What are the most effective medications available to treat fibromyalgia? What do the studies say? Are there medications that should be avoided. We take a look at the treatments of fibromyalgia in this podcast.
Kratom is derived from an evergreen tree in the coffee family that is native to Southeast Asia.
This tree’s leaves are often chewed and used as a stimulant for workers in the tree’s native country.
They may also be brewed into a tea and used as a sedative and analgesic.1
The different effects of Kratom depend on the dose ingested. The low doses obtained from chewing on the leaves cause stimulation, including increased alertness, talkativeness, and physical energy. At higher doses, obtained from drinking Kratom tea, sedation occurs.2
Although Kratom is prohibited in Malaysia due to the Poisons Act of 1952, it is still widely used because it grows natively, and teas are readily available locally.3
Kratom has gained popularity in the United States in recent years. An anonymous online survey conducted in October of 2016 attempted to answer several questions regarding its use. The survey was sent to 10,000 current Kratom users, and 8049 replied. Here are some of the findings.4
Most Kratom users are 31-50 years old.
They use Kratom for the following reasons:
Most side effects involve nausea or constipation.
The active chemicals present in Kratom are mitragynine and 7-hydroxymitragynine. These alkaloids are thought to work on opioid receptors as partial agonists.5
These actions are too complex to discuss here, but it appears that these compounds can provide opiate effects with less respiratory depression.6
Opiates are the main medications used to treat severe pain. Opiates also cause many adverse effects, such as respiratory depression, constipation, drowsiness, and dizziness.
The alkaloids found in Kratom may prove to be very beneficial as pain medications because respiratory depression is dangerous, and can cause death in opiate overdose.
The primary purpose of this post is to describe the euphoric effects of Kratom. Knowing that the alkaloids in this plant interact with opiate receptors, it is not surprising that euphoria can occur. The effects of Kratom can vary between individuals, but some of the euphoric effects I could locate include.
The kratom user’s guide. Sage Wisdom Web site. http://www.sagewisdom.org/kratomguide.html. Accessed August 27, 2020.
It should be noted that the above experiences were described by those who had Kratom products for sale. I have no personal experience with this substance, so I am unable to confirm such effects.
Kratom can cause several adverse effects. When used in doses up to 5 grams, Kratom may cause:7
At higher doses, 8 grams or more, one may experience:8
There have also been case reports of other serious side effects of Kratom. One of the most concerning is liver damage. One case report involved a 25-year-old man who ingested between one to six teaspoons of Kratom powder daily for two weeks. This patient developed intense abdominal pain, brown urine, itching, and profound jaundice.9
There have been reports of withdrawal symptoms occurring after the habitual use of Kratom.10
Kratom has also been implicated in at least 91 drug-related deaths.11
It is important to note that multiple drug exposures were present in most of these cases.
CNS Depressants – Combining Kratom with other CNS depressants may lead to fatal respiratory depression. Fatalities have been reported in patients who have ingested Kratom along with the mu-receptor agonist O-desmethyltramadol.14
Drugs that are metabolized by cytochrome P450 enzymes – Many medications are metabolized in the liver through the cytochrome P450 enzyme system. Kratom has been shown to inhibit this process.15
The combination of Kratom with C-450 substrates may increase blood levels and lead to toxic effects. There are too many affected medications to list here, but they can be found at the TRC natural medicines databaseTM.
Modafanil (ProvigilTM) – When Kratom is ingested along with modafinil, the risk of seizures may increase.17
Quetiapine (SeroquelTM) – The combination of Kratom and quetiapine may lead to increased quetiapine plasma levels. This is also due to C-P450 enzyme inhibition. A 27-year-old male was found deceased due to this combination.18
Kratom has been used in Southeast Asia for hundreds of years.19
It has gained popularity here in the USA and is widely available in smoke shops and through the internet.
I believe that Kratom’s alkaloids may lead to alternative medications to treat pain in the future. The fact that these substances can treat pain and cause less respiratory depression is promising.
After researching Kratom, I cannot recommend its use.
Although it may be beneficial for those suffering from opiate withdrawal, the adverse effects can be severe.
It also seems to be another substance used to “get high.” Using substances to achieve a euphoric effect is never a good idea.
Another issue with Kratom is that it is often mixed with other mind-altering substances or medications. This can lead to toxic blood levels. There are several case reports involving Kratom, causing death and liver damage when combined with other substances.
If you have any questions regarding Kratom or any other medication or natural product, please contact me. I hope you all have a great week and please stay safe out there!
Michael J. Brown, RPh, BCPS, BCPP
Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Feel free to send Michael a message using this link.
Disclosure: This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.
Disclosure: This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.
Fibromyalgia (FM) is a disorder affecting approximately 2% of the world’s population. FM is characterized by musculoskeletal pain occurring throughout the body. Patients with this condition may also suffer from:
FM is a chronic disorder with subjective symptoms making diagnosis difficult. At present, FM cannot be diagnosed based on objective data.
Fibromyalgia has previously been thought of as a diagnosis to use when symptoms did not fit any other condition. Some physicians are still unsure whether this is an actual disorder. Patients may become depressed or frustrated due to a lack of compassion from various caregivers.
Previously, many physicians believed patients were using fibromyalgia as an excuse to obtain pain medication. We are now finding that changing one’s lifestyle may be more effective than drugs.
The exact cause of fibromyalgia remains a mystery. It is most likely due to several factors. We believe some of these include:
There is some thought that FM may be the result of the body overreacting to pain signals. This could be due to an imbalance of neurotransmitters in the brain.
Even weak signals may be perceived as pain if this is true.
The main obstacle in determining fibromyalgia’s cause is the fact that most people with this disorder also suffer from other conditions.
Many have rheumatoid or osteoarthritis, migraine headaches, various mood disorders, and other maladies that cause pain. It is challenging to separate FM from these coexisting conditions.
A large number of the studies conducted on this subject have a small sample size, or patients are lost to follow up. More well-designed studies are needed to determine the causes of this debilitating condition.
A meta-analysis was performed using data from the year 2000 until March of 2019. The purpose of this analysis was to determine efficacy and proper dosage of Cymbalta (duloxetine) in the treatment of fibromyalgia. This included seven studies with 2642 fibromyalgia patients. The results showed duloxetine was more efficacious than a placebo for pain control in these patients.
The standard mean difference between duloxetine and placebo was -0.26 or 26% better pain relief.
There were more adverse effects suffered by the duloxetine group, and withdrawal effects were more significant in those receiving 120 mg/day. The study concluded duloxetine was a great choice for relief of pain in fibromyalgia patients
A study published in June of 2019 compared duloxetine (Cymbalta) with pregabalin (Lyrica) in the treatment of fibromyalgia.
All subjects were women with FM between 18-65 years of age. They were each assigned either duloxetine 30-60mg daily or pregabalin 75-150 mg daily for four weeks.
The Widespread Pain Index (WPI) was used to measure pain severity. This scale quantifies body pain by asking patients if they have pain or tenderness in 19 body regions. The higher the score, the more widespread the pain. Duloxetine was significantly better in improving the WPI score with a mean difference of (-2.32) when compared with pregabalin.
The prevalence of nausea and the dropout rate was significantly higher in the Duloxetine group as compared to the pregabalin group.
A Cochrane database review was published in 2018 titled “Serotonin and noradrenalin reuptake inhibitors (SNRIs) for fibromyalgia.” This was a comprehensive study focusing on the efficacy of SNRI’s on numerous FM symptoms.
This study concluded that only a minority of patients might benefit from treatment with duloxetine or milnacipran. Most patients will not gain relief from FM symptoms, or they will experience adverse effects leading to drug discontinuation.
There is no evidence to support the use of other SNRIs such as venlafaxine or desvenlafaxine in the treatment of FM.
There was a Cochrane review published on the effects of anticonvulsants on FM. Since the lead author received financial support from commercial sponsors, this review has been withdrawn from publication.
This study was, however, listed as a reference in the European League Against Rheumatism (EULAR) revised recommendations for the management of fibromyalgia.
Pregabalin is listed as a pharmacotherapy for severe pain and severe sleep problems. Neurontin (gabapentin) is not recommended in the treatment of FM, according to EULAR.
There is evidence that amitriptyline can help with sleep, fatigue and pain in FM at low doses. Five reviews involving 919 subjects found those receiving amitriptyline were 60% more likely to acheive a 30% reduction in pain. A moderate improvement in sleep and a small effect on fatigue were also shown.
Guaifenesin is an expectorant used primarily to loosen mucous in the airways. This helps the patient cough up the mucous and remove it from the body leading to more effective breathing. Guaifenesin is sold under the popular brand name Robitussin. It is also available under the brand name Mucinex as a 12-hour tablet formulation.
There is a protocol available on line that promotes the use of guaifenesin in the treatment of fibromyalgia. I do not see any harm in trying this method if you suffer from FM. Guaifenesin has few side effects. It is important to note that this protocol states that salicylates of any kind must be avoided for guaifenesin to be effective. This includes aspirin and all topical salicylate formulations. The protocol can be found at the link listed below:
http://www.fibromyalgiatreatment.com/the-guaifenesin-protocol.html
A study conducted in May of 2009 used a telephone survey of 632 women to gain insight into the subjective pain relief obtained by several agents in the treatment of FM.
Of the women surveyed, 434 claimed to have FM while 198 denied having the condition. The women had an age range of 18-80 years.
The results of this study showed that half of the FM group were taking antidepressant medication. Tri-cyclic antidepressants (TCA’s) had strong effectiveness while serotonin reuptake inhibitors (SSRIs) had only moderate effectiveness in treating FM. Few were taking SNRI’s at this time.
Almost 30% of the FM sample were taking non-steroidal anti-inflammatory drugs (NSAIDS).
I included this study because even though it was conducted in 2009, it showed that the most effective medications to treat FM according to the subjective reports of the patients were opiate narcotics and guaifenesin. The narcotics aren’t surprising, but guaifenesin is.
Kratom is a substance obtained from a tropical evergreen tree found in Southeast Asia. This substance has been used for centuries to improve stamina and increase the energy of workers in its native region.
Kratom is available as a supplement in the US. People utilize it to treat diarrhea, pain, and to decrease the symptoms of opiate withdrawal.
An anonymous national survey was conducted in 2016 in an attempt to discover the usage patterns of Kratom in the US. This survey included 8049 Kratom users.
It is known that Kratom is used as an alternative to opiates. Fibromyalgia had the lowest proportion of “significant improvement” responses in this survey. This is expected as opioids are not recommended as a treatment for FM
Cyclobenzaprine (Flexeril) is a muscle relaxant used for various musculoskeletal disorders.
A systemic review of 312 patients taking cyclobenzaprine for FM found 85% suffered side effects and only 71% of the subjects were able to complete the studies.
This review concluded sleep was slightly improved, but pain was not.
Cyclobenzaprine can be used for severe sleep problems in FM
Trazodone is an antidepressant used mostly for insomnia at the current time. This medication was not mentioned in the EULAR revised recommendations for the management of fibromyalgia.
If other sleep agents recommended fail, I would not be opposed to trialing trazodone. This drug is effective for sleep at low doses. Getting the proper amount of sleep is very important.
Citalopram belongs to a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). Seven systematic reviews were conducted looking at this drug class for the treatment of fibromyalgia. These medications may have a small effect on pain and fatigue but do not help with sleep. Since SNRI’s discussed above are more useful for FM, SSRIs are not recommended.
The EULAR revised recommendations for the management of fibromyalgia were published in 2017
The EULAR recommendations for the treatment of fibromyalgia maintain that prompt diagnosis and patient education are critical. The patient should be assessed for pain, level of function, and management should be geared towards improving the quality of life.
Non-pharmacological treatments should be initiated first. These include physical therapy with an emphasis on individualized exercise. Other therapies, such as acupuncture and hydrotherapy, may also be tried at this stage.
Psychological therapies should mainly consist of cognitive-behavioral therapy. If depression and anxiety are severe, psycho-pharmacological treatment can be utilized.
Recommendations for pharmacotherapy, according to EULAR, are as follows:
Drugs that should not be used:
Drugs recommended for severe pain:
Drugs recommended for severe sleep problems:
I have attempted to review the most up to date medication treatments for fibromyalgia in this post. I have included the recommendations from EULAR as well as information on Kratom, guaifenesin, and trazodone.
I do not recommend the use of Kratom at this time. I believe guaifenesin may have a benefit, and it has very few side effects. Trazodone is a good drug for insomnia at low doses, so it may be tried if other treatments fail.
After researching this subject, it seems that exercise, hypnosis, guided imagery, and other non-pharmacological treatments are the preferred treatment of fibromyalgia.
More research will surely be done on this subject, and hopefully we will obtain better treatments in the future.
Thank you for reading my blog, and please contact me with questions.
Michael J. Brown, RPh, BCPS, BCPP
Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Feel free to send Michael a message using this link.
