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Medications for Pain
General Notes on Drugs for FM & CFS

Drug therapy for pain in FM and CFS is to be avoided if possible, because of side effects and the possibility of addiction. If you decide to use the FDA-approved medications (Lyrica, Cymbalta, or Savella) and other medications for pain, it is important to have realistic expectatons. They don’t eliminate pain, but they may reduce it for a period of time in some patients. 

Because no medication is consistently helpful for people with FM and CFS, and because pain relievers sometimes lose effectiveness over time, experimentation is usually required. Also, patients are started on dosages that are a small fraction of normal dosage levels.
Many fibromyalgia patients also experience Myofascial Pain Syndrome (MPS), a pain condition localized in trigger points (specific locations in muscles or fascia, not to be confused with tender points used to diagnose FM). MPS may be treated with medication, physical therapies such as massage and myofascial release, and the injection of local anesthetics into the trigger points.
Some people with CFS and FM experience neuropathic or nerve pain, burning or electric shock sensations felt most commonly in the hands and feet. This type of pain is often treated with anti-seizure medications, such as Neurontin (gabapentin) or Lyrica (pregabalin). 
Specific Recommendations

People with FM and CFS who who seek pain relief through medications usually begin with non-prescription products, such as aspirin and other over-the-counter pain relievers such as Advil (ibuprofen), Aleve (naproxen) and Tylenol (acetaminophen). Prescription drugs that improve sleep or relax muscle tension can have a beneficial effect on pain as well.
A second category is antidepressants, of two kinds. Low doses of tricyclic antidepressants (amitriptyline, desipramine, nortriptyline) can be helpful, but these medications are frequently associated with significant side effects such as dry mouth, blurred vision, and weight gain, and they tend to work less well over time. 

More recently, NSRIs (Norepinephrine-Serotonin reuptake Inhibitors) have been shown to be effective for pain, have fewer side effects, tend to be weight neutral, and are durable. That is, they remain effective after months of use. These include Effexor (venlefaxine), Cymbalta (duloxetine), and Savella (milnacipran). Cymbalta and Savella have been FDA approved for treating pain from fibromyalgia.
Third, epilepsy drugs have long been known to reduce atypical or neuropathic pain, and have been useful in both CFS and FM. The first drug of this type was Neurontin (gabapentin). More recently Lyrica (pregabalin) has been FDA approved for the treatment of fibropain.
Fourth is Tramadol (aka Ultram, Ultracet, Ryzolt, and others). This drug is in a unique class called “opiate / non-opiate.” Tramadol has the strength of codeine but fewer adverse reactions and is rarely addictive. Therefore, it is very effective and safer for people with CFS and fibromyalgia than narcotic medications. 

Low Dose Naltexone
In the last decade or so, it has been recognized that glial cells in the brain can affect neurons. When activated or "angry," these glial cells sensitize neurons and magnify pain. Serendipitously, it was found that a low dose of the narcotic antagonist naltexone could calm angry glial cells and reduce fibropain. Thus, the antidote for narcotic overdose has become a pain remedy!

Experience has shown that about 60% of people with fibropain will respond to Low Dose Naltrexone (LDN). Since LDN is a narcotic antagonist, one cannot take narcotics such as codeine, hydrocodone or oxycodone at the same time as LDN. Also, you have to wean off all narcotics for several days before starting LDN or risk withdrawal symptoms.

This is an off-label investigational use of naltexone, so LDN is neither covered by most insurers, nor is it available at most chain drug stores. Fortunately, it is inexpensively and easily obtained at most compounding pharmacies. The usual dose is 5mg daily, in the morning. Side effects are unusual, although some individuals experience nausea or insomnia at first. Side effects can be minimized by starting with 1mg daily and increasing the dose slowly.
Finally, there are narcotics. Narcotics are not recommended except via a referral to a pain management specialist.
Dr. Lapp's clinic has developed online materials for physicians. Dr. Lapp also recommends two other recources:

a) The website of the U.S. ME/CFS Clinician Coalition formed in 2018 by a group of American ME/CFS expert clinicians, who have collectively spent hundreds of years treating people with ME/CFS.

b) The Physician's Primer on the IACFS/ME website. The primer was created by a team of experienced clinicians and covers diagnosis and management of ME/CFS.