Complete Medical Guide For Disease Volume XI; Fibromyalgia

The misuse of prescribed opioids in the USA has increased significantly over recent years with regular news reports of dubious marketing practices, questionable relationships between doctors, not-for-profit organizations and drug companies, and deaths associated with prescription opioids. Commencing opioids in CWP and fibromyalgia, especially those without a clear prescribing ceiling, needs a great deal of experience and justification. Drugs that fall into this cautionary category include buprenorphine, fentanyl, methadone, morphine, oxycodone, hydrocodone, and meperidine. Starting long-term opioids is not recommended in this pathway and should be reserved for use by pain specialists to prevent the risk of inappropriate escalation.

These cautionary recommendations are yet another example of the continuing concerns about the long-term use of strong opioids in chronic non-malignant pain. To deliver CBT, some of the following will need to be achieved: Best results are likely to be seen where pain specialists work with primary care in the community setting to share their expertise and support primary care physicians.

There is the potential to improve outcomes through improved access and earlier intervention. CWP, including fibromyalgia, comprises one of the most difficult areas of long-term pain to manage. Part of the reason is its intangibility. This creates potential pitfalls that the pathway seeks to address. Change will not come without significant organizational resources along with the will for specialist and non-specialist groups to create new pathways for care. The role of the specialist is likely not to be diminished.

Instead, they can expect to be more challenged as they will be managing those patients whose health has not improved despite their primary care clinician having followed a comprehensive guideline. New ways of working may need to emerge and be recognized so that specialists can support their primary care colleagues in this work. Most importantly, implementation of this pathway may transform care and health outcomes for people with CWP and fibromyalgia for the better. The authors of this article wish to acknowledge the following in the production of the British Pain Society Chronic Widespread Pain Patient Pathway along with the pathway group members see Appendix.

The Chronic widespread pain, including fibromyalgia care map 8 which can be found at www. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

1. Introduction

Sign In or Create an Account. British Journal of Anaesthesia All Journals search input. Close mobile search navigation Article navigation. Aims and objectives of the pathway. Chronic widespread pain, including fibromyalgia: Abstract Chronic widespread pain CWP , including fibromyalgia, is a highly prevalent condition with a range of disabling symptoms, both physical and psychological. View large Download slide. Survey of chronic pain in Europe: Epidemiology of chronic non-cancer pain in Europe: Prevalence of self-reported neuropathic pain and impact on quality of life: An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.

Low back and radicular pain: The American College of Rheumatology criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: Psychological and behavioural therapies in fibromyalgia and related syndromes.

Managing patients with multimorbidity: The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Prediction of function in daily life following multidisciplinary rehabilitation for individuals with chronic musculoskeletal pain; a prospective study.

A comparison of behavioral and educational interventions for fibromyalgia. The role of antidepressants in the management of fibromyalgia syndrome: Managing chronic nonmalignant pain: Adverse effects of chronic opioid therapy for chronic musculoskeletal pain. Clinical guidelines for the use of chronic opioid therapy in chronic non cancer pain.

A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. Mean age was Mean Fibromyalgia Impact Questionnaire total score was Patients reported high annual health care use and numerous work limitations related to FM. Patients were taking unique types of medications prescribed for FM, including duloxetine Most patients took more than one medication concurrently Type of current medications used was most strongly associated with medication history and physician specialty.

Burden of illness was high for patients with FM, and treatment patterns were highly variable. Importantly, the treatments with the most evidence to support their use were not always the most frequently chosen.

Fibromyalgia FM is characterized by chronic, widespread pain, and many associated symptoms such as mood, sleep disturbances, and fatigue. The underlying pathophysiology of FM may also be shared with other disorders, such as a common disturbance in serotonin and norepinephrine neurotransmitter function [4—10]. Furthermore, FM can co-occur with other conditions that also share these symptoms, such as irritable bowel syndrome, painful bladder syndrome, headache, and sleep disorders [5—7].

The specific symptoms for a given individual can vary, often requiring more than one treatment to achieve an optimal effect. Each of these guidelines recommends multidisciplinary approaches to the treatment of FM, including combinations of nonpharmacologic and pharmacologic interventions [11].

However, there are some variations in these recommendations due to the complexity of treatment of patients with FM. The use of a multifaceted treatment approach involving a variety of medications and alternative or complementary treatments is well supported in the previous literature [12—16].

According to a recent review [11] , the APS and AWMF assign the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy CBT , amitriptyline, and multicomponent treatment, while EULAR assigns the highest level of recommendation to a set of pharmacologic treatments i.

Although there is not enough evidence to support one of these treatment guidelines over another, in this article we focus on the guidelines written by the APS as the study reported here primarily involves a United States-based population. The APS treatment guidelines were introduced in [17] and updated in [18] to include information about pharmacologic treatments.

The APS guidelines recommend that opioid analgesics, aside from tramadol, be used with caution and only after all other therapeutic options have been exhausted [13—19]. Recommendations also include specialty referral, such as care provided by rheumatologists, physiatrists, psychiatrists, or pain management specialists. Data from retrospective administrative claims in the United States have demonstrated that patients with FM use multiple medications and report high economic burden [20—22].

However, the reasons for select treatment decisions and the clinical outcomes associated with drug selection cannot be determined through claims. To our knowledge, no study has addressed the factors associated with treatment selection for FM. The Real-World Examination of Fibromyalgia: Patients participating in this study were enrolled from July through May from 58 outpatient health care settings including 91 participating physicians in the United States, including Puerto Rico.

Sites included outpatient practices of rheumatology The number of sites per specialty was monitored to attempt to be reflective of the types and rates of physicians seen in actual clinical practice. Sites were required to be practice settings, not research settings. They were identified based on their prior experience in observational or clinical research, their interest in FM based on publications in the literature, or referrals from other sites.

Sites were further selected on the basis of the number of FM patients seen per month and whether they received good clinical practice training prior to the study entry visit of the patient. The protocol was approved by either a central or site-specific institutional review board. All patients provided written informed consent before participating in the study. As physicians had minimal study responsibilities beyond the baseline visit, compensation to physicians did not exceed what they would have normally received for a single regular patient office visit approximately 1 hour.

Minimal inclusion and exclusion criteria were used to ensure this study remained noninterventional. Patients were identified by their care provider during routine office visits. The physicians' decisions regarding the proper treatment and care of patients were made in the course of normal clinical practice.

Thus, patients were eligible for the study if they were at least 18 years of age, met criteria for FM in the opinion of the enrolling physician, were under the care of the participating physician, were cognitively able to understand and complete patient self-rated scales in English or Spanish via telephone interviews, and were available for 12 months to participate in the study.

This was a baseline assessment of a prospective month observational study. This study was designed to describe the burden of illness and treatment patterns of patients with FM, and to examine patient, physician, and care factors that influence treatment choices. All patient care by the enrolling physician occurred as part of the physician's routine clinical care. Data were collected from three sources: The physician survey was completed by the participating physician prior to enrolling patients into the study.

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Once informed consent was obtained, the patient visit form was completed during a standard office visit for which the physician was prescribing a new pharmacologic treatment defined as any agent not used in the last 6 months. Physicians were asked to complete portions of the form related to the patients' medical history, physician's relationship with the patient, and a complete description of ongoing, discontinuing, and newly started pharmacologic and nonpharmacologic interventions for FM. The patients completed the portion of the form related to their demographic and medical history.

No further study-specific office visits or physician information was required. All further data were collected with CATI, in which patients were asked to respond to various questions regarding their health status and care. Patients were assessed via telephone interviews in English or Spanish at five different time periods: Only the baseline information is included in this article. Each interview took approximately 30—45 minutes to complete. Baseline interviews had to be conducted within 14 days of the study entry visit. The physician survey included physician demographics, the physician's perception and experience treating FM, practice characteristics e.

Data included patient demographics, medical history, socioeconomic status, and work or disability status. Burden was assessed by measuring prior health care utilization and by domains deemed important to determine treatment success in studies of FM by the Outcome Measures in Rheumatology Clinical Trial fibromyalgia steering committee. These domains included pain, fatigue, global functioning, sleep quality, health-related quality of life, physical function, depression, anxiety, and dyscognition [23].

Specific validated measures are as follows: The average severity score BPI-S ranges from 0 no pain to 10 pain as bad as you can imagine. The average interference score BPI-I measures the degree to which pain interferes with various functions, and has a range from 0 does not interfere to 10 completely interferes. The Patient Health Questionnaire PHQ; range 0—30 [27,28] captures complaints of common physical symptoms seen in primary care settings. Each symptom was graded by the patient as 0 bothered not at all , 1 bothered a little , or 2 bothered a lot.

Anxiety symptoms were collected with the Generalized Anxiety Disorder GAD-7; range 0—21 [29] items were scored from 0 [not at all] to 3 [nearly every day]. The PHQ-8 [30,31] was used to measure depression severity items were scored from 0 [not at all] to 3 [nearly every day] , with ranges from 0 to Individuals' perceptions of insomnia, including symptoms of sleep, fatigue, and cognition, were measured with the Insomnia Severity Index ISI; range 0—28 [32]. The Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire MGH-CPFQ; range 7—42 [33] measures patients' cognitive and physical well-being, and the Multidimensional Fatigue Inventory MFI [34] measures five constructs related to fatigue, including general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue.

Each subscale ranges from 0 to For all scales, higher scores indicate worse health status. Treatment variables of interest included 1 type and number of pharmacologic treatments patients were currently taking including new and continuing medications , 2 type of nonpharmacologic interventions used in the last 12 months as reported by the patient, and 3 treatment use patterns including patients new to treatment, switching from, or augmenting with prior treatments.

Pharmacologic treatment could include, but was not limited to, any medication for the management of FM, including antidepressants, pain medications, anticonvulsants, stimulants, sleep agents, or anxiolytics. Clinical and Experimental Rheumatology. Cerebral blood flow alterations in pain-processing regions of patients with fibromyalgia using perfusion MR imaging.

American Journal of Neuroradiology. A standardized scale to measure beliefs about controlling pain B. Evidence of dysfunctional pain inhibition in Fibromyalgia reflected in rACC during provoked pain. Patients with fibromyalgia display less functional connectivity in the brain's pain inhibitory network. Decreased gray matter volumes in the cingulo-frontal cortex and the amygdala in patients with fibromyalgia. Patients with pain disorder show gray-matter loss in pain-processing structures: White and gray matter abnormalities in the brain of patients with fibromyalgia: Striatal grey matter increase in patients suffering from fibromyalgia—a voxel-based morphometry study.

Diffusion-weighted and diffusion tensor imaging in fibromyalgia patients: Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia. Elevated insular glutamate in fibromyalgia is associated with experimental pain. Localized 1H-NMR spectroscopy in patients with fibromyalgia: Arthritis Research and Therapy. Quantification of pain-induced changes in cerebral blood flow by perfusion MRI.

Rheumatic Disease Clinics of North America. The hypothalamic-pituitary-adrenal axis in the pathogenesis of rheumatic diseases. Endocrinology and Metabolism Clinics of North America. Neuroendocrinologic findings in primary fibromyalgia soft tissue chronic pain syndrome and in other chronic rheumatic conditions rheumatoid arthritis, low back pain Journal of Rheumatology. Diurnal hormone variation in fibromyalgia syndrome: Neuroendocrine and hormonal perturbations and relations to the serotonergic system in fibromyalgia patients.

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Scandinavian Journal of Rheumatology, Supplement. Evaluation and management of endocrine dysfunction in fibromyalgia. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. Growth hormone perturbations in Fibromyalgia: Seminars in Arthritis and Rheumatism. A metabolic basis for fibromyalgia and its related disorders: Follicular phase hypothalamic-pituitary-gonadal axis function in women with fibromyalgia and chronic fatigue syndrome.

Normal profile of sex hormones in women with primary fibromyalgia. Annales Academiae Medicae Stetinensis. Bone turnover and hormonal perturbations in patients with fibromyalgia. Autonomic nervous system derangement in fibromyalgia syndrome and related disorders. Israel Medical Association Journal. Simultaneous heart rate variability and polysomnographic analyses in fibromyalgia.

Abnormalities of cardiovascular neural control and reduced orthostatic tolerance in patients with primary fibromyalgia. Elevated plasma levels of neuropeptide Y in female fibromyalgia patients. European Journal of Pain. Alpha sleep characteristics in fibromyalgia. Interrelations between sleep and the somatotropic axis. Higher plasma IGF-1 levels are associated with increased delta sleep in healthy older men.

Journals of Gerontology A. Low levels of somatomedin C in patients with the fibromyalgia syndrome: Familial aggregation in the fibromyalgia syndrome. Family study of fibromyalgia.

Medical Professionals

The genetics of fibromyalgia syndrome. Possible association of fibromyalgia with a polymorphism in the serotonin transporter gene regulatory region. Confirmation of an association between fibromyalgia and serotonin transporter promoter region 5-HTTLPR polymorphism, and relationship to anxiety-related personality traits.

Significance of catechol-O-methyltransferase gene polymorphism in fibromyalgia syndrome. An association between fibromyalgia and the dopamine D4 receptor exon III repeat polymorphism and relationship to novelty seeking personality traits. Genetic linkage analysis of multicase families with fibromyalgia syndrome. The prevalence and clinical impact of fibromyalgia in systemic lupus erythematosus. Sleep disturbances, fibromyalgia and primary Sjogren's syndrome. Wolfe F, Michaud K. Severe rheumatoid arthritis RA , worse outcomes, comorbid illness, and sociodemographic disadvantage characterize RA patients with fibromyalgia.

Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia? Retrospective analysis with long term follow-up. Interrelations between fibromyalgia, thyroid autoantibodies, and depression. Pamuk ON, Cakir N. The frequency of thyroid antibodies in fibromyalgia patients and their relationship with symptoms. Association between thyroid autoimmunity and fibromyalgic disease severity. Antipolymer antibody reactivity in a subset of patients with fibromyalgia correlates with severity. Antipolymer antibodies in Danish fibromyalgia patients.

Anti-polymer antibodies are correlated with pain and fatigue severity in patients with fibromyalgia syndrome. Medical symptoms without identified pathology: Annals of Internal Medicine. Chronic widespread pain and fibromyalgia: Best Practice and Research. Features of somatization predict the onset of chronic widespread pain: Prevalence of post-traumatic stress disorder in fibromyalgia patients: Psychiatric disorders in patients with fibromyalgia: The role of psychiatric disorders in fibromyalgia. Depression and pain comorbidity: Archives of Internal Medicine.

Antidepressant treatment of fibromyalgia. A meta-analysis and review. A randomized controlled trial of citalopram in the treatment of fibromyalgia. Evidence-based data on pain relief with antidepressants. The pain of fibromyalgia syndrome is due to muscle hypoperfusion induced by regional vasomotor dysregulation.

Not the Last Word: Fibromyalgia is Real

Antioxidant status, lipid peroxidation and nitric oxide in fibromyalgia: Biology and therapy of fibromyalgia: Fibromyalgia, infection and vaccination: Fibromyalgia-associated hepatitis C virus infection. British Journal of Rheumatology. Chronic Coxsackie B infection mimicking primary fibromyalgia. Fibromyalgia and parvovirus infection. Fibromyalgia in human immunodeficiency virus infection. Dinerman H, Steerc AC. Lyme disease associated with fibromyalgia.

Intrathecal HIV-1 envelope glycoprotein gp induces enhanced pain states mediated by spinal cord proinflammatory cytokines. Thompson ME, Barkhuizen A. Fibromyalgia, hepatitis C infection, and the cytokine connection. Gabuzda D, Wang J. Chemokine receptors and virus entry in the central nervous system.

Role of microglia in central nervous system infections. American Journal of Physical Medicine and Rehabilitation. Illness from low levels of environmental chemicals: Sim J, Madden S. Illness experience in fibromyalgia syndrome: Social Science and Medicine. Journal of Manipulative and Physiological Therapeutics. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Fibromyalgia, arthritis associated with systemic disease, and other arthritides.

Harrison's Principles of Internal Medicine. Buskila D, Neumann L. Fibromyalgia syndrome FM and nonarticular tenderness in relatives of patients with FM. Fitzcharles MA, Boulos P.



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Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: Possible serotoninergia syndrome associated with coadministration of paroxetine tramadol. Duloxetine and other antidepressants in the treatment of patients with fibromyalgia.

Pragmatic consideration of recent randomized, placebo-controlled clinical trials for treatment of fibromyalgia. Efficacy of duloxetine in painful symptoms: Conceptual framework and item selection. Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome. Treatment of fibromyalgia with antidepressants: Journal of General Internal Medicine. Treatment of fibromyalgia with cyclobenzaprine: Treatment of fibromyalgia syndrome with antidepressants: Treatment of fibromyalgia and its symptoms. Expert Opinion on Pharmacotherapy.

Beliles K, Stoudemire A. Psychopharmacologic treatment of depression in the medically III. Pharmacological treatment of fibromyalgia and other chronic musculoskeletal pain. Strength training and stretching versus stretching only in the treatment of patients with chronic neck pain: A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients.

A randomized trial of tai chi for fibromyalgia. The New England Journal of Medicine. Tai chi and postural stability in patients with Parkinson's disease. The role of Spa therapy in various rheumatic diseases. Hydrotherapy, balneotherapy, and spa treatment in pain management. Mechanisms of action of spa therapies in rheumatic diseases: Melzack R, Wall PD. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: Cognitive-educational treatment of fibromyalgia: Cognitive-behavioral approach to the Treatment of chronic pain patients.

Regional Anesthesia and Pain Medicine. Thieme K, Gracely RH. Are psychological treatments effective for fibromyalgia pain? Exercise in warm water decreases pain and improves cognitive function in middle-aged women with fibromyalgia. Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: Journal of Rehabilitation Medicine. Gusi N, Tomas-Carus P. Cost-utility of an 8-month aquatic training for women with fibromyalgia: Transcranial magnetic stimulation for pain control. Double-blind study of different frequencies against placebo, and correlation with motor cortex stimulation efficacy.

Repetitive transcranial magnetic stimulation of dorsolateral prefrontal cortex increases tolerance to human experimental pain. Diffuse analgesic effects of unilateral repetitive transcranial magnetic stimulation rTMS in healthy volunteers. Changes to cold detection and pain thresholds following low and high frequency transcranial magnetic stimulation of the motor cortex.