A recent study in Pain Medicine this October 2012 reviewed the burden of illness and treatment patterns of 1700 fibromyalgia patients. It was a “baseline assessment of the Real-World Examination of Fibromyalgia: Longitudinal Evaluation of Costs and Treatments (REFLECTIONS), a prospective observational study. Baseline data (including a physician survey, a patient visit form, and computer-assisted telephone interviews) were collected from July 2008 through May 2010 in 58 care settings in the United States, including Puerto Rico.” Of the patients most were female (94.6%) and white (82.9%) with the average age of 50 years and mean duration of illness was about 5.6 years. The mean Fibromyalgia Impact Questionnaire total was 54.4 (range 0-80) and the Brief Pain Inventory average pain level was 5.5 (range 0-10).
Patients according to the Pain Medicine study reported yearly high health care usage and frequent work limitations in regards to their fibromyalgia disability. Most of the patients in the study experience significant disability, insomnia, symptoms of depression and/or anxiety and cognitive dysfunction. For example, “patients reported an impaired ability to focus/concentrate, a reduced ability to recall information, word-finding difficulties, and decreased mental clarity.”
According to the study patients were prescribed 182 “unique types of medications prescribed for FM, including duloxetine (26.8%), nonsteroidal anti-inflammatory drugs (26.6%), pregabalin (24.5%), opioids (24.2%), tramadol (15.3%), benzodiazepines (15.2%), cyclobenzaprine (12.9%), milnacipran (8.9%), and others.” Pain-topics states often patients were prescribed more than one medications; “Polypharmacy was prevalent: only 22% of patients were taking only one medication, most (78%) took an average of 2 to 4 (mean 2.58; 95% CI, 1 to 5) different medications concurrently. The type of current medications used was most strongly associated with patient medication history and medical specialty of the prescriber, with specialists tending to more often prescribe newly approved drugs.”
In addition to medications Pain-topics states all patients “All patients with FMS had used some form of nonpharmacologic therapies in the prior 12 months, and such therapies were newly prescribed for 61% of patients during the study baseline visit. Nonpharmacologic therapies consisted most commonly of rest, exercise, massage, counseling, and heat/cold modalities; although prayer/meditation and cognitive distraction approaches also were prominently noted. Hypnosis, biofeedback, energy healing (eg, Reiki), and acupuncture were noted relatively infrequently (in 1% to <9% of patients). Cognitive behavioral therapy had been used by only 4.5% of patients, despite good evidence for its efficacy; whereas, trigger-point injections, with less supportive evidence, had been administered to 27% of patients.”
There are too many available treatments for FM one might say, however, there are only a few specifically assigned to treat the syndrome and very little research or evidence to suggest other approaches are valid. The study states the burden of illness is high for patients with FM and treatment patterns are very inconsistent. Medications with the most evidence to suggest they are beneficial were not the most frequently chosen. Among the assortment of medications prescribed only three are specific for FM and that would be duloxetine (also known as Cymbalta) prescribed in 27% of the patients, pregabalin (also known as Lyrica) prescribed in 25% of the patients and milnacipran (also known as Savella) prescribed in 9% of the patients. We can see only a moderate proportion of the study population was receiving these specific FM medications even taking into account two of the three were fairly new during the data collection time period. In fact the Pain-topics suggests the“variety of medications prescribed for FMS, as discovered in this study, seems rather astounding, ranging from analgesics to antidepressants or anticonvulsants to psychotropic medications (eg, sedative/hypnotics and stimulants) to muscle relaxants. Small percentages of patients (<3%) were prescribed antipsychotics, antivirals, corticosteroids, lidocaine, a dopamine agonist, and nutritional supplements/vitamins.” Granted FM is a complex syndrome and specific medications may well not work for one person as they do for another. We also have to factor in the pervasive sleep issues and comorbid conditions. However, adding in too many medications and resorting to sometimes odd off label medications can lead to difficult side effects and other unforeseen problems where one might have just considered other more appropriate non-drug therapies and lifestyle changes. There might be a lack here of knowledge of what to do with FM patients when there are so many problematic symptoms. We end up with a complete lack of consistency here and random therapies and drugs.
However it must be noted as stated by Pain-topics “This present study by Robinson et al.  was limited by its observational, cross-sectional nature and insufficient data to fully capture all factors that might have influenced treatment selections. Furthermore, a possible reporting bias must be considered, since the study was funded by Eli Lilly and Company, a manufacturer of select drugs used in FMS treatment, and 4 of the 8 authors were either employees or otherwise subsidized by the company.” Which is a valid point because while there are three specific treatments for FM consider that they may not be all that effective for treating all they symptoms of the condition either. For example if the core symptoms can be consider to be pain, fatigue, cognitive dysfunction and sleep impairments the three recommended medications may improve pain but have a side effect of actually causing more fatigue and cognitive dysfunction in some people. Or it may simply be a matter of improving one area and not being effective in any other area. Or they may not be effective at all.
Also consider an alternative survey done by CureTogether (see site for full chart of all therapies and drugs listed in survey for effectiveness) of 1144 patients, and ongoing, that suggest the recommended three treatments” Lyrica, Cymbalta, and Savella as making their Fibromyalgia worse, not better” Most effective treatments according to their patient survey are “rest, heat, sleep, stress reduction”. However again we must consider the people taking the survey is taken from a pool of people who for one are seeking them out and for another have access to the internet and so forth. For another it is not as broad in scope; for example, yes, getting sleep is primary but how you get that sleep is the question… are you using an herbal, therapy or pharmaceutical aid? The same could be asked for stress reduction. Nevertheless the second study done by CureTogether indicates Lyrica and Cymbalta are in fact very popular currently so perhaps there is some consistency in pharmaceutical treatments. However, if these studies are any indication one would certainly like to see more studies on their effectiveness along with more research into the effectiveness of therapeutic approaches to create more firm guidelines for doctors to approach patients with. Certainly not 182 random drugs. Certainly not random combinations. Or whimsical therapeutic approaches that are not supported by evidence over the ones that are. Again the burden of illness is high. The treatment of the illness is highly inconsistent. It clearly is a difficult to treat syndrome with many symptoms and often comorbid conditions. Often there is no concrete plan of action or guidelines to follow and this perhaps is in itself a problem.
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