonin become depressed. If depression occurs, stop taking it immediately and alert your doctor. Melatonin should not be taken by people with autoimmune conditions (Lapin, Mirzaev, Ryzov et al. 1998). Melatonin may help reduce seizure-like symptoms.
NSAIDs: Nonsteroidal anti-inflammatory agents include over-the-counter medications such as aspirin, ibuprofen, paracetemol (acetaminophen in USA) and naproxen; also prescription medications like Voltaren and Celebrex. (Voltaren is now available over the counter in the lower 25mg strength.) NSAIDs can have serious side effects including: asthma, cell toxicity; and chromosome abnormalities (Leach, Frank, Berardi et al. 1999). A large majority of the patients who develop serious GI complications on NSAIDs have never had previous mild side effects. Treatment with antacids and H2 receptor antagonists may increase the risk for subsequent serious GI complications (Singh, Ramey, Morfeld et al.1996). September 2004 update: The USA's Food and Drug Administration (FDA) has issued a Public Health Advisory warning that the NSAID drug Vioxx (Rofecoxib) can increase the risk of heart attacks and strokes, and the drug company Merck has withdrawn Vioxx from sale. FDA info about this.
(Vitamins and minerals are addressed in a separate Nutrition chapter.)
Pharmacies and Pharmacists
Have all your prescriptions filled at one pharmacy so your pharmacist can warn you of any possible drug interactions, no matter how many doctors you have. Your pharmacist can be a great ally and teacher. Learn about your medications. Develop a working relationship based on mutual respect and trust. Educate your pharmacist about FMS and CMP. The handout "Information for Pharmacists" from The Fibromyalgia Advocate * may be helpful. If your pharmacist treats you like a drug addict or malingerer, let him/her know that this is inappropriate, and that you do not allow inappropriate behaviour from health care providers.
Compounding Pharmacists
Compounding pharmacists are different than standard pharmacists. They are like the ancient apothecaries, only with all the present day knowledge and technology available. All pharmacists learn something about compounding prescriptions, but compounding pharmacists are specialists in the formulation of pharmaceutical compounds from basic ingredients, in the exact dosage form, strength and combination you require. You may need a dye-free, sugar-free, alcohol-free or preservative-free formulation, for example.
When you take a medication orally, you dose the whole body. Often this is not necessary for localised symptoms. It isn't sufficient for any pharmacist to put a drug into topical form. This drug must be bioavailable in this form, and a true compounding pharmacist knows how to do this. Standard topical preparations compounded include NMDA-receptor inhibitors and Calcium Channel Blockers, medications such as Neurontin, NSAIDs and opioids. Your doctor may not be utilising this option, and you may be able to provide him/her with an important contact.
Generic Medicines
Doctors and patients are led to believe that this means the generics are the same as the brand names. This is not always true. Generic and brand name drugs are not always exact equivalents. Some FMS and CMP patients may be sensitive to the differences.
This list of medications is only a partial listing of those used in FMS and CMP, and doesn't even include all that we have in our book. For details on the use of common pharmaceutical and non-pharmaceutical medications for chronic pain, see The Chronic Pain Control Workbook (Catalano and Hardin, 1996) and Pain: Clinical Manual (McCaffery M. and C. Paseo, 1999).
Allegron (nortriptyline HCl): This tricyclic antidepressant is used for insomnia. Some people find it stimulating, however, and must take it in the morning to allow restorative sleep that night. USA NAME: Pamelor
Aropax (paroxetine HCl): This serotonin and norepinephrine re-uptake inhibitor may also reduce pain, and has been found helpful in menopausal hot flashes (Gender Issues). Some people find it stimulating, and may need to take it in the morning to allow for sleep that night. USA NAME: Paxil
Most people who find Benadryl stimulating rather than sedating seem to have the same response to Allegron, Aropax and Tramal (nortriptyline, paroxetine and tramadol) known as Pamelor, Paxil, and Ultram in USA. I don't know why, but I suspect it may be a clue to the parameters of a subset of FMS.
Atarax (hydroxyzine HCl): This antihistamine and anxiety-reliever may be useful if itch, rashes or hives is a problem. NOT AVAILABLE IN AUSTRALIA
Buspar (buspirone HCl): This drug may improve memory, reduce anxiety, and help regulate body temperature. It is not as sedating as many other anti-anxiety drugs. USA NAME: BuSpar
Catapres (clonidine) : This drug may help Restless Leg Syndrome (RLS) (Wagner, Walters, Coleman et al. 1996).
Celebrex, Vioxx: COX-2 medications are sometimes called super aspirin. They are easier on the gastrointestinal tract than earlier NSAIDs. They may carry a greater risk of heart attack, stroke, or other cardiovascular problem (McAdam, Catella Lawson, Mardini et al. 1999). ALSO Ariva IN USA. Note: Vioxx has now been withdrawn because of these risks. See update.
Desyrel (trazodone): This antidepressant may help with sleep problems. It must be taken with food. It should not be used in women who may be or may become pregnant. NOT AVAILABLE IN AUSTRALIA
Diflucan (fluconazole): This antifungal penetrates all body tissues, including the central nervous system. Very short-term use can be considered if cognitive problems and/or depression are present and yeast is suspected. Yeast problems may indicate need for diet modification.
Effexor (venlafaxine HCl): This is an antidepressant and serotonin and norepinephrine re-uptake inhibitor. Food has no effect on its absorption. When discontinuing this, taper off slowly.
Elavil (amitriptyline): This antidepressant is inexpensive, but it can cause photosensitivity, morning grogginess, weight gain, dry mouth, and slow intestinal movements. It may cause RLS.
Euhypnos, Nocturne, Temaze, Temtabs (temazepam): This hypnotic may be useful to improve sleep. There are few reports of "hangover" effect. in Aus. USA NAME: Restoril
Flexeril (cyclobenzaprine): This may sometimes stop spasms, twitches, and some tightness of the muscles. It generates stage-four sleep, but it may cause gastric upset and a feeling of detachment.
Ethyl Chloride: This vapocoolant spray is useful for spray and stretch treatment, to inhibit pain impulses, and to allow for passive stretching.
Guaifenesin: the active ingredient in many expectorants, and is used experimentally for FMS. Most OTC guaifenesin preparations contain sugar, alcohol, and/or pseudoephredine. These should be avoided. For information about obtaining Guai in Australia, see Guai Support Group - Aussie website of the international Guai-Support mailing list run by Tesa Marcon.
Inderal, Deralin (propranolol HCl): This may help reduce the pain load, although your blood pressure may drop with its use. Antacids will block its effect.
Lidocaine, intravenous: Studies show that in animals, intravenous lidocaine can provide prolonged relief of some types of allodynia (Chaplan, Bach, Shafer et al. 1995). Lidocaine is the active ingredient in Xylocaine and other topical preparations.
Neurontin (gabapentin): This anticonvulsant is effective for hyperalgesia and allodynia (Attal, Brasseur, Parker et al. 1998). You may be able to lessen any side effects by drinking extra water. As dosage increases, bioavailability decreases. A 400 mg dose is about 25% less bioavailable than a 100 mg dose. This medication should not be discontinued abruptly.
NMDA (N-methyl-D-aspartate) inhibitors: NMDA antagonists can moderate or eliminate some symptoms of central sensitisation, such as secondary hyperalgesia (Oestreicher, Desmeules, Piguet et al.1998.) NMDA-receptor inhibitors may be effective in the treatment of some types of chronic pain (Sang, 2000). Ketamine reduces pain in a sub-group of FMS patients (Graven-Nielsen, Aspegren, Henriksson et al. 2000). NMDA inhibitors also boost the effect of opioids. NMDA inhibitors include:
ketamine (Ketalar),
dextromethorphan (contained in Actifed, Benadryl, Dimetapp, Lemsip flu, Logicin, Orthoxicol flu, Robitussin, Tussinol, Panadol flu, Tylenol Cold and flu etc),
memantine NOT AVAILABLE IN AUSTRALIA,
amantadine (Symmetrel - anti-Parkinson's drug),
methadone (Physeptone) see Medications, Pain and Opioids,
dextropropoxyphene (contained in Capatex, Di-Gesic, Paradex), and
ketobemidone NOT AVAILABLE IN AUSTRALIA.
Opioids: Due to the fact that some doctors consider the use of opioids to be controversial in the treatment of FMS and CMP, these medications are covered in depth at the end of this list - see Medications, Pain and Opioids .
Piracetam: This is an extract of ginko biloba. It seems to step up the flow of messages between the two halves of the brain (Flicker and Grimley Evans, 2000). It may stimulate the cerebral cortex and increase the rate of metabolism and energy level of brain cells.
Procaine injection for TrPs: Trigger point (TrP) injection protocols can be found in Travell and Simons Trigger Point Manuals. TrP injections must be given in the proper manner, with the patient properly positioned for each specific muscle, and performed with spray and stretch, rewarming, and range of motion exercises. Perpetuating factors must be addressed for lasting effects. TrP injections are not to be done with steroids.
Relafen (nabumetone): This NSAID may be better tolerated because it is absorbed in the intestine, thus sparing the stomach. NOT AVAILABLE IN AUSTRALIA
Remeron (mirtazapine): This antidepressant is unrelated to SSRIs, tricyclics or MAO inhibitors. It seems to cause fewer occurrences of common side effects. NOT AVAILABLE IN AUSTRALIA
Rivotril, Paxam (clonazepam): This is an anti-anxiety, anti-convulsive and anti-spasmodic medication. It may help with muscle twitching, RLS, and nighttime teeth grinding. USA NAME: Klonopin
Serzone (nefazodone HCl): This antidepressant is unrelated to SSRIs, tricyclics, or MAO inhibitors. It inhibits serotonin and norepinephrine, but has a low bioavailability that varies.
Sinequan (doxepin HCl): This tricyclic antidepressant and antihistamine combination can cause sedation. It may enhance the effects of Klonopin, and can reduce muscle twitching by itself. Also available as Deptran in Australia.
Soma (carisoprodol): This central nervous system muffler works rapidly. Effects last from four to six hours. It helps patients to detach themselves from their pain, and can damp the sensory overload of FMS. It should not be used as the only pain control. There are some reports of dependency. It can cause respiratory depression given in conjunction with propoxyphene. Treatment of FMS with the combination of carisoprodol, acetaminophen and caffeine is effective (Vaeroy, Abrahamsen, Forre et al. 1989). NOT AVAILABLE IN AUSTRALIA
Sonata (zaleplon): This is a short-term-acting hypnotic. You don't have to take it every night if you don't always have insomnia, because you can take it at bedtime or even later on those nights you have difficulty. You do need four hours to sleep it off (Elie, Ruther, Farr et al.1999). NOT AVAILABLE IN AUSTRALIA
Stilnox (zolpidem): USA NAME: Ambien This is a hypnotic for insomnia. It can be a tremendously effective sleep aid, but you may have to get in bed right after you take it. One study showed that short-term treatment with Ambien (5 to 15 mg) doesn't affect FMS pain, but is useful for sleep and subsequent daytime energy (Moldofsky, Lue, Mously et al. 1996). William Dement, the father of the field of sleep medicine, writes that Ambien is the safest and most useful sleep medication for long-term use as well (Dement and Vaughan, 1999). There have been some reports of serious depression from Ambien. Some patients have reported difficulty discontinuing it, and had to decrease it by a quarter pill a night. Others have had no problem. I have had an alarming number of people contact me saying that their doctors have refused to prescribe this medication because it is addictive, in spite of the fact that studies show that it has a lower abuse potential than other hypnotics (Soyka, Bottlender and Moller, 2000).
Tramal (tramadol HCl): USA NAME: Ultram This medication for moderate to severe pain acts on the central nervous system. It may cause constipation, nausea, dizziness, headaches, weariness, tightening of jaw and neck muscles, and vomiting. Some doctors have reported psychological addiction to tramadol that is even harder to break than narcotic addiction. This medication can lower the seizure threshold.
Wellbutrin (bupropion HCl): This antidepressant is sometimes used in FMS in place of Elavil, but it can promote seizures. Currently available in Australia as the quit-smoking drug Zyban.
Xanax (alprazolam): This anti-anxiety medication may be enhanced by ibuprofen. It aids the formation of blood platelets, which store serotonin, and it raises the seizure threshold. It must not be used during pregnancy. When you stop taking it, taper off gradually. Also available as Kalma in Australia.
Zanaflex (tizantidine hydrochloride): This muscle relaxant may help with RLS. It may help to reduce muscle tightness, and may have sedative effects. This is another medication you may have to take just before bed, as there have been reports of loss of muscle control. Some patients also mention hallucinatory effects. NOT AVAILABLE IN AUSTRALIA
Zofran (ondansetron) This medication helps about 50% primary FMS patients, according to one study (Hrycaj, Stratz, Mennet et al. 1996). The response was not the same in post-traumatic FMS.
Zoloft (sertraline HCl): This is commonly used to help with sleep problems. There have been several reports of night sweats with strong ammonia odour. It may be useful for pre-menstrual syndrome (Yonkers, Halbreich, Freeman, et al. 1997).
Too often readers have told me, "My doctor would not prescribe this medication because it is too hard to get someone off it." It's hard to stop taking a medication that will relieve your pain. It's nearly as hard as trying to figure out why any doctor in his/her right mind would want you to do so. In the best of all worlds, early FMS and single TrPs would be promptly diagnosed and treated. In our present reality, central sensitisation and allodynia of FMS coupled with the pain generated by TrPs can make this world a living hell for patients who haven't been promptly diagnosed and treated. We must deal with reality as it is today, unhampered by outmoded belief systems. Pain control is imperative to reduce any further sensitisation of the nervous system, as well as to allow these therapies to take place without additional shock to the pain sensing system.
I am not advocating opioids as the first method of pain control, or as the singular method of pain control. When other options have failed, the medical literature documents that opioids -- in conjunction with a thorough pain control program including bodywork, mindwork and life style adjustment -- are a logical and humane option in the treatment of severe FMS and CMP. For more information on this subject, see The Fibromyalgia Advocate *.
There are possible side effects with opioids, and some people do have a tendency towards addiction, but, according to these and many other references, this is not common in chronic pain patients. Opioids often slow intestinal motility. Measures should be taken to prevent constipation. Temporary sleepiness and confusion is common after initial opioid therapy, and after dose increases. Nausea may occur for the first 3 or 4 days.
Some opioids are available in suppository form if nausea and vomiting is present . Transdermal patches are also available. The liquid form may be very useful because of the ease with which you can vary the dosage. On days when pain is severe you may need your full dose, but on good days you can take a lesser amount.
| Some AUSTRALIAN OPIOID MEDICATIONS prescribed
for chronic pain Codeine: available mixed with paracetemol and other substances, both over-the-counter as a pharmacy medicine (Panadeine, Mersyndol etc) and in prescription strengths (Panadeine Forte, etc); also in pure form (prescription only). Oxycodone: Endone, OxyNorm, OxyContin
[sustained release], Proladone
[Suppositories] |
The information in this article is from Chapter 21 of the second edition of Fibromyalgia and Chronic Myofascial Pain: A Survival Manual by Devin J. Starlanyl and Mary Ellen Copeland, published by New Harbinger Publications, Oakland CA in 2001. ISBN 1-57224-238-8.
More information from the book is available on Devin Starlanyl's Fibromyalgia & Chronic Myofascial Pain Syndrome web site .
Adapted for Australian readers by Moira Smith, with permission. Australian drug brand names and other drug information are correct to the best of my knowledge.
The Australian information was collected with the help of the myDr Medications Search (using the MIMS Australian database) and Raymot's International Generic-Brand Dictionary of CNS Drugs; Psychotropics; Pain Medications.
* Also by Devin Starlanyl: The Fibromyalgia Advocate: Guide to Fibromyalgia and Chronic Myofascial Pain Syndrome. New Harbinger Publications, Oakland CA; 1998
Doctors' Answers to "Frequently Asked Questions" - Fibromyalgia on Drug InfoNet
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last revised 18 Jan, 2005