Are Opiates Really That Bad for Fibromyalgia?

Are Opiates Really That Bad for Fibromyalgia?

By Ginevra Liptan, M.D.

Ginevra Liptan, MD

Ginevra Liptan, MD

Many people with fibromyalgia have gone to their doctors to ask for help with pain management, only to be told that opiate pain medications like Vicodin or oxycodone are not a recommended treatment option for fibromyalgia. This is confusing and frustrating for patients who wonder why their doctors are so hesitant to prescribe them this form of pain relief.

It boils down to this: In published studies, daily use of opiates hasn’t been shown to work very well for fibromyalgia over the long run. This leads to medical journal articles stating such things as “opioid use for the management of pain in fibromyalgia is strongly discouraged and is not recommended by any current practice guideline.”

Here’s the problem with this type of blanket statements: these recommendations are based on the results of only a few small studies showing they were ineffective for fibromyalgia pain. Since no large trials have been done, the recommendations against opiate use for fibromyalgia are based on data from less than 100 subjects! Also, these small studies only looked at patients taking opiates every day for pain, and we know that daily, long term use of opiates does result in negative side effects and diminishing medication benefit over time. None of these small studies assessed the most successful use of pain medications, which is when they are taken just as needed for flares.

In my fibromyalgia practice, I have found that patients do better when not taking opiates daily, but rather taking them just as needed for severe pain flares, ideally less than 10 days out of the month. This schedule limits the development of most of the negative side effects of opiates and allows medications to maintain effectiveness over time, while still providing relief during the worst pain episodes.

I suspect in 20 years we will be using primarily cannabis-based prescriptions to manage fibromyalgia pain and look back at a time when we only had opiates as the “dark ages” of pain management. But currently we really have very limited medication treatment options for fibromyalgia pain. And until we have better tools, we need to utilize those tools we do have–and right now that is opiate-based pain medications. Most doctors grudgingly acknowledge this, and knowing they don’t have much else to offer their fibromyalgia patients, end up reluctantly prescribing them opiates (Berger 2010). In a recent study, 57% of almost 100,000 fibromyalgia patients had been prescribed opiate pain medications.

(http://onlinelibrary.wiley.com/doi/10.1111/papr.12364/abstract)

Until we have better options, opiates have an important role to play in managing fibromyalgia pain. The key is in using them correctly for the maximum benefit and minimum harm. Now is not the time to make blanket proclamations against using opiates for fibromyalgia, instead we should be studying which opiates and dosing regimens work best for fibromyalgia.

Editor’s Note: Ginevra Liptan, MD is both a fibromyalgia patient and physician specialist. Her new book The FibroManual: A Complete Fibromyalgia Treatment Guide for You…And Your Doctor releases May 3, 2016.

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Authored by: Ginevra Liptan, MD

There are 34 comments for this article
  1. Michele Diaz at 7:29 am

    My very first memory involves waking up and screaming from the pain in my legs. I was 3 1/2. I can still remember the taste of it. Yes. I could taste the pain & I didn’t understand what was happening or why. This was 1973. My pediatrician told my parents I was attention seeking & exaggerating growing pains (I grew to be 4’11” & the leg pains never stopped). By 5, I learned to hide my pain & scream into my pillows. By 8, my mother died from complication of SLE (lupus). At 13, I learned to beg my friends to not tell their parents about my excruciating pain, as I hid in their closets, screaming into pillows & stuffed animals.
    As a young adult, I learned to save pain meds, from injuries or dental work, for the days the migraines &/or leg pains crippled me.
    At 28, I had a slip & fall at work. After being bullied & abused by WC, I walked away with a diagnosis of fibromyalgia, chronic pain & chronic fatigue. And my own team of drs who gave me small scripts of pain meds & muscle relaxers. I began a new life. My pain was unpredictably unpredictable. But I was empowered by the ability to take Oxycontin & percocets to bury the pain or get through a sadistic flare. Eventually, no one could tell I had chronic pain. I worked. I was a mother. A wife. Pet handler. Rose gardener extraordinaire. Artist.
    For almost 10 years, I used a small amount of pain meds & my life was pretty normal.
    That was then.
    The last 9 years have been a living hell. I lost my team of drs. I lost my small scripts of pain meds & muscle relaxers. I no longer can keep a job. I can no longer be a normal mom or housewife. I’ve burned holes in my stomach from taking 800mgs of ibuprofen every 6 hrs to ease the tmj, neck & hip pain, joint pain & migraines. Not that it helps as much as percocets did, but what can I do?
    I don’t have insurance & not working means I cannot afford to pay a pain management clinic $250 plus a month for pain meds. That is IF I could prove I was disabled. You can’t show fibromyalgia on an MRI or X-Ray. Which would show the bursitis is was diagnosed with over 16 years ago, but no longer have the records for to prove it.
    So when I read that opiate medications do not help fibromyalgia, it is like being slapped in the face.
    WHO DECIDED THIS AND WHAT PROOF IS THERE?
    I cannot take SSRI’s or gabapentin due to paradoxical reactions! But that is all I’m offered by community clinic drs, who treat me like a drug seeker & junkie because I wrote down I have fibromyalgia & migraines. I have never, ever asked them for pain medications. I only go to get my allergy meds, muscle relaxers & antivirals. Yet. I’m still treated like a junkie. How embarrassing!!!!
    They don’t care. No one cares.
    My life is miserable without the small script I used to get. How can I tell my youngest child that Mommy can’t do all the things I did for her older sibling? How do I explain to my child that Mommy can’t go to her school function because the noise & hard seats will put me into a painful flare?
    WHEN DO I GET TO LIVE MY LIFE AGAIN? HOW LONG AM I TO BE PUNISHED FOR CRIMES I HAD NOTHING TO DO WITH?
    OPIATE MEDICATION HELPS CHRONIC PAIN!!!
    WE ARE NOT ADDICTS!!

  2. Richard A. Lawhern, Ph.D. at 11:54 am

    Elizabeth, so far I’ve personally reached out to three different law firms via web gateways. None of them bothered to respond to my inquiry. I will continue to make this effort. However, we have to recognize that there could be significant issues and barriers.

    1. In many cases, the government protects itself from lawsuits by refusing to grant permission for being sued in the performance of its normal constitutional duty as interpreted in the courts. The idea is that we’re supposed to be able to turn these folks out of office if they screw up, so we shouldn’t need to sue them. The practice is an altogether different issue.

    2. Grounds for suing the government will very likely be different from grounds against a private practitioner. When the CDC defines practice standards, we might not be able to sue them for malpractice (and if this sounds like a Catch 22 situation to you, I truly understand because it does to me too). What might possibly stick is a suit for medical negligence or malfeasance in office (faulty performance or non-performance of an assigned duty of care).

    3. I’ve heard a few mentions of suing on grounds of violation of civil rights. That one sounds interesting, but it would probably have to break new ground in public law. We have to remember that despite a lot of furor and argument, the Patient Bill of Rights never got enacted in public law. Arguably, Big Pharma quietly killed it by threatening to cut off campaign contributions to any politician damn fool enough to campaign for it. That’s a real possibility in the present complex of issues.

    4. I’ve also heard the idea of a “call your Congressman” day — to so completely flood Congressional office switchboards that they can’t accomplish normal business. If we can put together 10,000 or 100,000 people willing to place three calls each to their own Senators and Representative, that might have some possibilities. (In this, I should credit Pat Anson of the National Pain Network).

    I’ll keep on plugging. Would anybody like to join a corresponding committee to help out? Feel free to let me know at lawhern@hotmail.com

  3. Elizabeth Brown at 10:23 am

    Please STOP assuming what works for “one” person, under the Umbrella of Fibromyalgia, will work for “everyone”. This is not only unscientific, it is simplistic and insulting.

    Those of us with this Disease, we know from intimate, personal experience what works and what does not. We are far more educated that the “street heroin user” that the DEA tries relentlessly to associate us with.

    Scientists and Anesthesiologists did make a discovery that manages intense pain, and it is the very thing that helps many Fibromyalgia Patients, do something as simple and mundane as the dishes.

    We do not “get high”, we do not “get giddy”, we do not “abuse” we certainly do not share!! I can not afford to share!

    So please. We need help now from Lawyers to sue for the suicides of people who have been denied help, Hippocratic oaths broken, government interference killing innocent and responsible Chronic Pain Patients, because this is the most vile and disgusting way to treat ill and disabled people and I never thought I’d live in a country, especially the USA where we were actually denied our medical treatment.

    I never thought I’d live to see people so ‘easily suggestible’ and sorry for the world but plainly ignorant of this disease and it’s current management, to believe campaign hyperbole such as the absurd non scientific rhetoric happening now. The “epidemic” came and went. Policies have been in place for years now to cross reference pharmacy pick ups.

    ALL of this is about money. Where is the Class Action LAw Suit to sue for the loss of lives loss of productivity, loss of jobs, families torn apart from suicides, where are the law suits against the medical community breaking it’s Hippocratic oath?

    Where are the list of names to expose of the Politicians who endorse this denial, National Pain blog?

    IEvery Dr. I have seen has expressed their pure frustration with the Usurping of government upon the Scientific and Medical community. THIS is an issue that has to be fought against.

    We have Poliy Wonks and Corporate bottom lines usurping actual Medical Care in this country, and we’re not going to talk about it and fight it in Congress? Because those of us who are here on the front lines of Fibromyalgia have been poked and prodded, we have invested thousands into every profiteering whim these unscrupulous “officials” come up with.

    We are not to be denied treatment, it is our right and this is a clear Human Right’s Violation that needs traction and a Class Action Lawsuit with Dr.s, Scientists, Suicide victims families, and current sufferers on board. SO WHEN CAN WE GET THIS GOING?

    Please direct us to fight, not just complain! We all know the symptoms, venting is not changing anything!

  4. Em Raven at 5:27 am

    Yeah so uh, you do know opiates have been used for at least as long as recorded history along with mj right? Only once they were made illegal did people start flipping fits about what works better. Saying opiates will be the dark age is just promoting mj, which I’m fine with, but criticizing someone else’s preferred med is not ok. Also there are TONS of us who react bad or are allergic to mj. It is also not appropriate for those with certain heart issues because of its effects on heart rate and pulse that opiates do not have. I’m getting real tired of people who mean well in the fibro (and chronic pain) community saying do this not that wait that not this is better. How about we just make everything accessible and stop passive aggressively demonizing other meds for our cause ok?

  5. THERESA FORD at 10:28 am

    How do I get my Dr to be more proactive with my pain. I have hemcromtosis also and I am on blood theropy

  6. Jolee at 10:53 am

    I have my own theories. I’ve had Fibro for many years, but didn’t get a DX until a year ago. From 2007 to 2014, I managed the pain (at this time from my back that regular therapies didn’t help). Having worked for doctors for years, including Orthopedics, Pain Management and Physical Therapy, I have an inside view. I also worked for insurance companies as a claims examiner.

    In the 1980’s the pharmacy reps would wheel in Vicodin, at that time the “new miracle drug.” Ironically, it wasn’t locked up, but kept in a big box in the clinical area, and they were wrapped like mints. If something bothered me, I could go get one. I took handfuls home. But for many years, there they sat. I never took them unless there was an issue. I’d pass them out to family going through dental work, etc. There wasn’t a taboo about them. No one was dying from them, they weren’t in the news, other than touted as a miracle drug.

    “These are the same pharmaceutical companies that in the mid-1990s began marketing opioids as safe, i.e., little to no potential for abuse, contradicting thousands of years of human experience with the opium poppy. They’re the same companies that launched massive campaigns to convince doctors that highly addictive narcotics were a first resort for patients with chronic pain.” http://tinyurl.com/o425yu7

    Because I worked in administration, I was involved in early managed care contracting, and understand how abuses in medical system began, and who was at fault. Greedy doctors were abusing the system. I saw it first hand, and I worked for well respected doctors. Medicare began to regulate their payments and this bloomed into Managed Care in which Medicare became the navigators, and whatever they were doing, private insurance would follow suit. As insurance companies clamped down on payments, doctors used people like me for creative billing methods. Hence, we played that game for many years. As payments continued to spiral downward, doctors cut vists shorter and passed out pain medications to keep their patient base happy. I could write a book on what I know but I’m keeping this shorter for what I know about pain medications.

    Over time, pain medications went generic and there wasn’t money for pharmaceuticals to continue passing them out like candy–because they became generic, the companies making the drugs dwindled to a few, making them less profitable. Something had to be done for their bottom lines.

    I attended the “free lunches,” as the big pharma machine kicked into gear and came into our offices and told our doctors about all the new medications that treated pain better than narcotics; and thus the spin began to discourage the use of narcotics for designer drugs that often were more dangerous to the patient, but paid big pharma the money they’d lost to the mass dosing of narcotics on the American people. They’re wonder drug had backfired because it worked so well!

    I could write a separate article on the perks of prescribing.

    In the early 1990’s congress got involved to stop the perks and passed laws preventing pharmaceuticals from gifting doctors with money for prescribing their drugs. They could no longer bring mugs, pens, pads, bags, T-shirts with their logos into the offices. Undefeated, Pharma used other means to perk the doctors, such as golf tournaments and lavish dinners and theater tickets. I know, I became the recipient of some of these gifts.

    Republicans got into congress and laws were rewritten to once again allow perks from big pharma and it remains the same today.

    To get the message out, the past ten years, big pharma and their lobbyists have paid government officials (DEA) wads of money to press their story that narcotics kill, that they’re evil and we have to start a war on these drugs. With Marijuana no longer the prison drug it once was, the DEA needed a job. They began making it harder for doctors to prescribe a medication that many people had used for years with excellent results, especially patients with chronic illnesses.

    The scare was and remains, and the news is also included to report, the “deaths” of thousands of Americans on Narcotics. The irony to this is more people die from alcohol related deaths (and the deaths of innocent victims because driving drunk) than ever died from an overdose. But it’s going to get worse. Big Pharma continues to funnel money into the hands of our government to take an effective, cheap drug off the market for their newer drugs that have side effects such as “sudden death.”

    An example of a drug used for pain releif and Fibro, is Cymbalta. There is now a clinical term for people trying to get off this drug. Apparently it’s ok to commit suicide from a drug, but lo if you should die from an overdose. Cymbalta: Black Box Warning for Suicide Risk!
    You can’t get off Cymbalta easily. BUT, this is not an addiction?

    Let’s talk about addiction and Fibromyalgia. Fibro is a cruel disease. It’s not going to just “go away.” You have to manage the pain everyday. using “addiction” for a pain patient is ridiculous,demeaning and part of Big Pharma’s push to get people of narcotics and onto their suicide drugs.

    And who paid this OP to write this? Follow the money.

    I have Fibro and nothing works for me but narcotics. I’m currently unable to get off of Cymbalta, having tried, but the confusion, zaps, thoughts of suicide have made it impossible. It also put 30 pounds on me in 2 months. I’ve refused any and all “newer” drugs pushed on me. If I take Percocets daily, I have a good quality of life. I take Oxi for bad flairs.

    I’m aware the days are coming when I’m going to bying this on the street, or until big pharma gets behind marijuana and produces a pill (they know how to do this now) with the advantages of cannabinoids without the high.

    The DEA would love for you to buy it on the street. Keep them in business. I wish people would realize why we’re being denied our medications. It’s Money. Plain and simple.

  7. sd at 8:17 pm

    I would challenge anyone- CDC, any government official,etc. that believes they know what makes me feel better and what medications do/do not work for fibromyalgia in patients. I once learned as a health care provider “Treat your patient, not the illness.” The illness is all inclusive under one name, one DSM code. The PATIENT will manifest symptoms in many ways and medications will affect each person different. I have tried everything…and I do mean EVERYTHING.
    Medications:
    Older classes of antidepressants: amitriptyline, trazadone
    Newer classes of antidepressants: Paxil, Cymbalta, Effexor XR, Savella
    Arthritis meds: Ultram (tramadol),
    Muscle Relaxers: Soma, Zanaflex, Flexeril
    Fibro meds: Lyrica
    Misc: Lidocaine patches, gabapentin
    OTC meds: Advil, Aleve, Tylenol
    Treatments:
    Chiropractic treatment, exercise, TENS unit, TRT therapy, acupuncture, massage therapy Along with many more medications and physical treatments I cannot remember at this moment.

    With the grace of God I have a doctor that has been willing to try all of these medications and treatments. I wanted to try everything before I settled on pills. I never have had to take pills my entire life- until now. After trying so many things, my doctor and I tried opiates.
    FINALLY! I had something that made me feel somewhat “normal”. I have had and still have pain (flu-like aches only to the power of 10). But at least I can function and do some things I used to be able to do.
    I have always been outdoors, especially in the summer. Planting flowers, loving Mother Nature, feeding wild birds, yard work, etc. For the winters, I worked out with a personal trainer, had figure skated for 23 years.
    Now, I can plant flowers if I limit my activity to about 2-3 hours and pace myself with breaks. No more personal trainer, no more figure skating. Now, it takes all I have to go for a walk with my husband. I used to love to go shopping.. I hate going to shop. It hurts. IF I want something I will shop online if I feel I can. I still work, but I struggle each and every single day. I need to at least get to a point to have a decent retirement. I just had my 25th anniversary at my job. I need a few more years- they will be a struggle.

    PLEASE leave me and my pain medication alone. I finally have enough relief to feel like I am somewhat “normal”. I can do limited things with my husband- go to a concert, see a movie. I don’t want to have to stay home all the time- I need to get out a little.

  8. Donna at 12:15 pm

    Tracey—nothing to add, you’ve hit the nail on the head. And, no, our politicians and others involved with this issue, have no common sense.

  9. Tracey at 10:23 am

    Why don’t these groups who arrogantly declare that opioid therapy does not “benefit” those with fibromyalgia (or any other chronic pain condition) ask me and you? 20 years ago, I began searching for a diagnosis and ways to control my pain. I was passed from doctor to doctor, prescribed every type of antidepressants, anticonvulsants, muscle relaxers, anti-anxiety meds, sleep meds, anti-inflammatories, etc to treat my pain. I tried several sessions with different chiropractors, several different types of physical therapy (deep ultrasonic massage, exercise, aqua), traction, diet modification, homeopathic remedies, TENS unit, yoga, pilates, marijuana (which was and still is not legal in my state), epidural steroid injections (caused me more permanent damage and pain), etc.

    After ten years of searching for some relief from my fibro (and a couple of bulging discs in my neck – c-spine was in an “s” shape), I was in a very deep, dark state of depression because I literally couldn’t take the pain anymore. I seriously thought about suicide. After years of being a human guinea pig for doctors to play with (medications), years of being told “it’s in your head,” years of being told “you’re too young to have fm,” years of getting *that look* that doctors give us pain patients (accusing us of being “drug seekers”), I was simply beaten down and exhausted.

    You see, I didn’t suffer from severe pain, but the moderate pain I had was constant, nagging at me day and night. I would wake up each morning, knowing that I would have another day of pain (body aching all over, head feeling too heavy for my neck muscles, which caused daily headaches – headaches that would not go away even with high doses of NASAIDs). My husband finally encouraged me to try just “one more” doctor. Well, I picked a nurse practitioner that was new in town. When I went in to see him, I was in tears because I was expecting the worst. I told him everything I’d tried. Never have I had a doctor treat me with that much dignity and respect. He spent over 30 minutes actually LISTENING to me.

    He prescribed me Effexor xr, Tramadol, and Temezapam (for my occasional bouts of insomnia). Ten years later (now), I am still taking all 3 of those meds (temezapam on an as needed basis) as they STILL help me. After 10 years, two Tramadols 4 x’s a day STILL keeps my pain level down, so that I can exercise on a daily basis (including exercises I learned in physical therapy), stretch several times a day, stay active, work, and actually participate in and enjoy life. I still use my TENS unit when needed. I still use heat on my neck. I still take ibuprofen or naproxen as needed. I still incorporate that same diet modification plan. In other words, the long-term opioid therapy enables me to participate in activities that further help diminish so much of my pain.

    My point is every pain patient is different. We all have different types of pain, diseases, injuries, syndromes, etc that should be treated individually. Tramadol works for me, but I realize it does not work for everyone (particularly for more extreme types of pain). I can’t function on marijuana (sedates me too much) though I know others greatly benefit from it. Until last December, I had no idea what the CDC and other states were doing. I had no idea that so many people are being made to needlessly suffer, getting cut off from the medications that have helped them for decades.

    After watching my dad suffer needlessly the last 5 years of his life (he passed away a year ago), only to finally receive pain relief when he was placed on hospice care (3 weeks prior to his death), I am beyond angry this is happening. IT SHOULD NOT TAKE A DIAGNOSIS OF DEATH BEFORE PAIN IS ADEQUATELY TREATED!! As I was catching up reading, researching, and talking with others, I cried (and still cry). Reading so many comments from all of you who are in such severe pain and are under-treated or untreated breaks my heart.

    We would NEVER allow our pets to be neglected like so many of you are! Since when did Joe Blow, some random stranger at the CDC, have the ability to KNOW what I and others benefit and not benefit from, especially when many of us are obviously benefiting from years of long-term opioid therapy? Joe Blow doesn’t know me. He doesn’t know you. He has no clue which patients have opioid malabsorption issues. He has no qualifications to determine what helps individual patients because he has NEVER examined us, NEVER studied us over the years, NEVER even met us.

    What other classes of medications are demonized the way prescription opioids are? None! My 20 year old son is STILL having severe withdrawal symptoms from weaning off a low dose of Abilify (an atypical antipsychotic med that can help boost the effects of anti-depressants) as of 4 weeks ago. Abilify is a much-needed med for some with mental illnesses, but it causes physical dependence, has serious side effects, withdrawal symptoms (that can last for months) and can cause serious permanent damage. Why is this medication not demonized? What about Cymbalta? Lyrica? Effexor xr? Neurontin? These are all popular medications in the treatment of chronic pain, yet they also cause physical dependence and in some cases long periods of severe withdrawal symptoms.

    Epidural steroid injections? Corticosteroids have NEVER been FDA approved to be injected directly into the spine. In fact, in April 2014, the FDA released a statement stating this medication can cause rare, but very serious permanent damage (including paralysis, stroke, blindness, and death) if used in this manner (ESI) and required manufacturers to place a warning on each vial of corticosteroids stating the above. Why is an agency (CDC) funded by the government allowed to recommend (in their “guidelines”) a treatment (ESIs) as “safe” and “effective” that another agency (FDA) funded by that same government condemns as dangerous and unproven?

    Since when did bureaucrats, who have no personal experience in dealing with chronic pain and no medical knowledge, become so enabled to pass such restrictive legislation that it directly interferes with and violates our rights as patients to receive adequate medical treatment, which may include long-term opioid therapy? Since when has restrictive laws, regulations, “guidelines,” EVER helped lower addiction rates? The government can ban, restrict, and over-regulate to its heart’s content, but this country will always have addicts. Addiction is a mental health disease that is caused by both genetic and environmental factors. It is not caused by pills and other substances. The abused substance is only a symptom.

    Any substance that can be used, can be abused. Canned air? (huffing) – let’s ban it. Nutmeg? (mild hallucinations) – let’s ban it. OTC cough syrup (robo-tripping, dmxing)? Let’s ban it. Alcohol is the number one abused substance in our country and has been so for years. It’s caused hundreds of thousands of deaths and injuries and torn families apart. Let’s ban it. Oops, I forgot – we already tried that and the ban didn’t work. Heroin? Let’s ban it. Oops, I forgot – it’s already banned and the ban doesn’t work. Meth? Oops, I forgot – it’s already banned and the ban doesn’t work.

    Do our politicians, DEA, and other government bureaucrats not have any common sense? Our country needs a solid, easily-accessed, affordable mental health system before it can ever even think about lowering addiction rates. As the DEA has been focusing most of its efforts over the past few years on “curbing drug abuse” by harassing, bullying, and ruining innocent doctors’ lives, they’ve directly allowed large quantities of heroin to be smuggled into our country (not just heroin, but also illegal forms of fentanyl and “pharmaceutical” pills created in illicit home-made labs). Go after the drug dealers! I guess it’s too easy to monitor doctors’ prescriptions than to actually get out and bust the real culprits.

    The media? Oh, the media loves stirring the pot. The media hops on to any issues, any stories that will create big ratings for them. Behind the media sits those who are too lazy to research what the media is telling them. These are the same people who regurgitate everything our government and media spews to them on a daily basis without even thinking about it. Instead of taking the time to research and form their own opinions, the sheep simply listen, mimic and follow. It appears that we no longer have journalists who actually research to report BOTH sides of an issue (with the exception of the very few who have made efforts to report how these laws affect us pain patients).

    We (the pain community) do not abuse our medication. We are responsible in keeping our medication locked up. We don’t sell our medications. We do not mix our medications with alcohol or illegal street drugs. How is possible it that I’ve taken an opioid (tramadol) – and even hydrocodone a few times for acute injuries – and a benzo (temezapam) together for the past 10 years, while never overdosing? Gee, maybe because I follow the directions on the bottles (not consuming alcohol and/or taking handfuls of pills).

    Since when has punishing and shaming an entire community of people (pain community) for the actions of others (addicts) ever helped reduce addiction rates? Since when has forcing a chronically ill person to pee in a cup each month ever lessened our addiction rates? Since when has severe restriction and/or bans on substances ever reduced our addiction rates? Why is it “acceptable” for recovering addicts to have easy access to prescription opioids (methadone, suboxone) – a class of medications solely for the reduction of physical pain, yet “unacceptable” for those with chronic pain to have that same access when they’re the ones who actually suffer from physical pain? What this government is doing is outrageous – not only outrageous, but inumane, unethical, and cruel.

  10. Gail Ford at 7:48 am

    I have to agree with this article. I have had fibro for at least 16 years and diagnosed 9 years ago. I have tried every medication including 2 different opiates. When I first started with the opiates I would use occasionally and they took the edge off my pain. But I needed to use them more frequently and they were less effective. My depression and anxiety were getting worse and I was in really bad shape. My family was on me to stop taking a narcotic. I told my pain management doctor that I wanted to be weaned off and that’s what I did. It wasn’t fun and it took at least 6 months for my head to get “right” since opiates screw with your brain chemicals. I live in Delaware and they had passed medical marijuana but then our governor was intimidated by the feds and it took a while to get our first dispensary. I was able to get a card for chronic pain due to fact I have tried all the medications and alternative treatments with little to no help. I had no idea there were so many marijuana strains, so I am currently “experimenting” with what works for me (just as we all do with the umpteen medication). I do not like the head high so I am using strains with less of those effects. I hope more states pass medical marijuana or better yet legalize it all together since they are very limited in the conditions that qualify for medical marijuana.

  11. marty at 5:48 am

    I worked for 25 plus years with Fibro. Never found anything that helped me except to keep moving, work, change eating habits , and a few other things. I tried everything. 5 years ago I had to give in because the OA and RA took over my body, so I take vicodin for that. I don’t have good days because I am in pain 24/7 but the vicodin at least helps to dull the pain so I can function at home. I can honestly say it does nothing to help my Fibro still. never did and never will.

  12. Donna at 6:43 pm

    Amy,
    Your story is very encouraging! I would love to have the choice of trying medical Marijuana for my pain. It is a shame it has not been approved for this use in every state in the year 2016. Seems foolish for our politicians/policymakers to continue fighting againsthe it’s use as a viable treatment, instead opting to continue spending $$$ in the failed war on drugs. Legalize it, grow it, sell it and tax it. But I guess too many people wouldn’t have justification for their jobs.

  13. Teresa Cramer at 3:05 pm

    The biggest problem I have encountered with my “pain management” doctor is that I keep being told that I was referred to him for my lower back pain. My response to him is to say that I am trying to be responsible and above board in coming to him to try to control the pain from many conditions instead of asking each of my doctors for pain medication. He was very eager to administer epidural injections. They are considered procedures, and procedures are more generously reimbursed by insurance companies. I have a neurologist, urologist, rheumatologist, orthopedic doctor, dermatologist, and primary care nurse practitioner. I have migraines, interstitial cystitis, chronic pelvic pain, fibromyalgia, chronic fatigue syndrome, Sjogrens syndrome, narrowing in the a/c space in my shoulder, polymorphous light eruption, and a herniated disc in my lower back. Other than the skin issue, they are all conditions that are included on the “pain management” doctor’s website as conditions treated at his practice. When I pointed that out to him, he finally put me on 50 mg Nucynta twice daily. According to every piece of literature I can find about Nucynta, this isn’t even considered a therapeutic dose. After being on that dose for one month, I told him that I thought I needed to go up to 100 mg. He disagreed. I have continued, every two months for more than a year, to say that it is not enough. I am just ignored. I also get two 7.5/325 mg hydrocodone a day to use for breakthrough pain. The fact that I have to use both of them every day should be an indication that the Nucynta dose needs to increase. I don’t dare “rock the boat” for fear that he will cut me from his practice, and I will lose what little relief I get. The power that pain management physicians hold over their patients a key part of the problem. Patients are held hostage by a physician who can cut them at any time. I take my medication as prescribed, do not share or sell it, and don’t abuse it. I have legitimately painful conditions but feel that the diagnosis of fibromyalgia overshadows them. All I want is some relief. It has gotten to the point that you have to have cancer or a terminal illness to be able to obtain narcotics. None of the conditions I have are going to kill me, but I am dying a very slow and painful death. I am not living. Despite trying to keep a positive attitude and practice mindfulness, I merely have a miserable existence. I am an intelligent, talented 45 year old woman who has been reduced to going on disability and living with my parents. I would love to find a physician as compassionate and caring as Laurence Badgley seems to be in his post. I am definitely not suicidal, but there are many days I would prefer death over the life I currently have.

  14. Shirley hinton at 10:13 am

    I hope my simple letter will be posted.
    All the imformation is good to know all of that helps but can somebody please recognize what the indecision and stigma about pain medication pain control is doing to the average sufferer we innocently just ask for relief we wish to live our lives as we did before we were hit with this indescribable pain many of us very accomplished many of us have given much back to our family friends and country having had this 15 years or possibly more I can safely say that we are discriminated against not taken seriously far too often and stigmatized in the most ridiculous way inferring we are drug addicts nothing could be further from the truth we are used as ping pong balls to ease the guilt law enforcement feels in its inability to control the drug use in our country illegal drug use I am strongly pro law enforcement many family members have given their lives to support law and order they have seen me suffer and they’re just beginning to learn what life is like for a person like me honestly I really don’t care what it’s called opiate etcetera etcetera I just want to be functional safe and contributing once again there has to be something done to seriously consider our plight we deserve no less there are no words to describe as it is the same with many other illnesses what we go through the tears we shed the sorrow we feel the guilt we feel the isolation we feel the same were made to feel because of the misunderstanding of pain from the beginning being told oh you look fine you don’t look sick that was the start of my long journey I am among the fortunate very fortunate I can only imagine the many who are alone and suffer alone God alone understands I pray that something is done soon to help the many pain sufferers chronic pain doesn’t go away pain robs you of life pain we are a strong group I read recently paraphrasing sometimes the ones that fly alone have the strongest wings God be with us may our lives count for something

  15. HJ at 10:01 am

    Dr. Badgley:

    Thank you for this:

    “The only authorities on pain control are patients themselves, whose human rights have been hijacked by governmental lobbyists and the Insurance Industry. The physician class should be ashamed for allowing this to happen”

  16. Amy at 6:07 am

    For those who are unfamiliar with medical marijuana, there are daytime strains that do NOT get you high but act as pure physical medicine. I too have fibro for decades and through exercise/yoga, healthy eating habits (very little sugar, minimal caffeine and minimal alcohol) regular sleep using a night time strain that does have the psychoactive aspect of the marijuana which does not matter bc it enhances sleep thus eliminating a nightly sleeping pill and mm has an anti inflammatory aspect as well seems like a win win. While I’ve been to many many doctors to treat my fibromyalgia, I’ve had success managing my symptoms through trial and error and have figured out what works for me. Doctors can help out with this syndrome but you MUST be your own advocate and figure out what works for you. It’s a daily reevaluation and every day is different. I no longer take ambien after daily use for years and years. I take an occasional very strong anti inflammatory as needed, determined by me. I take an occasional muscle relaxer but only at night which helps with sleep as well. It took decades to figure out what works for me and while I am in pain every single day I can say I have it well under control and went back to work at age 55 and haven’t missed a day yet.

  17. Donna at 11:07 pm

    Since the cause of fibromyalgia is not known (there are theories), how can anyone even be able to say that opioid do not work? There can be variation in the illness, as well as the variation in persons who suffer from it. Also, what if the diagnosis is incorrect? Seems fibro has turned into the “go-to” diagnosis for doctors. You hurt? You are told it’s fibro.
    And as another poster has pointed out, there are usually other illnesses present.
    My pain doctor gives me 25 mcg Fentanyl, and Norco 7.5mg twice a day. I had to fight for it and was told that if I didn’t get sufficient relief she would take me off of it as he considers my doses to be “extremely high” and she subscribes to the idea that opiods do not help fibro. She also said it does not help my arthritis or nerve pain. Apparently she is such a god in her mind, that she knows more about my body than I do. She would kick me out of the practice if I tried to suggest I was being undertreated. I sometimes think I should be able to sue for the way I am treated. It is abuse.

  18. Kristina Schwende at 10:28 pm

    I have been to doctors offices and even in the ER because my pain levels were so high. As soon as they looked at my chart their demeanor changed from concerned to skeptical, obnoxious, or downright hostile! I have been using opioid medications for 6 years. I have NEVER abused them yet I’m treated like an addict. I live with a constant uneasiness over what on earth I will do when my pain doctor retires. I’ve heard the horror stories of people who are suddenly denied their pain medications. People are being forced to illegal options or even suicide! I have tried pot but it made me so loopy I couldn’t function, and I was bordering on hallucinations – I hated it plus it hardly touched the pain. Doctors take an oath to do no harm. What on earth is this?!? If an animal were left to suffer like this, there would be a public backlash and charges of cruealty would be laid. Are we really less deserving than the family pet?

  19. Laurence Badgley at 10:04 pm

    During my 46 years of General Practice of Medicine, I have cared for countless Fibromyalgia patients. This terrible disorder has multifactorial causation, and each sufferer has an idiosyncratic etiology. I have written extensively in various blogs, including at G+, about the true causes of Fibromyalgia. Each sufferer has a district metabolism, but we all have natural opiate-like endorphins and multiple types of cannabinoid neurotransmitters. Derivatives of opium poppy plants, the opiate class of medications, help some. Others are helped by biochemicals found in Cannabis. The only authorities on pain control are patients themselves, whose human rights have been hijacked by governmental lobbyists and the Insurance Industry. The physician class should be ashamed for allowing this to happen.

  20. Kristine (Krissy) at 8:01 pm

    Few people with Fibromyalgia have only Fibromyalgia for one thing. I have been through so many treatments over the past 32 years I don’t care to even try to remember them all, nor would I wish the pain of reading my personal trials on anyone. But from Aleve, when it was a prescription, to aspirin that ultimately burned holes in my stomach, Oxycodone, Fentanyl and Rx Ibuprofen are the only drugs that work for me. I think we all know that this subject is as individual as the love of art and music. The dark age of opioids was a long, long time ago. We are amidst the new age of opioids and they are obviously working for many or these advocacies and news agencies wouldn’t exist.

  21. BL at 5:08 pm

    I was diagnoised with fibro in the late 80’s. My dr prescribe hydrocodone 10 mg/acetaminophen 500 mg several times a day. Times have changed.

  22. Nancy at 2:50 pm

    Ive tried cannibas for pain…3 different strains recommended from the supplier.
    I did get stoned to the point I could barely walk…began almost hallucinating and thought I heard voices. My pain may have diminished but I was too stoned to notice. Im not sure if I took too much or am just really sensitive. Hated the way it felt.
    I am using opioids now…they work. Constipation is the major issue. I do feel I am building up a tolerance or not being medicated adequately.
    I’m not sure which or what medication is best. But don’t let us lose our options.

  23. MaryAnn Lawrence at 1:10 pm

    All I can speak from is my experience. I was diagnosed with FM in 1986, I have been on every promising drug, have tried every treatment, proven and unproven recommended to me. Still I was a wife, mother, had a fulltime job and considered myself a functioning hard working member of society. I thought I was strong but then I developed arthritis of the spine. My doctor & I tried every combination to ease my chronic pain, Until I found the right strength of Narcotic (Vicodin) 10/650. I was not high, had numerous promotions at work, had minimal pain which wiped out depression and anxiety from pain. I could sleep, I have had the same pharmacy for 26 years. Took it as was prescribed. Then my Doctor moved away in 2010. Even though my medical record proved my compliance I was made to feel as if I was a drug seeker. Things have gotten to the point I don’t even ask anymore. I am now 100% disabled at 54. In the War on Drugs they have created numerous cases. I would like to know the stats on how many chronic pain patients have killed themselves, went to heroin for pain relief or like myself take more OTC pain meds daily to get nothing more than a tiny bit of relief to get out of bed. Pain Management Doctors have given me more joint injections that NEVER work. So in place of one pill I take 10 prescriptions and OTC medicine which I’m certain will eventually lead to my premature demise. I don’t care what regulations they want to place on me as a chronic pain patient. Put me in a database, Send me home with a lockbox that only dispenses 1 pill every 6 hours. I am basically a shut in now. I have family to visit, places I would like to see, friends to hang out without hurting. My mind can not focus due to extreme pain. I found what worked for me, no ill effects, not feeling high and knowing it is out there and I could live again is the cruelest form of torture.

  24. Kristin Devine at 11:52 am

    To each is own. But I’ve had fibro for 5 years. And without my meds, dilaudid, soma, and extended release morphine and low does of Xanax. I would die. The pain is awful I can’t function without my pain meds.

  25. Bobbie Cunha at 11:41 am

    This comment is directed at Kelly Ann Otoby. She states that she does not gain relief from her fibromyalgia pain by using Oxycodone. She also states that she is an Ambassador for the fibromyalgia program in South Lake Medical Center in Newmarket, Ontario Canada and says that the many fibromyalgia patients she has spoken to do not gain relief from Oxycodone or Vicodin. She states that for her the best relief comes from Cannabis. First, Kelly, I’d like to say that I’m very happy for you that you have found something that gives you relief from your fibromyalgia pain. Whenever I hear this, I am always glad that there is one more person suffering less from this dreaded disease. I assume that you are aware that all fibromyalgia patients are not the same (because of the position that you hold in Canada). I also suffer from fibromyalgia pain and over the past ten years I have been put through trials on countless medications and alternative plans including Lyrica, Cymbalta, Neurontin, Flexeril, gut cleanses, four expensive sleep studies, acupuncture, major dietary changes, Fentanyl pain patches, Cannabis, light to moderate daily exercise, long-acting Oxycontin, short-acting Vicodin, light touch chiropractor, and Mindfulness Training. After throwing away all of this money and feeling like a guinea pig, it turns out that what works for me is NOT what works for you. I’ve responded well over the past ten years to a combination of long-acting Oxycontin, short-acting Vicodin, light to moderate daily exercise and Mindfulness Training. I have several friends and associates who also suffer from fibromyalgia. Each of them suffer more or less than the others and each of them have found something quite different that works for them. Some of them could never do the gardening I do, and some of them are able to ride 6 hours a day on the back of a motorcycle (which I could not do). Some are able to keep their jobs, while others suffer so much, they have gone out on disability and are mostly bedridden. I agree with the author of this article that more extensive trials need to be done before we throw opiates as a treatment for fibromyalgia pain under the bus. I would also like to urge you to represent to the people you speak to through your ambassadorship that fibromyalgia is not an “equal pain” condition, nor does it have a “one size fits all” treatment. Thank you and best of luck with your ambassadorship in Canada.

  26. Kerry McKelvey at 9:59 am

    Your make a great point Dr Goodwin! I went from Dr to Dr for 18 years for severe pain, stiffness, and chronic fatigue I got after a lengthy time searching for a diagnosis for Cushing’s Disease and pituitary surgery. Going from one incredibly debilitating illness just to turn around with what Drs were calling Fibromyalgia seemed to just not fit very well into fibro given the extent of my pain and other symptoms. I needed high dose opioids just to get in my car to get to the doctor appts and groceries for my children in those early years. I had no side effects and no high. I was past a 10/10 on pain levels before opioids and was so grateful to reach the 7 or 8 after. After the media reports on OxyContin abuse in early 2000 the military pain clinic took everybody off opioids regardless of pain. I thought I’d give living without opioids a shot and over the next several years lost all the gains I made from physical therapy and could tell I was needlessly suffering and yet remained determined that although I had all the symptoms of fibromyalgia I still had nothing that explained the weight I never lost and the painful little lumps all over my body and severe stiffness. I went back on opioids but because of my diagnosis of fibromyalgia I was given the very minimum that gave a hour of some relief 3 x a day. I still just got worse over these several years and the suffering had me crying at many pain appointments and the at the doctors I managed to drag myself to get answers for what was not just fibro. They all just treated me like I was just wanting a quick and easy fix of opioids or an all out drug seeker. My pain was causing false negatives on my annual cortisol stim tests and the doctors blamed my opioids for causing hormonal changes even when I pointed out I had a diseased 1/3rd of a pituitary left trying to cope with severe pain! At yr 16 I traveled to a pain Dr every other pain Dr should be paying attention to because he increased my opioids and tested and treated my abnormal hormone levels and saved my life!! Now 18 years of a lost life robbed of a lot more than money I finally found I had Dercums Disease all these years and those lumps were thousands of tumors! Dercums is progressive when undiagnosed and treated with some of the ideas to treat fibro and deadly when it’s advanced as far as it has with me now! I still have to travel every two months to see my pain Dr because there’s only few Drs who would prescribe the amount of opioids required that give me a life of any quality and have a years wait to see the 1 Dercums specialist who is also a endocrinologist because it’s a metabolic disease and absolutely related to Cushing’s Disease but other endocrinologists think they don’t need to take a day or two to learn enough to guide patients in how to stop the progression. I look back on the unnecessary fight to get properly diagnosed and receive adequate pain relief for a condition known to be brutally painful and have a 98% response to opioids! I may still have fibromyalgia but it hurt me and my two children’s lives who had to be raised by a mom who could never go to their activities, ate takeout and TV dinners in a messy house with a mother who was suffering all the time. Indeed my story is similar to many with Dercums and yet the response is we aren’t diagnosed because it’s so rare. My experience is that we aren’t diagnosed because Drs have stopped listening to our complaints of painful lumps and don’t even bother to put oil or lotion on their hands and run them over these lumps and think they learned all they are required to know perform the absolute minimum to keep their license and patients alive. I bet you can count on two hands the pain doctors who are compassionate and dedicated to truly treat the sick. I belong to some Facebook support groups and the population of pain patients suffering and being yanked off pain meds every day is unconscionable! Thank you Dr Goodwin not going the way the majority of Drs and sacrificing income and free time by continuing to read and learn from experience from other Drs and all the studies we’ve already spent billions that should already be used in clinics today!

  27. Dave at 9:37 am

    Dr Goodwin- its the underdetermination of scientific theory that leads to diagnostic bias of “fibromyalgia” and the failure to look for transdiagnostic epiphenomena.
    The question in my mind is not whether a treatment works for fibro or other conditions- but what is the best treatment(s) based on the needs of the individual seeking care. Its like the stock market- why invest in a good stock-when you can invest in a better stock? Shouldn’t we be trying to deliver the best for each person suffering from fibro and other painful conditions?
    The vague but more important individual circumstance should not be relegated to stock treatments. When the NIH paid for an independent review of opioids- it found that treatments for pain lacked sophisticated algorithms and were not customized. Heroic simplification and violent abstraction in treating everyone with fibromyalgia as a class rather then an individual is regressive and not working. Its time to recognize people in pain aren’t the same as everyone else in pain- there is great biosocial heterogeneity. Its time that the health care industry and government recognize individuals as needing individualized treatment- and that means more then adjusting dosages.
    I find it interesting that laboratory medicine doesn’t bother to test neurotransmitter levels- or levels of endogenous opioids before prescribing medications to alter the aforementioned. That to me is shotgun style. Even Dr Amen calls for looking at brain scans before prescribing psychotropics. Quick reductionistic medicine makes no sense from any point of view other then a penny wise pound foolish perspective.

  28. C Hawkins at 9:36 am

    My fibromyalgia is worse on my severe back pain days. Sometimes my arms hurt so bad it’s unrealistic. Since I was in a pain management clinic I could not get near any pot. Gabapentin made my pain worse and all the doctor offered was injections stating pain meds are a last resort. I have had back problems for 30 years and was over injected by doctors. My sciatic joint is practically decomposed from cortisone. If I turned down another injection the doctor thought I wasn’t trying to get better but just was addicted to opioids. I have no idea why he became a doctor but giving repeated cortisone injections into pain people is not the best option.
    I have severe reactions to cortisone but I’m guessing that is no concern of his.
    Before a doctor says pain meds don’t help fibromyalgia they better have several studies to back up those statements. What works for one patient doesn’t work for every patient and the ability to adapt your care for each is what a true caregiver should do.

  29. HJ at 9:25 am

    I read the article and I want to scream. The “dark days” of opiate prescribing?!?

    What about folks who don’t WANT to use medical marijuana? Are we going to be left with a choice?

    Are doctors going to say, “Oh, go smoke some pot”? What if we persist that that’s not what we want? Will we be turned away… yet again?

    I have plenty of reasons to feel the way I do. Legitimate reasons. I’ve already got fatigue. If you’re going to be home all day, then fine… but I cannot imagine being a productive employee in an office when I’m using marijuana. Daytime/work is when I MOST need my medication. Also, even if legalized, my employer is unlikely to feel favorably about me using pot for pain relief. And I’m morbidly obese so I really, really don’t need the munchies. Oh, and I have asthma, so I’d have to ingest it some other way than smoking.

    So, don’t be so quick… for the sake of your patients… to write off pills. I am fortunate that tramadol helps me. I also have cervical spondylosis and widespread osteoarthritis.

    I’m not against medical marijuana. If it helps and if you can maintain a better quality of life with it, then I would be happy for you. Just remember it’s not going to be for everyone!

    And to other chronic pain patients… please, be respectful… I almost left chronic pain support groups because people kept telling me how I should try kratom. If medical marijuana becomes legal and widely available, don’t judge me if I choose other options. I’ve already been called a “pill popper” because I said I wasn’t interested in kratom. I thought we were all in the same battle…

  30. Dave at 8:02 am

    There are many tools for pain and fibromyalgia- unfortunately people in the health care industry know and utilize few of the tools. In addition, the reductionistic tendency to oversimplify and to see everyone with fibromyalgia- as needing the same treatment- isn’t helping to improve care. It is unfortunate that doctors are wtoo willing to be bound by guidelines that focus more on oversimplifying and McDonaldizing care rather then helping people in pain.

  31. Scott michaels at 7:06 am

    i think its funny. for 30 years i was a daily pot smoker. i did it to get stoned. its was frowned on by society.it was illegal. now that i havent smoked in 10 years, i live with extreme pain and take pain pills daily. i dont get high at all from the oxycontin. never did. now society is saying stop the pain pills that work. go back to weed and walk around stoned all day. pot never took my pain away. opioids do. beside that i dont want to get fat eating all the time

  32. Richard A. Lawhern, Ph.D. at 6:28 am

    Thanks for your contribution, Dr. Liptan. In a more equitable and grounded world, you might have been a very effective member of the CDC working groups on revised guidelines for use of opiates in chronic pain. As both a patient and physician, you are far better prepared to address a balance between valid needs of pain patients and the efforts of drug addicts or profiteers to game the medical system by diverting prescription drugs. Certainly you seem to know far more about the subject than psychiatrists or practitioners of psychosomatic medicine whose entire practice is based on little more than supposition or mythology.

    Best wishes for your continued professional success.

  33. Kelly Ann Oxtoby at 5:12 am

    I have had Fibromyalgia for over 19yrs now and have been on Cymbalta, Lyrica, Salvella and am now on Tridural (Tramadol Hydrochloride Extended Release tablets) 300mg (max dose) and find that it does help take the edge off. From my experience Oxycodone does nothing to help with the pain. I used to take Oxycodone for migraines, but can not now that I am on Tridural, it did nothing to relieve any of my fibro pain. I am an Ambassador for the Fibromyalgia program being run out of the South Lake Medical Centre in Newmarket, Ontario Canada and the many Fibromyalgia patients I have spoken to do not gain relief from Oxy or Vicodin. The best relief I have found is from Cannabis. Cannabis seems to put a barrier up, feels like an invisible shield between you and the pain. If someone asks me if the pain is still there and I think about it, the pain is still there but Cannabis disconnects you from it for a while to gain some relief and peace from the hell that is PAIN.

  34. Jeremy Goodwin, MS, MD at 3:28 am

    It amazes me how many view specific conditions as occurring alone when , in fact, most occur alongside or as a result of other conditions. For example, severe spinal pain from damaged facets following fusion surgery or discogenic pain and nerve root irritation leading to somatic referred pain or even sciatica, or the neuropathic pain originating in the neck that initiates cervicogenic headaches can also exacerbate fibromyalgia as it can myofascial pain and vice versa. Vicious cycles and downward spirals can occur.

    Opioids may work very effectively against spinal pain. Whether delivered by mouth or via an intrathecal pain pump, by attenuating severe midline spinal pain, flare-ups of FMS usually diminish as well. It is irrelevant that the affect is indirect. It works! It may also prevent wind-up and centralisation of peripheral
    pain that can become something hard to treat, like FMS.

    Since most patients who see pain specialists have co-morbidities, it is reasonable to use opioids if and when they prove clinically helpful for the control of pain and improvement in function.

    It is important to
    monitor hormonal balance amongst other things too but if these parameters are cared for then various side affects are less likely to occur or to prove problematic. It is the complexity and relationships between different conditions that justify whatever works to be used, especially within a multi-modality and interdisciplinary setting (including the integration of alternative treatments and psychology).