Pain Management
Source: “From Fatigued to Fantastic” by Jacob Teitelbaum, M.D.
Pain Treatments for CFS and Fibromyalgia Sufferers
(Antidepressants #165-173 or Lithium #76 often helps pain.) THE NATURAL TREATMENTS CAN BE SUBSTITUTED FOR OR ADDED TO THE PRESCRIPTION PAIN MEDICATIONS. If side effects occur, they often can be avoided by starting with a low dose and raising it each 3-7 days as your body gets used to the medication. It may take 2-6 weeks for a treatment to start working.
Natural Pain Therapies
___ 193. Rolfing, Trager, Myofascial Release, Chiropractic, other body work & manipulation modalities, and/or Acupuncture. In Annapolis Maryland, Bren Jacobson (410-224-4877) does superb Rolfing.
___ 194. EndFatigue Pain Formula - Contains Willow Bark, Boswellia, and Cherry. Take 2 tabs 3x day. It takes 2-6 weeks to see the full effect. At that time, you can often lower the dose to 1 tab 3x day or 2 twice a day. Available from Integrative Therapeutics or Enzymatic Therapy.
___ 194A. Limbrel (Rx) - 250 or 500 mg caps. This prescription flavonoid is a natural anti-inflammatory (similar in effects to Motrin) but much safer. Usual dose in 250-500 mg 2x day.
___ 195. NAET - Treat food and other sensitivities and pain often resolves. See http://www.naet.com and the book “Say Goodbye to Pain” available on the site. Other related techniques such as JMT can be very helpful for rheumatoid and other arthritis problems.
___ 196. Niacin - (not niacinamide or “flush free niacin”). Take 100-500 mg (100 mg is usually enough to cause the desired flush) of niacin 3-4 times a day on an empty stomach as needed to cause a “flushing” feeling, which occurs within ~ 10-20 minutes. This can significantly help pain by flushing nutrients into and toxins out of painful areas, and is very inexpensive. Try to keep the dose at 1000 mg a day or less if this is enough to cause flushing, as higher doses can rarely cause liver inflammation or unmask diabetes. This treatment also helps to lower cholesterol and decrease brain fog.
___ 197. NF Joint Gel - Simply roll it on and rub it in. For best results, massage Joint Gel into your skin until absorbed. You can use Joint Gel up to 3 to 4 times daily.
___ 198. Lipoic Acid - 200 mg 3 times a day for neuropathic pain. Benefit usually begins to be seen by 2-3 months. It has been shown to be helpful for diabetic neuropathy and burning mouth syndrome (200 mg 3 times day for 5 months).
___ 199. Glucosamine Sulfate - 500 mg, 3 times a day (for arthritis). Takes 6 weeks to see if it will help. When the maximum benefit is seen, you can decrease to the lowest dose that maintains the effect.
___ 200. MSM - 3 grams a day for arthritis.
___ 201. Eskimo 3 Fish Oil or Arctic Omega - (see # 
can markedly decrease inflammation and pain. Dry eyes and mouth suggest you need it.
___ 202.* Megazyme (Enzymatic Therapies) or Biozyme (Integrative Therapeutics) - Like a super Wobenzyme. Take 2-4 capsules 3 times a day between meals. May dissolve clots in the blood vessels. Can be helpful for pain and other symptoms (takes days to weeks to work). Especially helpful with inflammatory pain.
___ 203. Purple Pectin for (especially arthritis) Pain - Purchase Certo in the canning section of your local grocery. It is the thickening agent used to make jams and jellies. Certo contains pectin, a natural ingredient found in plants. Take 1-3 tablespoons of Certo in 8 ounces of grape juice 1-2 times a day (1 to 2 tbsp a day is enough for most people, but you can try more). If it’s going to help, you’ll likely know in 7-14 days. As the pain disappears, the dose can be reduced to 1 teaspoon in grape juice once or twice a day as needed. Many people have found this simple, safe and cheap treatment to be very effective!
___ 204. Heel Lift - ______ inches for _____ foot (for uneven hip heights).
___ 205. John Sarno, MD’s - Approach for localized pain. The mind can decrease blood flow to muscles to distract us from uncomfortable emotional feelings. When you feel pain, tell your mind you will use the pain as a signal to look for and feel uncomfortable feelings for 10-15 minutes, then do so. The pain will often leave within 6 weeks. Also read my book “Three Steps to Happiness - Healing through Joy!” available in our office as this will help you to let go of feelings that may be buried and causing pain.
___ 206. Rhus Tox (homeopathic treatment) - Dissolve under the tongue as directed on the bottle as needed for muscle pain.
___ 207. Magnets - Start with spot magnets, insoles and seat. If they help in 2 months, consider a mattress pad. Available from Bren Jacobsen (410-224-4877) or Amy Podd (410-757-7295).
___ 208. Copper/Magnet Bracelet - Use nail polish remover to remove any coating on the inside of the bracelet so the copper is in direct contact with your skin.
___ 209. Quercetin - For prostate pain. 500 mg twice a day decreases symptoms in both prostadynia and prostatitis.
___ 210. Flexyx - Flexyx can be very effective. It is a brainwave biofeedback system (www.flexyx.com).
___ 211. Humibid (Rx, guaifenisin) - 600 mg _____ tablets _____ times a day (see instruction sheet). No aspirin or herbals can be taken while on Guaifenisin. GuaiLife - a shorter acting form may be more effective. See www.fludan.com for more information.
___ 212. Cetyl Myristoleate - 385 mg capsules - 3 capsules 2 times a day for 10 days. You can raise the dose to a maximum of 17 gm a day. For pain - benefits often persist after the 10 days of treatment.
Pharmacologic Pain Treatments
If you are not clear about the source/type of your pain, there are many reasonable sequences in which to try the medications. One reasonable order to try them in is the one listed below. It can take 2-6 weeks to see the full effect of the medication. When there are several medications with the same number (e.g. 215A, 215B, 215C), if the first medication helped but was not tolerated because of side effects, go to the next medication of the same number. If it simply did not help significantly, go to the next number. If you get partial benefit from a medication, continue it and add the next medication as needed to get pain-free. A reasonable order to try pain meds is : #……216, 215, 214, 222,221, 220A, 220C, 220B, 230A, 228A, 223, 231,235,237, 234, narcotics.
___ 213. Tylenol (acetaminophen) - For many people, this can be a safe and effective pain medication. Simply be aware that chronic use at too high of a dose can cause liver and sometimes kidney problems. Do not take over 4000 mg a day, and for chronic use it is best to stay under 2000-3000 mg daily. If you are taking over 1500 mg of acetaminophen a day on a regular basis, get an extra 500-650 mg of NAC and take it each day along with the vitamin powder. Otherwise, you will deplete a key antioxidant (which is why Tylenol can damage the liver).
___ 214.* Ultram (Rx, tramadol) - 50 mg 1 to 2 tablets up to 4 times a day as needed for pain. Side effects are less with 4 or less tablets a day. May cause nausea/vomiting. Caution: May very rarely cause seizures or raise serotonin too high when combined with antidepressants.
Topical Treatments
___ 215.* Arizona Pain Formula Cream (Rx) - Rub a pea size amount onto painful areas 3 times a day as needed. You can use this on up to 3 or 4 “silver dollar” sized areas at a time. Use ITC Compounding Pharmacy by mail (303-663-4224).
___ 216.* Lidocaine Patches (Rx, lidoderm) - Can be cut into pieces to put over different areas. Leave the patch on for 12-18 hours then off the rest of the day. It can help localized pain (i.e., it helps pain that is right under the patch).Up to 4 patches can be used at a time each day. It can take 2-3 weeks to see if it works.
NSAIDs
___ 217. Daypro (Rx) - 600 mg - 2 each morning as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the Emergency Room immediately.
___ 218. Voltaren (Rx) - _____ mg _____ times a day as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the emergency room immediately.
COX-2 Inhibitors
___ 219A.* Celebrex (Rx, celecoxib) - 100 to 200 mg 1 to 2 times a day for pain. Do not take if you’re allergic to sulfa or Aspirin (e.g. hives). Do not use over the 200 mg a day while on Sporanox or Diflucan. FlexAgility (#112B) is a natural form and is safer.
GABA Agonists
___ 220A.** Lyrica (Rx, pregabalin) - 100 mg 2-3x day. After 2-4 weeks can increase to a maximum of 200 mg 3x day. Helpful for pain, increasing deep sleep, and restless legs syndrome. The main side effects are dizziness and drowsiness, which tend to decrease over time, and weight gain (in ~ 2-4% of those taking up to 300 mg/day. It is more common with higher doses). If too sedating, take the entire dose at night (up to 250 mg).
___ 220B. Gabitril (Rx) - 2-4 mg twice a day and increase by a maximum 4 milligrams daily, each 3-7 days to a maximum of 24 mg a day. Helps both pain and deep sleep. The main side effects are sedation, dizziness and gastric upset.
___ 220C. Neurontin (Rx, gabapentin) - ____mg ____ times a day (to a maximum of 3600 mg a day). Cut back and increase by 100 mg a day each 4-5 days if it causes any uncomfortable or unusual neurologic symptoms or excessive sedation. Begin with 100-300 mg at night, slowly increase to 300-900 mg 3 times a day as is comfortable. In some, pain relief is immediate, in others, it can take a minimum of 1200 mg a day. You can go up to 3600 mg a day.
Muscle Relaxants
___ 221. Flexeril (Rx, cyclobenzaprine) - 10 mg - ½ to 2 at bedtime. Muscle relaxant - can cause dry mouth.
___ 222.* Skelaxin (Rx, metaxolone) - 400 mg 1-2 tablets 4 times a day as needed for pain. This is usually non-sedating.
___ 223. Baclofen (Rx) - 10 to 20 mg 1 to 3 times a day (sedating).
___ 224. Norflex Tablets (Rx) - 1 tablet twice a day.
___ 225. Dantrium (Rx) - (25 mg) For muscle spasm take 1 a day for 1 week. Then one 3 times a day for 1 week, then 2 tablets 3 times a day for 1 week then 100 mg 3 times a day. Adjust to the lowest dose that feels the best. Stop or lower dose if severe diarrhea occurs. Check liver blood tests (#271) at 6, 12 and 24 weeks and then each 1 to 6 months to make sure there is no liver inflammation.
___ 226. Robaxin (Rx, methocarbimol) - 750 mg - 1 to 2 capsules 3 to 4 times a day as needed for pain (sedating).
Antidepressants
Antidepressants can be very helpful in alleviating pain even you are not depressed! Do not presume that your pain specialist thinks that you have a psychological problem if you’re offered an antidepressant. Tricyclic antidepressants (e.g. Elavil/amitriptyline, doxepin, etc.) can be dramatically beneficial (even at very low doses) for neuropathic pain. They also improve the sleep problems caused by the pain. SSRI antidepressants such as Prozac, Effexor, and Celexa can also be highly effective for pain. These medications raise serotonin, which lower levels of a major pain messenger (substance P).
Tricyclics
___ 227A. Elavil (Rx, amitriptyline) - 10 mg- ½ to 5 tablets at bedtime. May cause weight gain or dry mouth. Good for nerve pain and vulvadynia.
___ 227B.* Desipramine (norpramin - use 25-150 mg at bedtime) or ____nortriptyline (Pamelor - 10-25 mg at bedtime) cause less sedation and other side effects than Elavil, and may be as effective. If sedation is still a problem, consider switching to doxepin 10-40 mg at bedtime.
___ 227C.* Doxepin (Rx, Sinequan) - 5-10 mg, 1-3 capsules at bedtime or Doxepin liquid 10 mg/cc. If a lower dose is needed you can start with 1-3 drops at night. A powerful antihistamine. Some people get the greatest benefit with the least next-day sedation with a dose of less than 5 mg a night.
SSRIs
___ 228A. Effexor (Rx, venlafaxine) - 37½ mg _____ tablets - _____ times a day.
___ 228B. Prozac (Rx, fluoxetine) - 20 mg - _____ capsule(s) each morning. Begin with 10 mg a day the first week if the full dose makes you hyper.
___ 228C. Celexa (Rx) - 20 mg ____ tablet(s) a day
___ 229. Cymbalta (duloxetine) - a norepinephrine and serotonin reuptake inhibitor. It has fewer side effects and does not cause weight gain. It has been shown to be very helpful in treating FMS pain.
Alpha 2 Adrenergic Agonists
___ 230A.* Zanaflex (Rx, tizanidine) - 4 mg - Take with food - ½ to 2 tablets 1-2 times a day as needed for spasm and/or pain (sedating). Begin with 2-4 mg at night. If side effects occur raise dose more slowly, increasing by 2 mg at bedtime each 4 nights until you are on 8-12 mg at bedtime. Stop if it causes nightmares.
___ 230B. Catapres TTS 1 Patch (Rx) - Wear 1-3 at a time and change patch weekly. Related to Zanaflex but cheaper and lowers blood pressure more. Helps pain and raises growth hormone.
NMDA ReceptorAntagonists
___ 231.* Klonopin (Rx, clonazepam) - ½ mg - begin slowly and work your way up as sedation allows. Begin with ½ tablet at bedtime increasing to 1-2 mg 3x day as needed. Can be very effective for sleep, pain and anxiety (it is in the valium family). Klonopin may be addictive. Taking one quarter to one half tablets in the morning (not more) can actually decrease brain fog in some pain patients.
___ 232. Dextromethorphan (Rx, DM) - 25 mg - 2 times a day if on narcotics (e.g. codeine/Vicodin) makes the narcotic more effective and less likely to lose effectiveness.
___ 233. Amantadine (Rx) - 100 mg 1-3 tablets each morning may help nerve pain and also is an antiviral. The most common side effects include visual blurring, dizziness, and nausea.
Other Medications
___ 234. Keppra (Rx) - Is another new anti-seizure medication that we are just starting to explore which has been effective when other treatments have not helped. The dose is 250 to 1500 mg twice daily. Can help “burning pain”.
___ 235. Topamax (Rx, topiramate) - Begin with 25-50 milligrams daily, and increase it by 25-50 milligrams a week until you get the desired effect. This medication is usually given twice a day at a total daily dose of 50-100 milligrams/day for migraines and 200-300 milligrams a day for nerve pain, although lower doses can be effective. This is a medication that I have seen work wonderfully in patients who failed numerous other treatments and sometimes starts working within a few days. If you get side effects, decrease the dose and perhaps later increase it more slowly until you get the desired effect. The most common side effects are diarrhea, loss of appetite, sedation, and nausea. The nausea will often go away after one has been on the Topamax for three months. It also has the benefit of causing weight loss as well as pain relief. Besides sedation, its most worrisome albeit unusual side effect is that it can make your body very acidic- to the point where it is dangerous. Because of this, it is reasonable to check a blood bicarbonate level every so often (especially if you start developing symptoms such as fatigue) to make sure that it is over 17.
___ 236. Benadryl - 25+ milligrams 3-4 times daily can often markedly decrease pain (worth trying).
___ 237. Lamictal (Rx, lamotrigine) - 25 mg - 1 at bedtime for 1 week. Can then increase to 1 three times a day for 1 week. You can go as high as 100 mg 4 times a day. Although rare, it can cause a rash that, if you stay on the medication, can be fatal. Although most rashes would not be this, to be on the safe side. STOP LAMICTAL AT FIRST SIGN OF ANY RASH!
___ 238. Trileptal (Rx) - 150 mg twice a day. Can go as high as 600 mg 2 times a day.
___ 240. Mirapex (Rx, pramipexole) - ¼ mg - begin with 1 a night and increase by 1 tablet weekly as needed to a maximum of 6 mg. In one study it resulted in a 50% reduction in pain after 2 months at an average dose of 4.5 mg at bedtime. If stomach pain occurs, Nexium or similar medications are used during the first month. If restless leg syndrome worsens, Klonopin is also added at bedtime. Both of these side effects generally go away as the dose is increased.
___ 241. Risperdal (Rx, risperidone) - ¼ mg to 1½ mg a day (not more). Begin with ¼ mg and increase by ¼ mg each 6 weeks. Going above optimal dose will cancel out the effect. Takes 2 weeks to work. Blocks Serotonin (not dopamine at this low dose). Helps pain, anxiety and sleep.
Acetylcholine Raisers
___ 242. Aricept (Rx, Donepezil) - 5 mg in the AM (or 2½ mg AM and noon) to a maximum of 20 mg a day. Central acetylcholinesterase inhibitor - decreases both pain and opiate induced fatigue by 50% in cancer patients. Effects begin within 1 week. Rotate with #108C (Galanthamine) if tolerance occurs.
Cannabinoids
___ 243. Marinol (Rx) - 5 mg capsules 1-2 twice a day. As this is a THC extract it may cause sedation and increased appetite.
For Opiate Side Effects
___ 244. Constipation is common - (see #180-6). In addition, opiates can lower testosterone and this should be checked for and treated if loss of libido occurs. They can also cause B2 vitamin deficiencies, so be sure to take the B-complex (see treatment # 1). Provigil (#158) and Aricept (see #242) can also decrease opiate induced fatigue.
I.V. Treatments
___ 245. Lidocaine Intravenously (I.V) (Rx) - _____mg (_____mg 1st dose) I.V. each 3 to 20 days as needed. Give 75 mg IV over 10-15 minutes, followed by up to 120 mg per hour (total dose 200-400 mg). Take with I.V. Myers - see #152. For the first dose, give 60 mg over ½ hour first and only continue if blood pressure is stable.
For Interstitial Cystitis
___ 246. Elmiron (Rx) - 100 mg 3x day is reasonable to try. It may take 3 months to work. Take with water at least 1 hour before or 2 hours after eating.
___ 247. MSM (Methyl Sulfonyl Methane) - at a dose of 6-18 grams a day can mimic the effect of DMSO and may be helpful as well.
___ 248. Some practitioners have found that patients with interstitial cystitis often have chronic very alkaline urine. This can be aggravated by excessive coffee and cola intake. PH strip paper can be obtained cheaply at most pharmacies and one can test multiple urine samples at home to see if the pH is regularly over 7.0. Also take the enzyme product URT (enzyme product No. 24) 4 capsules five times a day between meals. During flares add the enzyme product called “kidney” two capsules every 20 minutes as needed. In two to four weeks the symptoms may subside and the products can then be taken just as needed. (Available from our office at 410-573-5389).
___ 249. L-arginine - 500 mg 3 times a day for 3 months
___ 250. Saw Palmetto - 160 mg twice a day for six weeks. If it helps, continue as needed.
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