# Fibromyalgia - Legit or BS



## Jaybird21 (Mar 26, 2013)

Hey everyone, how do you handle fibromyalgia patients complaining of pain. Do you treat? Do you withhold? What are your parameters for either. Thanks!


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## Clipper1 (Mar 27, 2013)

If you think it is BS you should try presenting your reasons to the AMA which classified it as legit in 1987. Besides the AMA, the National Institutes of Health (NIH), and the World Health Organization (WHO), the American College of Rheumatology (ACR) and the European equivalent organizations have also listed it as legit.  Fibromyalgia is not a new since it was described over 100 years ago.


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## Thricenotrice (Mar 27, 2013)

If the pain is great, and the pt truly looks like they're suffering a great deal, I will call and ask for pain mgmt (can't give it before base contact for me). These people are generally in pain all the time to a certain degree (from my experience), and would need to be in severe pain or discomfort for me to get on the horn to help them out. I'm not saying I don't want to help a pt, just gotta be presenting with more pain thn usual.

Imo


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## Summit (Mar 27, 2013)

BS??? Look, there are some who still debate whether it is psychosomatic pain, but they are in the minority and it doesn't matter as pain is pain. If the patient is calling EMS, it isn't you place to tell a patient in pain that it is "BS"  because you don't like the diagnosis they received. Take it up with the ACR and AMA.

Opioids are not good regular therapy for fibromyalgia (save for ultram). However, in a flare, it can control things. Why let them suffer? I don't know what your protocols say exactly and I'm nobody's medical director, but I'd think a good approach would be to consider this is a chronic pain patient. Ask them their pain, and then ask them their pain goal. They may say they are at an 8 or 9 and live at a 3-5 and if you could get them down to a 5 or 6 they could deal with that. I'd treat within your protocols to accomplish that pain goal as long as the treatment was tolerated. I'd definitely make sure the pain wasn't masking another problem. I'd definitely make sure to find out what meds the patient was already on (including pain meds). They are likely on several medications (non-opiod) with fun side effect profiles particularly peripheral edema, heart blocks, dizziness, visual field disturbances, and weight gain.


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## VFlutter (Mar 27, 2013)

Fibromyalgia is a real medical condition. Unfortunately it is commonly faked by drug seakers since it can not be definitively diagnosed or ruled out. But that does not make the condition any less legitimate. 

As Summit mentioned Fibromyalgia is not a free pass for unlimited narcotics. I know many patients who would take their Gabapentin over Morphine or other narcotics.


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## mycrofft (Mar 27, 2013)

"Got protocol?"
If I didn't know everyone was being hypothetical, I'd get the impression they were practicing medicine without a doctor's license.


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## Jaybird21 (Mar 31, 2013)

Personally, I do not treat these patients unless they're showing physiological signs of pain. I feel like it is my duty to give pain medication to those that obviously need it. I also feel it is my duty to ensure I am giving pain medication when it is indicated. Just because someone tells me they are hurting does not mean I will instantly give out pain meds. I have several close physician friends and they all state that this is a disease that has gained enormous prominence for all the wrong reasons over the past several years. It also seems to be a trash can diagnosis in which physicians will call a patients problem fibromyalgia simply because they've ruled out a handful of other problems.


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## Akulahawk (Mar 31, 2013)

Jaybird21 said:


> Personally, I do not treat these patients unless they're showing physiological signs of pain. I feel like it is my duty to give pain medication to those that obviously need it. I also feel it is my duty to ensure I am giving pain medication when it is indicated. Just because someone tells me they are hurting does not mean I will instantly give out pain meds. I have several close physician friends and they all state that this is a disease that has gained enormous prominence for all the wrong reasons over the past several years. It also seems to be a trash can diagnosis in which physicians will call a patients problem fibromyalgia simply because they've ruled out a handful of other problems.


Have you ever treated/transported a patient who was in sickle cell crisis? Even early in crisis, they may not actually look like they're in pain, yet their pain level is 10/10 or even "stepped on a Lego" level pain. I'm saying their pain level really _is_ that bad and you'd never believe it because of how they look. Then you get the labs back that show they're in crisis... 

The point is that you shouldn't prejudge these patients by how they appear. Their bodies may be "used" to chronic pain and therefore never show the physiological signs that you're used to. I imagine that the same would be the case for Fibromyalgia patients as well. Unfortunately, through experience, they probably _know_ what medications work well when they're in a flareup and probably wouldn't want to be on any meds other than what normally controls their pain, and some of those meds are normally "psych" meds instead of what we normally think of as pain meds.


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## VFlutter (Mar 31, 2013)

Jaybird21 said:


> Personally, I do not treat these patients unless they're showing physiological signs of pain. I feel like it is my duty to give pain medication to those that obviously need it. I also feel it is my duty to ensure I am giving pain medication when it is indicated. Just because someone tells me they are hurting does not mean I will instantly give out pain meds. I have several close physician friends and they all state that this is a disease that has gained enormous prominence for all the wrong reasons over the past several years. It also seems to be a trash can diagnosis in which physicians will call a patients problem fibromyalgia simply because they've ruled out a handful of other problems.



Except many patients who suffer from chronic pain may not exhibit obvious physiological signs unless they are in extreme pain. What do you consider "obvious"? So if someone lives with chronic pain then they should not be given any medication? Why wait until the point until it is painful enough to produce an physiological response? At that point it will most likely harder to adequately control. You see this with patients on PCA pumps, the ones who hold out until they are in extreme pain end up using more narcotics and having poorly controlled pain compared to the patients who use it when pain starts to occur. 

I am of the opinion that we should very liberal with pain management. I am not saying give out narcotics to everyone who claims to be in pain but I would err on the side of over treating as opposed to under treating. As mentioned a lot on this website it is important to have a wide variety of narcotic and non-narcotic options. 

I have several close physician friends and they all give out Norco like candy. Not a really strong argument.  

Trash can diagnosis implies that it is fake. Fibromyalgia is a diagnosis of exclusion and does not have a definitive diagnostic test. Does that mean that it is not a real condition or that it does not warrant treatment? 

Sarcoidosis, Sudden infant death syndrome, and Bell's palsy are also diagnoses of exclusion. 

I have no doubt that Fibromyalgia may be over diagnosed but that does not mean we should ignore pain management for anyone who claims to have the condition. Next time you have a patient with Fibromyalgia see if they have a history of Shingles...


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## Aidey (Mar 31, 2013)

Chase said:


> Sarcoidosis, Sudden infant death syndrome, and Bell's palsy are also diagnoses of exclusion.



Not taking sides here, just point out that all of those have physical findings. Sarcoidosis has a large number of them, SIDS has a dead body, and Bell's is usually fairly obvious. 

I think people's issue with Fibromyalgia is that not only is it a diagnosis of exclusion, there are no objective tests for it. Heck, there are barely diagnostic criteria.


Edit: On topic, more and more chronic pain patients are on pain contracts that prohibit them from receiving narcotic medications from ANYONE but a certain doctor. These patients are sometimes subject to blood/urine tests to determine if they have consumed anything besides their prescribed medications. This includes acute flare ups of chronic conditions. We may think we are doing our patients a favor giving them fentanyl/morphine, but if they violate their contract they may lose all of their pain medications. I know it sounds inhumane, and some people here are going to say "who cares, I'm giving them meds anyway", but it is something to seriously consider.


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## FLdoc2011 (Mar 31, 2013)

That and narcotics are not drugs of choice for fibromyalgia anyway....


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## Rialaigh (Apr 1, 2013)

Aidey said:


> Not taking sides here, just point out that all of those have physical findings. Sarcoidosis has a large number of them, SIDS has a dead body, and Bell's is usually fairly obvious.
> 
> I think people's issue with Fibromyalgia is that not only is it a diagnosis of exclusion, there are no objective tests for it. Heck, there are barely diagnostic criteria.
> 
> ...




Great point. I know we have patients that are "pain center patients" that come into the ER and most of them will tell us right up front they are pain center patients and they take this each day and they do NOT want anything narcotic from us unless we can reach their doctor, they want to be checked out, labs drawn, CT done, etc...

Does anyone (or can anyone per protocol) use Versed (midazolam) alone for pain management without coupling it with a narcotic?


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## chaz90 (Apr 1, 2013)

Rialaigh said:


> Does anyone (or can anyone per protocol) use Versed (midazolam) alone for pain management without coupling it with a narcotic?



If you're treating true pain with a benzodiazepine alone, isn't that kind of using the wrong hammer? I could be completely wrong and ignorant on this, and I know how effective benzos can be when potentiated with opioids, but I feel like there are better options for treating pain than a benzo.


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## Carlos Danger (Apr 1, 2013)

Neuropathic pain generally doesn't respond well to mu-receptor agonism. So for _that_ reason, I don't see much reason to give opioids, unless you have a very long transport and the patient is very uncomfortable. In that case, you might be able to use small doses of benzos along with small doses of opioids take the edge off enough to make them a little more comfortable. That would be an MC call. Ketamine might be a better choice.



Jaybird21 said:


> Personally, I do not treat these patients unless they're showing physiological signs of pain. I feel like it is my duty to give pain medication to those that obviously need it. I also feel it is my duty to ensure I am giving pain medication when it is indicated. Just because someone tells me they are hurting does not mean I will instantly give out pain meds. I have several close physician friends and they all state that this is a disease that has gained enormous prominence for all the wrong reasons over the past several years. It also seems to be a trash can diagnosis in which physicians will call a patients problem fibromyalgia simply because they've ruled out a handful of other problems.



Really?

Do you think you'll always see "obvious physiological signs" when someone is in pain? What about patients who are on beta blockers? What about diabetics? What about the elderly? Do you even know their baseline VS? How do you know their HR doesn't normally run 20 below what you are seeing now? 

What do your protocols say? Are your medical directors really OK with you making people suffer during transport just because you aren't sure they "really need" analgesia?

There is a reason why the universal definition of pain is that "it is whatever the patient says it is". It is because you don't know.


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## mycrofft (Apr 1, 2013)

Does everyone actually have that degree of latitude between drugs for pain control of a known (by pt hx) diagnosis?


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## RocketMedic (Apr 2, 2013)

Aidey said:


> Not taking sides here, just point out that all of those have physical findings. Sarcoidosis has a large number of them, SIDS has a dead body, and Bell's is usually fairly obvious.
> 
> I think people's issue with Fibromyalgia is that not only is it a diagnosis of exclusion, there are no objective tests for it. Heck, there are barely diagnostic criteria.
> 
> ...



I never considered this. I do now, thanks Aidey. You bring up a good point.


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## Bullets (Apr 4, 2013)

Akulahawk said:


> Have you ever treated/transported a patient who was in sickle cell crisis? Even early in crisis, they may not actually look like they're in pain, yet their pain level is 10/10 or even "stepped on a Lego" level pain. I'm saying their pain level really _is_ that bad and you'd never believe it because of how they look. Then you get the labs back that show they're in crisis...



We have a significant population of people who are at a higher risk of SCA and have a few patients who have frequent attacks. Ive had one be in Lego pain where it wasnt obvious. 

That said, if you are in NJ, YOU GET NOTHING (because our protocols are crap)


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