This national award winning book was written for the tens of millions of people worldwide who suffer from fibromyalgia and other chronic painful conditions. I systematically approach the concepts of fibromyalgia, the manifestations of this condition and other chronic painful processes, and I review available medications and their modes of actions. I focus on how one needs to begin their journey.
Targeted Age Group:: 18 and above
What Inspired You to Write Your Book?
I wanted to empower patient’s.
Book Sample
FOREWORD
All of the information in this book is strictly the opinion of Jeffrey B. Loomer, M.D. This book is based on my personal experience of treating thousands of patients over a period of greater than twenty years. The practice of medicine is an inexact art. Qualified experts in all fields of medicine certainly may have differences of opinion, which are reflected in the way they practice medicine.
The purpose of this book is to reach out to all the people who suffer from fibromyalgia and chronic pain. I believe this is an area of medicine which is underserved. Ironically, there are millions of people in the United States and throughout the world, who on a daily basis, have to deal with these conditions. It is my true belief that nobody should have to suffer with chronic pain. The medical community has the capacity to treat these people. I find it amazing that there is such disconnect between the medical communities’ ability to treat fibromyalgia and chronic pain and the lack of attention these patients are given.
I believe that throughout the years (having managed thousands of these patients successfully), that I have developed a sensible and effective way to treat these patients with cost effective medications. I have, in a positive way, changed the lives of thousands of people.
It cannot be overstressed; all of the information in this book is presented with the intention of having the reader communicate with their healthcare provider who is responsible for the medical management of their patients. Under no circumstances should any person take it upon themselves to either self-medicate or self-adjust any medication. This is very dangerous and could result in serious bodily injury and possibly death.
This is not a “how-to” book. It is about information, which will empower the patient regarding taking the appropriate measures to put them in the best position to obtain effective medical care for the management of fibromyalgia and chronic pain.
Believing that the information in this book will be helpful to the reader, I feel I have presented worthwhile information in a novel and unique way which I have not seen in print elsewhere. I have taken over twenty years of personal medical practice experience, and created a book where patients and healthcare providers can become effective partners, and begin a productive and meaningful journey to address and manage fibromyalgia and other chronic painful conditions.
INTRODUCTION
Medicine has come such a long way since the time of Hippocrates, the father of medicine (460-375 BC). Over the past 100 years, medical knowledge has grown exponentially; yet, it is ironic that we are only just at the dawn of accepting and understanding a condition that has been with us throughout the ages. Historically, fibromyalgia has been given little recognition let alone validation by the medical community. I have been treating patients with fibromyalgia for over 20 years. I first became acquainted with this condition in 1990, when I was in the first year of my Rheumatology Fellowship at Dartmouth. I had just finished my three-year Internship and Residency training in Internal Medicine. During those tough three years, I was exposed to a vast array of medical conditions; ranging from minor ailments that were addressed in the outpatient clinic setting, to complex medical diseases, many which required management in the intensive care unit. Would you believe, after four years of medical school and three years of post-graduate training in Internal Medicine I never heard of fibromyalgia!
In my opinion, this exemplifies why physicians know very little about fibromyalgia; there has been little opportunity regarding formal training of this condition in medical school and post-graduate medical training programs. I often have wondered how this apparently prevalent condition has “fallen through the cracks” for so many years. I do have a theory about this phenomenon. First, medical students simply are not educated on fibromyalgia because historically there have been few experts in this field. As you already can see we are not off to a good start where, after four years of medical school, the knowledge that a young doctor possesses about fibromyalgia is only minimal at best.
Second is Internship and Residency. For young physicians, who choose to go into fields of medicine, other than Internal Medicine and Family Practice, the potential for these doctors to gain practical knowledge regarding fibromyalgia diminishes with each passing year. For those doctors, who take the plunge into Internal Medicine and Family Practice, it is extremely unlikely they will see a fibromyalgia patient in the hospital, unless they are involved with a patient who is being worked up in the ER or briefly admitted to the medical unit for unexplained pain. These patients quickly are ruled in or ruled out for more serious acute medical conditions. When it is determined these patients are not in acute medical danger, they often are classified as having fibromyalgia, as they are shown out the door of the hospital. Discharge instructions will tell these patients to follow-up with their primary care providers in a week or so.
The primary care providers do not know what to do with these patients. Many are branded as hypochondriacs and malingerers. If these patients are lucky, they may get a referral to see a rheumatologist, but they may have to wait a few months until an appointment becomes available. Many rheumatologists will not accept patients with the diagnosis of fibromyalgia. At this point, given this scenario, it is not looking very promising for patients with fibromyalgia. However, this is the reality of the situation. If you have been keeping track of the years, you are looking at a well-intended physician, who after four years of medical school and three years of Internship and Residency training (seven years in total), who may have virtually no knowledge, let alone experience, in treating fibromyalgia and that is a scary thought! By the way, after a doctor completes the hospital training program, it is quite possible one of the first few patients who walk into the physician’s office will have fibromyalgia; the patient who was sent home from the ER the previous week! This begins the start of a long relationship of mutual frustration between the physician and patient. I really do believe this represents the life cycle of the fibromyalgia patient and the medical community.
By now, you are probably wondering if there is anyone out there who can help people (you) with this condition. The answer is “yes,” but it will not be easy. This is my reason for writing this book. Physicians need to be educated about this condition. Patients with fibromyalgia need to be embraced. The present disabling life cycle of fibromyalgia needs to be broken. I know I am not the only rheumatologist or medical physician who has been treating fibromyalgia patients for many years. I know what I have learned from my patients and I am thankful to them for that. I have treated several thousand patients with fibromyalgia and other chronic painful conditions, and the vast majority of them have done quite well. Let us read on and see where you stand with these conditions, and see where you can begin your journey to liberate yourself from pain.
CHAPTER ONE
What Exactly Is Fibromyalgia?
This certainly appears to be a simple question, but in fact, the answer is quite complex. I often have looked at other people’s definitions of this condition. Textbooks say one thing, not much, while self-proclaimed authorities, many of them non-physicians, have written books, and of course there is the Internet, where if it is “on-line” it must be true. . On occasion, while strolling through Barnes & Noble, I would thumb through the section of books on fibromyalgia, whose numbers seem to be growing annually, and I have yet to come across a book that really delves into the therapeutic management of this condition. How can one expect a nutritionist or chiropractor or psychologist (just some of those who have authored books on fibromyalgia) to be an expert on the management of fibromyalgia when they are not physicians? Most physicians do not know much about fibromyalgia, but at least they can write prescriptions for treating this condition. There may be a few patients with fibromyalgia who can derive benefit from a holistic approach towards the treatment of their condition, but they are few and far between. I am going to cut to the chase on this issue; the vast majority of people with fibromyalgia need to be on a patient-specific medication regimen to effectively control their symptoms, but I have not seen much written about the specific medication regimens that are necessary to effectively treat fibromyalgia.
There may be several reasons for this. I believe that even in well-established medical communities in large urban and suburban regions, there are only at best a handful of doctors who know how to treat fibromyalgia. If we concentrate on just the physicians who treat fibromyalgia, the ones who really know what they are doing, you will begin to understand that these are unique practitioners; their patients and referring physicians are well aware of this fact. These are physicians, who for years, have been thinking and practicing medicine, in a good way, outside of the box.
Before the summer of 2007, there were no FDA (Food and Drug Administration) approved medications for the management of fibromyalgia. At the time of the writing of the second edition of this book (as with the first edition), there are still only three medications that are specifically approved by the FDA for the treatment of fibromyalgia. It is important to note that these three medications have been on the market for years, but the FDA had approved them for the treatment of other conditions. I will discuss these medications and others later in the book. I have been prescribing these medications and many others for some time for the management of fibromyalgia. [Note: When a medication has an FDA approval for the treatment of a specific condition, and the physician chooses to prescribe that medication for another condition, this is known as “off-label” prescribing of the medication.]
Ironically, in my opinion, there are plenty of effective medications on the market (brand names and generics) to effectively treat fibromyalgia. I have been having significant success treating my fibromyalgia patients with medications that are already on the market, some of which have been around for decades. In order to successfully treat this condition, the physician has to know what to look for and how to clinically approach the patient suspected of having fibromyalgia.
Patients are frequently referred to me because of “chronic pain.” These may be individuals who for years have been dealing, most unsuccessfully, with chronic discomfort. The ways in which these patients have been managed by the referring physician varies greatly. It is amazing and sad how people can be managed ineffectively for years. I always wonder one of two things: why these physicians did not refer these patients out sooner; or why these patients did not, on their own, seek out more effective management?
In reality, the answer to this question is rather complex, and in most cases, no one is to blame. It can be quite frustrating for the general physician to manage patients with chronic painful conditions; many are uncomfortable treating these patients. If a doctor is to be effective, in managing patients with chronic painful conditions, they have to be comfortable, particularly in the prescribing of narcotics. There are plenty of patients who are, in fact, appropriate candidates for the prescribing of narcotics. In my opinion, if a physician, for whatever reason, refuses to incorporate the judicious use of narcotics in their practice, they will be ineffective in managing chronic pain in a fair number of patients who fall into this category.
How does a physician begin to develop a productive working relationship with the patient with chronic pain? It does not take long during the initial visit with a new doctor to get a sense where this new relationship is going. The attitude of both parties (physician and patient) is extremely important during the first visit encounter. A doctor, who is comfortable treating patients with chronic painful conditions, will not feel intimidated when a new patient comes to their office complaining of chronic discomfort with years of prescribed narcotic usage. Sometimes a patient on a complex pain management regimen actually will discharge their primary care physician, and seek help from a different primary care physician. The problem, in this situation, is the new primary care physician may be uncomfortable with prescribing opioids (narcotics), and the patient is right back where they started. Often, doctor offices have signs posted in the waiting room stating they do not prescribe narcotics. They tell the patients that they will manage all of their other conditions and write prescriptions for their other non-pain management medications. The only good thing for the patient in this situation is that these doctors tell their patients up-front they do not manage chronic pain, and they usually have a pain specialist to whom they will refer them.
My approach, to the patient who comes to my office complaining of chronic pain, is quite simple. I need to spend at least 50 minutes with a new patient. I want to review the records the patient has brought with them. Patients will sometimes get upset if their records were not sent to my office ahead of time. Patients usually know what tests were done and their results. I am often quite effective with making a diagnosis on the basis of taking a good history from the patient followed by a careful physical examination. Personally, I feel it is important for the doctor to obtain the history from the patient, and it goes without saying that the doctor should perform the physical examination.
In order to effectively manage the patient, with a chronic painful condition, the clinician has to determine the etiology (cause and origin) of the pain. Not all painful conditions are fibromyalgia, but patients with chronic painful conditions often have fibromyalgia. To determine if someone has fibromyalgia, the physician has to have a good understanding of what to look for. So, here is the million dollar question (which due to inflation, a struggling economy, and after taxes is really worth about half a million dollars).
What is fibromyalgia? The answer is rather straight-forward. Fibromyalgia is a syndrome. What is a syndrome? A syndrome is a collection of clinical features which as a whole defines a medical condition. Now that you know the definition of a syndrome you can begin to understand, and possibly identify, this condition in yourself; however, do not take it upon yourself to start diagnosing your family and friends. It is alright for a patient to have an understanding of a condition before going to a doctor. Just remember, you will not be an instant expert, and keep in mind a competent physician, during the course of an initial evaluation, will be considering other diagnoses too. I often have patients who either are referred to me, by their primary care provider or come on their own, telling me they think they have fibromyalgia, and they are usually right!
The most common scenario, regarding the fibromyalgia patient, is they are referred to me with the presumption of another diagnosis, such as, rheumatoid arthritis or lupus; the patient will say to me their blood work showed one of these two conditions, and I was going to treat it. This is a perfect example of a referring physician innocently missing the boat. An abnormal blood test certainly does not make a diagnosis. A positive rheumatoid factor (one of the blood tests used to diagnose rheumatoid arthritis) does not necessarily mean a patient has rheumatoid arthritis. A positive ANA (antinuclear antibody), a test used to diagnose lupus and other connective tissue diseases, does not mean a patient has lupus. The results of these tests can certainly mislead the practitioner who ordered them, not to mention scaring the patient.
It may take several months for a new patient to get an appointment to see a rheumatologist, and during that time they are worrying about a condition they really do not have. To make things worse, for the last several weeks, they also may have been on the Internet learning all about “their new condition” including both accurate and inaccurate information. Now, my job has the added complexity of deprogramming these patients and explaining to them what they really have. My favorite situation is when the primary care physician tells their patient they have a connective tissue disorder (such as, rheumatoid arthritis, lupus, or another diagnosis that falls under my field of expertise), and the patient chooses to embrace an inaccurate diagnosis by their primary care physician after I have told them they do not have that condition! Now, they think that I do not know what I am talking about!
At the end of the day, fibromyalgia is a clinical diagnosis. There are no abnormal blood studies or specific radiographic (x-ray) findings that establish a diagnosis of fibromyalgia. Fibromyalgia is not an inflammatory condition. I will say it again (this is a very important concept), the diagnosis of fibromyalgia is made on a clinical basis. Complicating the picture is the fact that fibromyalgia often co-exists with other medical conditions, and other conditions can have clinical features consistent with fibromyalgia, more about this later.
What is the constellation of historical and clinical features that add up to make the diagnosis of the fibromyalgia syndrome? The most common feature, in patients with fibromyalgia, is their inability to obtain a restful night of sleep. One of the first questions I will ask a new patient is about their quality of sleep. How do you sleep at night? Do you have difficulty in getting to sleep, staying asleep, or a combination of the two? The vast majority, of fibromyalgia patients, will respond by telling me they sleep poorly. It is interesting to note how many times patients tell me that this conversation never came up with their primary care provider. Some patients will tell me they sleep well. This, however, should not be the end of the line in questioning the patient suspected of having fibromyalgia.
The next important question, that should be asked, is about the “quality” of the sleep process. Sleep quality is a key feature in identifying, understanding, and treating patients with fibromyalgia. The usual response to the sleep quality question is these patients feel exhausted when they wake up. I often am told by patients they sleep only for a few hours at a time. It certainly is not difficult to understand these people would be exhausted in the morning since they are not getting a good night’s sleep.
What about the patient who tells me they sleep 10-12 hours a night? The same sleep quality questions have to be asked. Sleeping 10-12 hours a night does not mean a person will be rested in the morning. Feeling rested in the morning and having full energy to meet the challenges of the day depends on the “quality” of sleep. Six hours of good quality sleep is more beneficial than 10-12 hours of poor quality sleep. This initial line of questioning occurs in the first few minutes of sitting down with the new patient. Just on this basis, of how the sleep quality questions are answered, quickly clues me into the patient who likely will have fibromyalgia.
When discussing the sleep quality issue with patients, I like to use the electric power tool analogy. Let us just say you are a carpenter and use a rechargeable power tool throughout the day. At the end of the day the battery charge will be low, therefore, it has to be recharged so it will be able to be functional the next day (recharge the battery overnight). Now, just for a moment, consider yourself to be a power tool that needs to be recharged at the end of the day. Going to bed is like climbing into a big electric charger, it should supply you with enough energy capacity by the morning to propel you through the day. This should be the normal cycle, more or less. If the power source to the carpenter’s power tool is faulty and a continuous full battery charge is not accomplished by the morning, the tool will run out of energy halfway through the day. Without the power tool functioning, the carpenter cannot accomplish any further meaningful work for that day. There really is not much difference between the functional capacity of people and a rechargeable power tool; they both need a stored energy source to be fully functional. If a person wakes up exhausted after a night of sleep, regardless of the number of hours of sleep, that person will not have the proper “recharge” to meaningfully get through the day. If you are not rested when you get out of bed, how are you going to feel a few hours into your day, let alone by the end of the day?
The poor sleep pattern process is a fundamental problem I have recognized in thousands of patients whom I have treated with fibromyalgia. Successful identification and management of this process is the initial step to treating fibromyalgia. Based on my experience, with treating this condition for over two decades, I almost consider fibromyalgia to be a sleep disorder. I make this statement on the consistent observation that in general, these patients have poor sleep patterns and many, for the most part, improve when the poor sleep pattern is addressed and successfully treated. Keep in mind, not all people with sleep problems have fibromyalgia. Other medical conditions can cause disruption of the sleep pattern. Some people do not sleep well because of a condition called sleep apnea. In this condition, people will actually stop breathing for a few seconds and then they wake up. They often are not even aware this process is taking place. I frequently will ask the sleeping partner, if present during the evaluation, if they notice this abnormal sleep process. The sleep apnea process may be associated with snoring, so this is also an important question to ask. One myth is that sleep apnea only occurs in the obese individual. This is not true. Thin lean people certainly can suffer from sleep apnea. If this condition is suspected, the patient needs to be referred to a sleep study lab for evaluation.
Patients with sleep apnea often have features consistent with fibromyalgia. Usually, if sleep apnea is identified, and appropriate treatment is initiated, the fibromyalgia symptoms often resolve. A sleep study is quite painless. The patient packs an overnight bag and reports to the sleep lab in the evening (many labs are open seven days a week). Electrodes are hooked up to the head, heart, and a device is placed at the end of one finger to measure the amount of oxygen that is present in the bloodstream. Remember, this really is a non-painful study. (Though by the time the patient is all hooked up they look like the average patient in an intensive care unit!) This would be a good time to bring a digital camera and snap a few pictures; make up your own story and distribute them to family and friends. (I never said I was normal folks!) There is also a closed circuit visual monitor for the technicians to observe the patient’s activity as they sleep. The study monitors the patient until the next morning. If the person displays episodes of not breathing, during the night, associated with brief periods of waking, and a lowering of the blood oxygen level, this would identify sleep apnea.
The treatment is quite simple. A pressurized oxygen mask is then placed over the patient’s face, and they are observed for further activity. The vast majority of patients identified with sleep apnea have an immediate and dramatic response to the oxygen mask treatment; this apparatus is called a C-PAP (Continuous Positive Airway Pressure) machine, and is obviously available for home use. You do not need all the other stuff from the sleep study facility, just the C-PAP machine (insurance should cover this piece of equipment). I thought it was important to discuss sleep apnea and give the reader some insight into this condition, its evaluation, and treatment because physicians often overlook this important cause of insomnia. One of the reasons for writing this book was to empower patients with accurate and appropriate medical information they can discuss with their physician. There is no reason why a well-informed patient cannot make suggestions to their healthcare provider; noting this will need to be done in an artful friendly manner as to not irritate the practitioner.
Now that we have established that a poor sleep process is a fundamental driving force for the development of fibromyalgia, we need to examine the consequences of this problem. Patients with fibromyalgia also experience extreme fatigue. This is one feature the patient always will describe to the healthcare provider; this symptom is not to be overlooked! Well, when you think about it, one would expect the patient with fibromyalgia to be fatigued. After all, they are not sleeping properly. How can someone expect to be rested in the morning if they are not getting a good night’s sleep? Let us take the equation one step further, building on the concept that a poor sleep pattern leads to waking up feeling very fatigued and not rested, most patients with fibromyalgia complain of aching all over, all the time. If this information is not volunteered by the patient, I am going to enquire about this. It is important for me to get a good understanding about the patient’s “pain.” Is it the muscles or the joints, or are both painful? How long has this been going on? What is the nature of the pain (dull, sharp, constant, intermittent)? What makes it worse; what makes it better; is there associated swelling of the joints; what time of the day are these pains at their worst or at their best? Patients often tell me that their joints swell, but subsequent examination usually reveals no evidence of swelling. This is not to say that patients are intentionally lying to me, it is just that their “perception” is different than what is actually going on. The description of joint swelling would alert me to carefully consider an inflammatory condition, and if truly identified on physical exam, would lead me to work up the patient for one of several arthritic conditions depending on other historical and clinical findings. Remember once again, fibromyalgia is not an inflammatory condition so swelling should not be present in a patient with fibromyalgia, except in situations where fibromyalgia and inflammatory conditions coexist. I often see this in my practice, but let us not complicate the fundamentals of fibromyalgia at this time. I will touch upon this concept later in the book.
It is certainly possible for a patient to experience swelling of the joints, which can last for several hours in the morning. It is important to keep in mind that if swelling is really occurring, this is not a feature of fibromyalgia and represents another process. I have to make clinical decisions on the basis of what people tell me and what I observe on physical examination. When a person tells me their joints swell the first question I immediately ask is whether their joints are “presently” swollen. If they tell me their fingers are presently swollen and my examination reveals no swelling, it is unlikely that an underlying inflammatory condition is present. On the other hand, if the patient tells me the joints swell for three to four hours in the morning, and I am evaluating them at three in the afternoon and joint swelling is not identified on examination; I am certainly going to consider an inflammatory condition. The investigative studies for this patient will be different than a patient suspected of having only “primary fibromyalgia” (fibromyalgia not attributed to another underlying condition). This will be discussed in more detail later.
Headaches are another common feature that patients with fibromyalgia experience. I often am told by my patients that they have been experiencing headaches from several months to several years. Many of these patients have been to see a neurologist, and unfortunately have not been helped with the use of various migraine medications. I have observed that many of my patients with fibromyalgia associated headaches experience significant relief once their fibromyalgia is under control. The treatment of fibromyalgia headache is often not simple, meaning it may be necessary to use a combination of medications to achieve the desired effect. This is actually a basic concept to the overall approach of treating fibromyalgia. In any event, the topic of headaches should come up during the initial visit. Sometimes patients will not mention headache unless I bring it up. Remember, fibromyalgia is a constellation of symptoms, and it is during the initial visit that I am trying to get an understanding of which symptoms a patient is experiencing, so that I am able to even consider a diagnosis of fibromyalgia.
Irritable bowel is another symptom patients with fibromyalgia often experience. This is a gastrointestinal process which can have several different presentations. Some patients have diarrhea; others may complain of constipation; and others may have a combination of diarrhea alternating with constipation. Keep in mind, all gastrointestinal disturbances, in the setting of a patient with fibromyalgia, cannot be assumed necessarily to be irritable bowel. When reviewing the gastrointestinal system, there are a number of questions that need to be asked. Examination is a key component, and sometimes the picture can be confusing. Irritable bowel can certainly coexist with other gastrointestinal abnormal processes. It will be up to your healthcare provider to determine whether additional gastrointestinal investigations are warranted.
About the Author:
Jeffrey B. Loomer, M.D., FACP, FACR, is a Board Certified Rheumatologist, who maintains a demanding private medical practice limited to the management of patients with connective tissue and chronic pain disorders. A large segment of his patient population suffers from fibromyalgia and other chronic painful conditions. His patient population base consists of people living in southern Arizona and some of the surrounding states. He has been in solo private practice in Tucson, Arizona since 1992.
Dr. Loomer received his Bachelor of Science Degree from the State University of New York College at Oneonta. He holds a Master of Science Degree in Biomedical Sciences from Barry University in Miami Shores, Florida. Dr. Loomer graduated from St. George’s University School of Medicine in Grenada, West Indies. He completed an Internal Medicine Internship at Greater Baltimore Medical Center in Baltimore, Maryland and an Internal Medicine Residency at New Britain General Hospital in New Britain, Connecticut. He then went on to complete a two year Rheumatology Fellowship at Dartmouth-Hitchcock Medical Center in Hanover, New Hampshire.
Dr. Loomer is a Fellow of the American College of Rheumatology and a Fellow of the American College of Physicians. Throughout the years, he has been involved with medical education in several different capacities. He was a Clinical Instructor in Medicine at Dartmouth Medical School, Medical House Staff Lecturer at Tucson General Hospital, Question Writer for the American Board of Internal Medicine Certification Examination, Peer Review Case Consultant for the Arizona Board of Medical Examiners, Admissions Committee Interviewer for The University of Arizona School of Medicine and has participated on Medical Advisory Boards to several pharmaceutical companies. In addition, Dr. Loomer has given many lectures on fibromyalgia, chronic pain and other rheumatologic conditions to physician groups in Tucson, Phoenix and New Mexico, as well as, local community based general public venues. Dr. Loomer has also worked with The American College of Rheumatology as a Congressional Delegate Patient Advocate in Washington, D.C.
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