Effective Treatment of Pain and

Fibromyalgia:

Treating the Root Causes

by Jacob Teitelbaum, MD

With pain medications causing over 45,000 preventable US deaths a year, it is time to recognize that there are far more effective, and safer, ways to get rid of pain!

And 45,000 deaths is a conservative estimate. Arthritis medications cause over 16,500 deaths a year from bleeding ulcers, along with a massive 40% to 300% increased risk of heart attack and stroke.^1,2 Meanwhile, over 15,000 people a year die from overdoses of prescribed codeine medications.

It is important to recognize that, like the flashing red oil light on your car’s dashboard, pain is your body’s way of saying that something needs attention. If you have your hand on a hot stove or have a broken leg, the cause is obvious. But most of the time with arthritis, migraines, fibromyalgia, or other common pains, the cause is less obvious. So what do most doctors do? Simply throw an often-toxic pain medication at the person!

Simply giving a pain medication without treating the cause of the pain is like putting a Band-Aid over a flashing red oil light. It looks better, but then you burn your motor out a few miles later. In the same way, if you give the person’s body what it needs, the pain goes away – just like the oil light goes out when you put oil in the car. This has been shown in our research, using fibromyalgia as one pain model.^3,4

In addition to the personal costs of pain, the financial costs are also staggering. A study in the August 2012 issue of the Journal of Pain showed that the economic costs of pain in the US are about $600 billion dollars a year, a staggering figure that is more that the total costs of cancer and heart disease combined!⁵ Yet most physicians are very poorly trained in treating pain, while being indoctrinated with a dogmatic belief that any holistic or non-MD practitioners who can help pain patients must be quacks. It’s no surprise then that around ¼ of adult Americans suffer unnecessarily with poorly treated pain.

Let’s begin by looking at how to treat the root causes of pain to get pain relief, using

fibromyalgia (FMS) and myofascial pain syndrome (MPS), or muscle pain, as a model. These same principles also appy to treating fatigue and chronic fatigue syndrome (CFS). FMS, CFS, and MPS are common names for an overlapping spectrum of disabling syndromes. It is estimated that FMS alone affects 3 to 6 million Americans, and as many as 12 million in milder form, causing more disability than rheumatoid arthritis. Myofacial pain syndrome (MPS) affects many millions more. Although we still have much to learn, effective treatment is now available for the large majority of patients with these illnesses.^3,4 CFS/FMS/MPS represents a syndrome, a spectrum of processes with a common end point, and I will often refer to the three together.

Research has implicated mitochondrial and hypothalamic dysfunction as common denominators in these syndromes.⁶ Dysfunction of hormonal, sleep, and autonomic control (all centered in the hypothalamus) and energy production centers can explain the large number of symptoms and why most patients have a similar set of complaints.

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FMS/CFS/MPS

Essentially, these three conditions represent an energy crisis in one’s body. Treating the root causes requires treating the underlying problems that deplete energy or interfere with energy production.

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To make it easier to explain to patients, we use the model of a circuit breaker in a house: if the energy demands on your body are more than it can meet, your body “blows a fuse.” The ensuing fatigue forces you to use less energy, protecting you from harm. On the other hand, although a circuit breaker may protect the circuitry in the home, it does little good if you do not know how to turn it back on or that it even exists.

This analogy actually reflects what occurs in CFS/FMS. As energy stores are depleted, hypothalamic dysfunction occurs early on, resulting in the disordered sleep, autonomic dysfunction, low body temperatures, and hormonal dysfunctions commonly seen in these syndromes. In addition, inadequate energy stores in a muscle results in the muscle shortening (think of rigor mortis) and pain that is further accentuated by the loss of deep sleep. Therefore, restoring adequate energy production, and eliminating the stresses that overutilize energy, restores function in the hypothalamic “circuit breaker,” and also allows muscles to release – allowing pain to resolve. Our placebo-controlled study showed that when this is done, 91% of patients improve, with an average 90% improvement in quality of life, and the majority of patients no longer qualified as having FMS by the end of three months.⁴

In addition to muscle pain, about half of those with FMS have a secondary neuropathy called small fiber neuropathy (SFN). Chronic pain in general can trigger SFN, and in my experience most with FMS begin with muscle pain and MPS, which then progresses in some cases to SFN. Interestingly, SFN also is being commonly seen in association with antibody deficiencies (mostly IgG1 and 3) in clinical work being done by Dr. Mark Sivieri, and may supply a “missing link” connection between the nervous system, immunity, and even autonomic dysfunction. More on this in future articles and in an upcoming webinar (see below).

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Common Causes of the Energy Crisis Causing Fibromyalgia May Include

infections

nutritional deficiencies

disrupted sleep

pregnancy

hormonal deficiencies

stress

toxin exposures

injury (especially brain and neck)

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Diagnosis

The criteria for diagnosing FMS/CFS are readily available elsewhere. There is a simpler approach to diagnosis that is very effective clinically. If the patient has the paradox of persistent widespread pain and severe fatigue combined with insomnia (if one is exhausted, they should sleep all night), they likely have an FMS related process.

Treatment

Two studies (including our RCT) have shown an average 90% improvement rate in FMS/CFS when using the “SHINE” protocol.^3,4 SHINE stands for Sleep, Hormonal support, Infections, Nutritional support, and Exercise as able. Using the acronym

SHINE will simplify treatment of these patients. This article will give you an excellent start in treating CFS/FMS/MPS, and there are other tools available for simplifying and improving treatment of these complex conditions.

Tools to Simplify Care of these Complex People

1. Free treatment tools

   . These include:

   1. intake questionnaires that elicit symptoms by diagnosis (e.g., thyroid, adrenal, candida) so that you can quickly determine the underlying contributing conditions;

   2. Treatment checklists. Are you repeatedly (and illegibly) writing down the same treatment recommendations over and over? Instead, simply check off the treatments that you want. They include detailed recommendations such as dosing, side effects, etc. Simply e-mail me at

      Endfatigue@aol.com

      and ask for the free treatment tools, and I will send them to you.

1. Our free

   Practitioners Alliance Network (PAN)

   . This is a free membership organization for health-care practitioners. Our mission is to provide a common platform for bringing together health-care professionals from widely diverse backgrounds in order to foster communication and to help practitioners grow their practices.
   PAN members participate chiefly through a private, members-only website where practitioners gain access to many free benefits that include:

1. membership in the PAN Forum, a practitioners-only social website and discussion forum where members can ask and answer questions – including questions for Dr. Teitelbaum;

2. access to the PAN Buyers Club, a group of companies that offer PAN members special discounts on nutritional supplements and office supplies for their practices (typically at rates of 7.5%–15% below wholesale);

3. opportunities for cross-referrals through a growing community of PAN members;

4. access to free live webinars conducted by Dr. Teitelbaum and guest presenters on health topics of interest to practitioners;

5. opportunities to help suggest, design, and participate as study authors in PAN-sponsored research studies. PAN has just launched a study on Alzheimer’s treatment using a holistic protocol. There will be many more.

3. Online training

   . There is an 8-hour online training that you can take at your leisure which will make you an expert on treating FMS/CFS/MPS and also get your name on our patient referral list. See www.vitality101.com/PAN for info.

4. Our free online Energy Analysis Program

   (at

   www

   .EndFatigue.com), which will analyze the person’s symptoms, and even pertinent labs if available, determine the factors contributing to the person’s energy crisis, and tailor a program to optimize that person’s energy. The questionnaire the person fills out is the same as the one in the treatment tools, so your staff can enter the info if you like and have the detailed analysis and treatment protocol come from you instead of the online program. That allows you to be “the Wizard”!

• All involved in the healing arts in any and all forms are invited to come and share what you know while learning from each other. Let’s come together to heal our health-care system!

Treating the Root Causes of Pain with SHINE

S –

Sleep

: Sleep is when tissue repair occurs, and is critical for the resolution of most types of chronic pain. A foundation of FMS/CFS is the sleep disorder. Using treatments that increase deep restorative sleep, so that the person gets seven to nine hours of solid sleep each night, is critical. Start treatment with natural therapies or with a low dose of sleep medications that do not decrease stage 3–4 sleep. Continue to adjust the treatments each night until the patient is sleeping 8 hours a night without a hangover.

The natural remedies that I recommend you begin with include the following:

1. Herbal preparations containing a mix of valerian root, wild lettuce, Jamaican dogwood, passionflower, hops, and theanine. These are all combined in an excellent product called “The Revitalizing Sleep Formula” by Integrative Therapeutics. Patients can take 1 to 4 caps at bedtime. These six herbs can help muscle pain and libido as well as improving sleep.

2. Melatonin: ½–1 mg at bedtime.

3. 5-HTP (5-hydroxytryptophan): 200 to 400 mg at night. Limit to 200 mg if on antidepressants or other serotonin-raising medications.

4. Magnesium at bedtime. A hot bath with 2 cups of Epsom (magnesium) salts and some lavender oil can be very helpful.

If natural remedies are not adequate to result in at least 8 hours a night of sleep, consider these medications:

• Zolpidem (Ambien): 2.5 to 10 mg q.h.s.

• Gabapentin (Neurontin): 100 to 900 mg h.s. can help sleep, pain, and restless leg syndrome (RLS) as well.

• Cyclobenzaprine (Flexeril): 3 mg.

• Trazodone (Desyrel): 50 mg. Use a half to 1 tablet q.h.s.

There are over 30 other helpful natural and prescription sleep aids.

Most people with insomnia do well just with the natural sleep support. In those with CFS/FMS, the added medications may be needed. Because of next-day sedation and each medication’s having its own independent half-life, FMS/CFS patients do better with combining low doses of several medications than with a high dose of one.

Although less common, three other sleep disturbances must be considered and, if present, treated. These are sleep apnea, UARS (upper airway resistance syndrome), and RLS, which is also fairly common in fibromyalgia.⁷

H

–

Hormonal support

: Hormonal imbalances are associated with FMS. Sources of imbalance include hypothalamic dysfunction, adrenal exhaustion from chronic stress, environmental toxins, and autoimmune processes such as Hashimoto’s thyroiditis. Most blood tests use two standard deviations to define blood test norms. By definition, only the lowest or highest 2.5 % of the population is in the abnormal (treatment) range. This does not work well if over 2.5 % of the population has a problem.

The goal in pain management is to restore optimal function while keeping labs in the normal range for safety. One way to convey the difference between the “normal” range based on 2 standard deviations and the optimal range which the patient would maintain if he/she did not have FMS is as follows:

Pretend that your lab test uses 2 standard deviations to diagnose a “shoe problem.” If you accidentally put on someone else’s shoes and had on a size 12 when you wore a size 5, the normal range derived from the standard deviation would indicate that you had absolutely no problem. You would insist the shoes did not fit although your shoe size would be in the normal range. Similarly, if you lost your shoes, the doctor would pick any shoes out of the “normal range pile” and expect them to fit you.

Thyroid Function

Suboptimal thyroid function is very common, and it is important to treat all chronic myalgia patients with thyroid hormone replacement if their free T4 blood levels are below even the fiftieth percentile of normal (Janet Travell – personal communication). Many CFS/FMS patients also have difficulty in converting T4, which is fairly inactive, to T3, the active hormone. Additionally, T3 receptor resistance may be present, requiring higher levels.⁸ In most CFS/FMS patients, I give an empiric trial of Armour thyroid, ½ to 2 grains every morning, adjusted to the dose that feels best to the patient as long as the free T4 is not above the upper limit of normal.

TSH testing is not reliable. Iodine support (I use Tri-Iodine 6.25 mg a day) can be helpful. Optimizing ferritin (iron) levels by keeping them over 60 is needed for proper conversion of T4 thyroid to active T3. Selenium 200 mcg can help in Hashimoto’s, but otherwise I limit selenium to 55 mcg a day, as higher doses are associated with a modestly increased diabetes risk.

Adrenal Insufficiency

I find the most reliable indicator of the need for adrenal support to be sugar cravings associated with irritability when hungry.

An excellent glandular/herbal mix for adrenal support that is very safe and

effective is Adrenal Stress End (from Integrative Therapeutics). I also consider

bioidentical prescription Cortef, 5 to 12.5 mg a day if needed.

Low Estrogen and Testosterone

These have been discussed at length in other Townsend Letter articles, so I will simply note that bioidentical and herbal support when needed is very helpful.

I –

Immune Dysfunction, Infections, Inflammation, and Impingement

: Immune dysfunction is part of the FMS process. Opportunistic infections present in FMS/CFS include yeast/candida, chronic sinusitis, nasal–toxin producing Staph aureus infections, numerous bowel infections, and chronic, low-grade viral and antibiotic-sensitive infections (e.g., Lyme disease). These may need to be treated, especially candida, though many infections resolve on their own as immune function improves.

Inflammation also needs to be addressed, and natural remedies do so brilliantly. My favorites are below

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Treating Inflammation Naturally

My favorite natural anti-inflammatories are:

1. BCM95 highly absorbed curcumin

2. boswellia

3. willow bark

4. omega-3 EFAs

These are contained in:

Curaphen

(by EuroMedica): This mix of highly absorbed curcumin, boswellia, DLPA, and nattokinase has been a pain relief miracle – sometimes helping when morphine has not. It continues to build in effectiveness over 6 weeks, but is often effective in 30 minutes. For severe chronic pain, I give 2 tabs 3× day for 6 weeks, then lower the dose or give as needed.

Pain Formula

(by Integrative Therapeutics): This mix of willow bark, boswellia, and cherry is especially helpful for arthritis and back pain. For severe chronic pain, I give 2 tabs 3× day for 6 weeks, then lower the dose or give as needed.

EurOmega 3

(by EuroMedica): This vectorized omega-3 is what I use for omega-3 support. One pill delivers the same effective level of omega-3s as 8 regular fish oil capsules, containing the EFAs but leaving out the unneeded triglycerides. So 1–2 a day are plenty, with lower cost, better compliance, no toxicity or rancidity, and no fish oil burps.

I combine all 3 of the above in those with pain and add them to any pain meds that the person is on. After 6 weeks, the pain meds can often be tapered down or stopped, and the dose of the herbals lowered (or taken as needed). In a head-on study, the components of Curaphen were much more effective than Celebrex for arthritis. At the beginning of the study, 79% of the people taking Celebrex were in moderate to severe pain, dropping to 50% after 12 weeks. In those who took Curaphen equivalent, these numbers were 86% and 21%, respectively. Basically, the medication resulted in major pain reduction in only 29% in the Celebrex group vs. 65% in the herbal group!⁹

Meanwhile, in another head-on study, willow bark was twice as effective as ibuprofen for back pain.¹⁰ Besides being more effective, the herbals result in “side benefits” instead of side effects!

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N

– Nutritional Deficiencies

: FMS/CFS patients are often nutritionally deficient. B vitamins, magnesium, ribose, iron, coenzyme Q10, malic acid, and carnitine are essential for mitochondrial function. These nutrients are also critical for many other processes. Although blood testing is not reliable or necessary for most nutrients, I do recommend that you check B12 and ferritin levels.

I begin people with FMS/CFS on the following nutritional regimen:

1. A quality multivitamin suited for their needs. It should contain at least a 50 mg B complex, 150 mg of magnesium glycinate, 900 mg of malic acid, 2000 IU of vitamin D, 500 mg of vitamin C, zinc 15 mg, selenium 50 mcg, chromium 200 mcg, and amino acids. Because there are dozens of important nutrients, and patients got tired of taking handfuls of tablets each day, I now use a powdered multivitamin called the Daily Energy Enfusion (by Integrative Therapeutics) in almost all of my patients (even those without CFS) for overall nutritional support. It contains over 50 nutrients in a single drink, replacing over 35 tablets each day. This should be taken long term with 1 EurOmega 3 daily.

2. If the ferritin is under 60 mg/ml, supplement with iron (with added vitamin C for absorption and not within 2–6 hours of a thyroid dose).

3. If the B12 level is under 540 pg/ml, I recommend B12 injections, 3000 mcg IM three times a week times for 15 weeks, then as needed based on the patient’s clinical response or 5000 mcg (5 mg) SL daily.

4. Coenzyme Q10: 200 mg a day.

5. Acetyl-L-carnitine: 500 mg twice daily for 4 months.

6. The person should avoid sugar and caffeine, and water intake should be increased.

7. An especially important nutrient? Ribose (Corvalen by Douglas Labs). This is one of the single most important nutrients for treating fibromyalgia, A study that we authored published in the Open Journal of Pain showed that ribose not only significantly decreased fibromyalgia pain but also increased energy an average of 61% at 3 weeks.¹¹

It is also very effective for heart disease as well. I consider ribose the most important nutrient discovery of the decade!

A Few Final Points

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Topical Pain Relief

When dealing with localized pain, it is often neither needed nor desirable to soak all 200 pounds of a person to treat 3 ounces of painful tissue, and topical treatments can be excellent. A few of my favorites include:

1. Comfrey topical (Traumaplant by EuroPharma). This is an amazing and often quickly effective treatment for many kinds of pain, and a top priority for everyone’s medicine cabinet. Try it and prepare to be amazed

2. Topical menthol creams (such as Tiger Balm) can help for tension headaches and other muscle pains

3. Compounded pain creams. For prescribing practitioners, this can be helpful for nerve and tendonitis pain.

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A Few Specific Pain Conditions

Migraines

• 1–2

  g

  IV over 15 minutes gives immediate elimination of the migraine in 85%!^12,13

Conclusion

Effective treatment is available for almost all pain, just not from standard physicians. Although this article focuses on metabolic aspects of pain relief, applying structural therapies (e.g., chiropractic and osteopathic manipulation and numerous forms of body work), biophysics (e.g., acupuncture and frequency specific microcurrent), and other modalities can also be dramatically effective. People with pain do best, as do their practitioners, when practitioners speak with each other, cross-refer, and share information!

Notes

1. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy Am J Med. 27 July 1998;105(1,Suppl 2):31S–38S.

2. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis BMJ. 2011;342:c7086. Available at http://www.bmj.com/content/342/bmj.c7086.full.pdf.

3. Teitelbaum J, Bird B. Effective treatment of severe chronic fatigue: a report of a series of 64 patients. J Musculoskel Pain. 1995;3(4):91–110.

4. Teitelbaum JE, Bird B, Greenfield RM, et al. Effective treatment of CFS and FMS: a randomized, double-blind placebo controlled study. J Chronic Fatigue Syndr. 2001;8(2):3–24. The full text of the study can be found at www.Vitality101.com.

5. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715–724. Epub 2012 May 16. http://www.ncbi.nlm.nih.gov/pubmed/22607834 Accessed Sept. 19, 2013.

6. Demitrack MA, Dale K, Straus SE, et al. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab. December 1991;73(6):1223–1234.

7. Yunus MB, Aldag JC. Restless legs syndrome and leg cramps in fibromyalgia syndrome: a controlled study. Br Med J. 25 May 1996;312(7042):1339.

8. Lowe JC, Reichman AJ, Yellin J. The process of change during T3 treatment for euthyroid fibromyalgia: a double-blind, placebo-controlled, crossover study. Clin Bull Myofasc Ther. 1997;2(2/3):91–124

9. Antony B, Kizhakkedath R, Benny M, Kuruvilla B. Clinical evaluation of an herbal formulation in the management of knee osteoarthritis. Poster presentation. Presented at Osteoarthritis Research Symposium Internationale (OARSI) Annual World Congress on Osteoarthritis. September 15–18, 2011; San Diego, CA.

10. Chrubasik S et al. Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med. 2000 July;109(1):9–14.

11. Teitelbaum JE, Jandrain J, Mcgrew R. Treatment of chronic fatigue syndrome and fibromyalgia with D-ribose – an open-label, multicenter study. Open Pain J. 2012;5:32–37.

12. Demirkaya S, Vural O, Dora B, Topçuoğlu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171–177.

13. Mauskop A, Altura BT, Cracco RQ, Altura BM. Intravenous magnesium sulfate rapidly alleviates headaches of various types. Headache. 1996 Mar;36(3):154–160.

14. Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. 1998 February;50(2):466–470.

Jacob Teitelbaum, MD

Medical Director of the Practitioners Alliance Network (PAN)

Author of From Fatigued To Fantastic! and Pain Free 1-2-3: A Proven Program to Get YOU Pain Free Now! and senior author of the landmark study “Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia – a Placebo-Controlled Study.