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Dear Friends,
I recently had the opportunity to be interviewed for an upcoming doctor's forum on fibromyalgia. I’ve transcribed this interview into a text format, adding and deleting some material when I thought it would help clarify my verbal answers. I think it helps clarify my philosophy on how best to treat fibromyalgia. I hope you find it helpful. As usual, I’ve crammed a lot of information into this newsletter. My editor always reminds me that it’s best to give a little and if people want more they can buy my books. Well, I just can’t help myself. I want those with fibromyalgia to see their illness in a different light. I also want them to feel better. And I’ve found that the more they know the better their chances are of getting better.
A lot of this material comes from my books, “Treating and Beating Fibromyalgia and Chronic Fatigue Syndrome” and “The Patient’s Self-Help Manual for Treating And Beating Fibromyalgia and Chronic Fatigue Syndrome.”
Tom McCracken, interviewer (INT) - Dr. Murphree I enjoyed hearing you speak at last years conference. Can you explain why there is such a disparity in the way doctors treat fibromyalgia?
Dr. Murphree (DR. M) “It takes an average of 7 years and 12 different doctors before a person is properly diagnosed with fibromyalgia. Patients are often passed from specialist to specialist in an attempt to rule out autoimmune disorders (rheumatoid, lupus, etc.), neurological disorders (multiple sclerosis), hormonal disorders (thyroid, adrenal, estrogen, progesterone, testosterone, etc.), musculoskeletal disorders (herniated disc, osteoarthritis, etc.), and of course, psychological disorders. Unfortunately, each specialist attempts to diagnose the patient and prescribe them with the medications that they feel will help reduce their symptoms. A neurologist may prescribe Neurontin for pain management, an arthopedic doctor prescribes a non-steroidal anti-inflammatory for pain management, the psychiatrist recommends an antidepressant, and so on. Eventually the patient is on several medications from several doctors, all, attempting to treat the multitude of symptoms associated with fibromyalgia.
INT – So there’s no consensus on how to treat fibromyalgia?
DR. M – Well, there are various protocols, but none that are widely agreed upon. Instead, doctors typically treat the various symptoms of fibromyalgia with the latest fad drug. Lyrica seems to be the "latest greatest" drug of choice. But, past history should temper our rush to proclaim a drug as a breakthrough for treating fibromyalgia. The traditional medical approach (drug therapy alone) hasn’t yielded much success. Each new popular drug has eventually proven to be ineffective in long-term management of fibromyalgia symptoms.
INT – Are you saying that drug therapy isn’t effective for fibromyalgia?
DR. M – We should consider the following statements from The American College of Rheumatology;
On tricyclic medications Amitriptyline (Elavil): Four controlled trials have evaluated the efficacy of Amitriptyline in Fibromyalgia… the longest trial showed no benefit when compared to placebo. Furthermore, use of the anti-anxiety medications Benzodiazepines, (Klonopin, Xanax, Ativan, etc.), corticosteroids, (medrol dose packs, prednisone, etc.), and nonsteroidal anti-inflammatory agents, (Mobic, Celebrex, Vioxx, Bextra, etc.), and pain medications have been shown to be ineffective and should be generally avoided.
INT – You don’t recommend patients take prescription drugs?
DR. M – No, I wouldn’t say that. I owned an integrative medical practice where the medical doctors I employed used prescription drugs to manage many of our fibromyalgia and CFS patients. Medications can be very helpful but, MEDICATIONS DON’T CORRECT THE PROBLEMS, THEY ONLY REDUCE THE SYMPTOMS. Doctors, who’ve had lasting success with fibromyalgia, including myself and the doctors I employed, found that correcting the underlying cause(s) of fibromyalgia with the chemicals (nutrients) the body needs yields long-term benefits. Drug therapy alone only temporarily reduces symptoms and oftentimes creates further health problems. The number one side effect of Ambien is flu-like symptoms; muscle aches, fatigue, and joint pain. By the way, no one has a Cymbalta deficiency. However, they very well COULD have low serotonin and norepinephrine levels. Both of these neurotransmitters (brain chemicals) are made from amino acids, (5HTP, L-Phenylalanine and or SAMe), and the vitamins and minerals that act as co-factors. These all-natural nutrients are what the body uses to make the chemicals it needs to maintain, coordinate, and self-regulate optimal health.”
INT – So a doctor should avoid using prescription drugs and instead recommend amino acids, vitamins, minerals, and other nutrients?
DR. M – Prescription drugs can be very useful in reducing symptoms. If a person has excruciating pain from a herniated disc, then a Medrol dose pack and a handful of Loritab is needed to give the patient the relief they need and deserve. If someone can’t sleep by using 5HTP, melatonin, or other natural means, then by all means they should be placed on a sleep medication that promotes deep restorative sleep. However, most doctors start patients on drug therapy first, neglecting the cause, and merely attempting to cover up the symptoms.
INT- So you do believe prescription drugs can be helpful?
DR. M - Yes, when used judiciously they can be very helpful. However, once again, no one has a sleep-drug deficiency. The question should be, why can’t they fall asleep on their own each night? Perhaps, it's from pain or low melatonin (sleep hormone) levels, or from medications they are taking. Some drugs, including SSRI (selective serotonin re-uptake inhibitors) like Celexa, Lexapro, Paxil, etc., and tranquilizers including Klonopin, Ativan, etc., decrease and eventually deplete the natural sleep-promoting hormone, melatonin. It makes more sense to use the body’s own natural chemicals needed to promote deep sleep. This includes the amino acid 5-hydroxytryptophan (5HTP), which turns into serotonin, boosts melatonin levels, helps promote deep restorative sleep, reduces pain, boost moods, reduces anxiety, gives you more mental clarity, and reduces or eliminates irritable bowel syndrome.
INT – What about the chronic pain associated with fibromyalgia, how do you treat this condition?
DR. M – Chronic, sometimes disabling, pain is by far the biggest complaint of those with fibromyalgia. Typically someone with fibromyalgia will have diffuse muscle pain that may, or may not, respond to traditional medical therapies. These therapies include non steroidal anti-inflammatory medications (NSAIDS), narcotic pain drugs (Loritab, Darvacet, Duragesics, OxyContin, etc.), tricyclic antidepressants (Elavil, Trazadone, Doxepin, etc.), Selective Serotonin Re-uptake Inhibitors (SSRI’s), Selective Serotonin and Norepinephrine Re-uptake Inhibitors (SSNRI’s), which include Cymbalta and Effexor, and neuropathic drugs including Neurontin (gabapentin), Gabitril, and Lyrica. While these drugs may offer relief for some who take them, they have potential side effects, and quite often don’t help reduce fibromyalgia pain, long term. A person taking NSAIDS is seven times more likely to be hospitalized for gastrointestinal adverse effects. The FDA estimates that 200,000 cases of gastric bleeding occur annually and that this leads to 10,000 to 20,000 deaths each year.
Pain medications, including narcotic drugs, can be very helpful in relieving acute and chronic pain. Unfortunately, pain medications eventually lose their effectiveness, have potential side effects and may cause dependence.
The nerve-pain blocking drugs, or GABA inhibitors such as Gabitril (tiagabine) and Neurontin (gabapentin), are anticonvulsant medications originally used to control seizures. They’re now being used to block nerve-related pain (neuralgia) including pain caused by herpes zoster. The new medication in this category is Lyrica. There are several side effects associated with their use, including somnolence (prolonged drowsiness or a trance-like condition that may continue for a number of days), dizziness, weakness, fatigue, double vision, edema (fluid retention), ataxia (muscular in-coordination), thought disorder, possible long-term ophthalmic problems (abnormal eyeball movements and disorders), tremors, weight gain, back pain, constipation, muscle aches, memory loss, asthenia (weakness), depression, abnormal thinking, itching, involuntary muscle twitching, serious rash, and runny nose.
Don’t these side effects sound like some of the symptoms associated with fibromyalgia?
INT – What about the drug Mirapex? I’ve heard some good things recently.
DR. M – Mirapex (pramipexole) belongs to a class of drugs known as dopamine receptor agonists. Dopamine is a neurotransmitter that helps regulate muscle movement as well as moods and pain. Mirapex was approved in 1997 for the treatment of Parkinson’s Disease. Recently, a study evaluating the effectiveness of Mirapex on the symptoms of fibromyalgia was conducted for the National Fibromyalgia Association. Run by Washington rheumatologist, Dr. Andrew Holman, the study’s results were presented in the journal, Arthritis and Rheumatism. Mirapex patients experienced a greater reduction in symptoms than those receiving the placebo. 42% of those treated with Mirapex experienced at least a 50% reduction in pain symptoms and 82% of patients taking Mirapex experienced some type of symptom relief.
This was a small study of only 60 patients. However, the results do look promising. But, before patients with fibromyalgia rush to get a prescription for Mirapex, please note that many of my patients who’ve tried Mirapex have experienced one or more of the following potential side effects:
Common side effects may include abnormal dreams, arthritis, chest pain, confusion, constipation, decreased sensitivity to touch, difficulty breathing, difficulty walking, dizziness, dizziness upon standing, drowsiness, dry mouth, hallucinations, increased urination, insomnia, involuntary movement (jerky motions), lack of appetite, memory loss, nasal inflammation, nausea, swelling, urinary tract infections, vision abnormalities, and weakness.
Less common side effects may include decreased sex drive, delusions, difficulty swallowing, fever, general feeling of illness, impotence, inability to hold urine, muscle spasms or twitching, pneumonia, skin disorders, thinking abnormalities, uncontrollable restlessness, unfounded suspicions, and weight loss.
Rare side effects may include abnormal ejaculation, abnormal heartbeat, agitation, blood clots, blood in urine, blood circulation problems, convulsions, difficult or painful urination, enlarged abdomen, eye disorders, heart attack, heart problems, joint problems, lung problems, mental illness, muscular problems, prostate problems, severe chest pain (angina), and thirst.
Interestingly enough, the makers of Mirapex routinely mention that the side effects to Mirapex are mild and may include nausea and weight loss. Weight loss as a side effect is very appealing to some patients. But the point is, these pharmaceutical reps and the information that is presented in commercials don’t accurately convey all the potential side effects, even the common ones like joint pain, breathing difficulties, insomnia, tremors, etc.
The muscle relaxer Zanaflex was once the "latest and greatest" drug for fibromyalgia. It was being prescribed to fibro patients like candy to a baby. Unfortunately, Zanaflex doesn’t promote deep restorative sleep and has caused at least 6 deaths due to liver failure.
Those who want to try Mirapex should do so. However, I think patients should be informed about the potential side effects. This goes for all medications. When was the last time your doctor explained how a drug worked, why they were prescribing it, and the potential side effects? There are good drugs that may offer symptom relief and are appropriate for those with fibromyalgia. And there drugs that should never be recommend for fibromyalgia due to their potential side effects. I go into great detail about the good and bad drugs in my Patients Self-Help Manual for Treating and Beating Fibromyalgia and Chronic Fatigue Syndrome. Many of my patients are taking drugs that are actually causing their problems with depression, fatigue, pain, anxiety, etc.
INT – Good point. But, what about chronic pain, isn’t it human nature for individuals to do about anything to get out of pain?
DR. M – Yes, I believe it is human nature to want to feel better right away. But typically pain is like many bodily symptoms, a sign that something has gone wrong in the body’s own self-regulating healing ability. Symptoms are a way for the body to get our attention. The source of chronic pain can be a mystery, especially if there are no known autoimmune factors involved (rheumatoid, lupus, etc.). Osteoarthritis (wear and tear arthritis) can complicate the chronic muscle pain seen in fibromyalgia patients. The many causes for chronic pain and inflammation should be explored until each one has been found and corrected. Food allergies, leaky gut, excess omega 6, stress, viruses, bacteria, mycoplasma, and heavy metal overload, are only a handful of the many potential causes of pain. Low levels of NSAIDS are one of the causes of pain.
Research has shown that low serotonin levels increase the amount of pain a person experiences. Research also shows that poor sleep can increase inflammatory and pain producing chemicals (cytokines) by 40%. Therefore, a consistent good night's sleep is the first place to start in reducing pain.
Serotonin, a neurotransmitter, helps regulate sleep, digestion, pain, mood, and mental clarity. Normal serotonin levels helps:
• raise the pain threshold (have less pain).
• you to fall asleep and stay asleep through the night.
• regulate moods. It is known as “the happy hormone.”
• reduce sugar cravings and over-eating.
• increase a person’s mental abilities.
• regulate normal gut motility (transportation of food-stuff) and irritable bowel
syndrome (IBS).
Serotonin helps boost melatonin levels.
Melatonin is the primary hormone of the pineal gland and acts to regulate the body’s circadian rhythm, especially the sleep/wake cycle. Serotonin turns into melatonin, which then promotes deep restorative sleep.
What Can Decrease Melatonin Levels?
• exposure to bright lights at night
• exposure to electromagnetic fields including TV and computer monitors
• NSAIDs (Celebrex, Vioxx, Mobic, Alleve, Bextra, etc.)
• SSRIs, yes the very same antidepressants that many take for FMS and CFS including Prozac, Zoloft, Celexa, Paxil, and Lexapro.
• Anxiety meds (benzodiazepines) like Klonopin, Ativan, Xanax, Restoril, etc.
• Anti-hypertensive meds including, Inderal, Torprol, Tenormin, Lorpressor, etc.
• Steroids
• Over 3 mg. of vitamin B12 in a day.
• Caffeine
• Alcohol
• Tobacco
• Evening exercise (for up to three hours afterwards)
• Depression
INT – Most of the people I know with fibromyalgia are taking prescription antidepressants. Do you think these are helpful?
DR. M – I go into a great deal of detail about why these drugs, including SSRI’s, usually don’t work over time and how they can cause depression, anxiety, and can permanently deplete serotonin brain receptors. SSRIS don’t make serotonin they only help a person hang on to and use the serotonin they already have. Unfortunately, most individuals with fibromyalgia don’t have any serotonin. There is nothing to re-uptake! No one has a SSRI (prescription anti-depressant) deficiency. They may have a 5HTP, L-Phenylalanine, or SAMe deficiency, which are the amino acids that make serotonin, norepinephrine, and dopamine.
Studies comparing 5HTP to prescription antidepressants generally used to treat fibromyalgia, including tricyclic drugs (Elavil) and SSRIs, showed 5HTP to be as or more effective than prescription medications.
INT – Do patients have to stop taking their prescription antidepressants before starting one of the amino acids you recommend?
DR. M – No, patients can combine prescription antidepressants with 5HTP, SAMe and amino acids. In fact, one European study showed that the combination of MAOIs, such as Nardil or Parnate, with 5HTP significantly improved FMS symptoms, whereas other antidepressant treatments were not effective.
INT – Are there other natural pain remedies that you recommend?
DR. M – There are several, but along with restoring some ones deep restorative sleep, the amino acids SAMe and DL-Phenyalanine are two good options. Before starting my detective work to find other causes of pain, I like to have my patients try one of these first.
S-adenosyl-l-methionine (SAMe)
Several studies involving SAMe and fibromyalgia patients yielded substantial improvement in over all pain levels (as well as depression).
S-adenosyl-l-methionine (SAMe) comes from the amino acid methionine and acts as a natural anti-inflammatory and blocks pain without the side effects associated with NSAIDs. SAMe helps boost serotonin and epinephrine levels (boosts energy and are potent antidepressants). It also helps increase the production of endorphins. Endorphins are the body’s natural pain blocking chemicals and are more powerful than morphine.
DL-Phenylalanine
DL-Phenylalanine is a combination of the D and L form of the amino acid phenylalanine. DL-phenylalanine blocks the enzymes responsible for the breakdown of endorphins and enkephlins, substances within the body that help relieve pain. One clinical study shows subjects taking DL-phenylalanine had a remarkable improvement in their condition. Improvements were seen in 73% of low back pain suffers, 67% with migraines, 81% with osteoarthritis, and 81% with rheumatoid arthritis.
There are several other options in reducing pain and inflammation including, high doses fish oil, glucosamine sulfate, malic acid, high doses of magnesium, MSM, repairing leaky gut, and hands-on therapies like chiropractic, physical therapy, and massage therapy.
INT – What about the fatigue that goes with fibromyalgia? What causes this debilitating fatigue that fibromyalgia patients complain of?
DR. M – There are a variety of reasons for the fatigue seen in fibromyalgia. Certainly poor sleep is one of them. However, low norepinephrine levels are a common occurrence. Many of my fibromyalgia patients have experienced stressful lives that eventually deplete their stress-coping glands, the adrenals, of the stress-coping hormones cortisol and DHEA. And studies show that 40% of those with fibromyalgia also suffer from low thyroid function.
INT – Ok, where do you start?
DR. M – Reestablishing deep restorative sleep is the first priority. Preferrably with 5HTP and melatonin if needed. Prescription drugs that do promote deep restorative sleep (Elavil, Trazadone, Ambien, Lunesta, and Flexeril) should be the last resort and should be taken with 5HTP. Then repairing adrenal hormones deficiencies are probably the next step to establishing healthy energy levels.
Adrenal fatigue is known to cause many of the same problems associated with CFS and FMS:
• hypoglycemia (low blood sugar)
• hypotension(low blood pressure)
• neural mediated hypotension (become dizzy when stand up)
• fatigue
• decreased mental acuity
• low body temperature (a sign of low thyroid function)
• decreased metabolism
• a compromised immune system
• decreased sense of well-being (depression)
• weight loss
• hyperpigmentation (excess skin color changes)
• loss of scalp hair
• excess facial or body hair
• vitiligo (changes in skin color)
• auricular calcification (little calcium deposits in the ear lobe)
• GI disturbances
• nausea
• vomiting
• constipation
• abdominal pain
• diarrhea
• crave salty foods
• muscle or joint pains
Individuals with fibromyalgia who suffer from adrenal fatigue (99%) will find that their stress-coping abilities are shot. They don’t handle stress very well. They will try to avoid stressful situations. Stress will make their symptoms worse and cause them to have flare-ups.
If they have a day when they feel good they may over do it (clean the house, paint the playroom, grocery shopping, etc.). Then they usually crash the next day. Therefore, restoring proper adrenal function is a crucial step in building up a person stress coping abilities. I believe that adrenal fatigue is a major contributory factor to the symptoms associated with fibromyalgia
INT – What do you recommend to restore normal adrenal function?
DR. M – I’ve used the prescription drug cortisol in the past, but now recommend my patients use over the counter adrenal cortex glandular supplements. These help repair and restore normal adrenal function and were the first medicines to be used before the synthetic drugs came along. They have few, if any, side effects when taken at low doses and unlike prescription cortisol, once adrenal function has been normalized (usually within 6-12 months) they can be discontinued with out fear of relapse.
Most individuals with fibromyalgia will also suffer from low norepinephrine levels. Those with low norepinephrine levels will have low energy, find it hard to “get going,” suffer from a decreased sex drive, are bored, and often feel they need to hibernate and get away from it
all.
INT – Effexor, Wellbutren, and Cymbalta help boost norepinephrine levels, right?
DR. M – Yes and no. Remember these drugs are like gasoline additives. They don’t make the neurotransmitter norepinephrine, they only help the brain hang on to the norepinephrine it already has. Once again, patients with chronic illnesses like fibromyalgia have usually depleted their neurotransmitters (brain chemicals) including norepinephrine. A prescription drug that acts as a gasoline additive won’t do much if there is no gasoline (norepinephrine) in the tank (brain). I like to use the amino acid SAMe which boosts norepinephrine levels. SAMe has been shown to quickly and safely elevate norepinephrine levels. I find that my patients notice a difference within 2-3 days after starting SAMe. And SAMe has pain blocking abilities as well as acting as a powerful liver antioxidant.
INT - You mentioned low thyroid, can you discuss this a little further?
DR. M – Studies have shown that as many as 63% of fibromyalgia patients suffer from some degree of hypothyroidism, a percentage much higher than that of the general population. These symptoms can include severe fatigue, headache and migraine, PMS, easy weight gain, fluid retention, irritability, anxiety, panic attacks, depression, decreased memory and concentration, hair loss, decreased sex drive, unhealthy nails, constipation, irritable bowel syndrome, dry skin, dry hair, cold and/or heat intolerance, low self-esteem, irregular periods, chronic or repeated infections, and many other complaints.
INT – Ok, should all these fibromyalgia patients be placed on prescription thyroid hormones?
DR. M – Individuals with true hypothyroidism (TSH levels above 3.04) may find that synthetic T4 thyroid hormones (Synthroid, Levothyroid, Levoxyl, etc.) help reduce or eliminate many of their low thyroid symptoms, including fatigue. Unfortunately, the majority of my patients who have symptoms of hypothyroid, have normal blood tests. Blood tests for thyroid function are often inaccurate since the tests measure how much thyroid hormone is in the blood stream and not how much is in the cells of the body. Thyroid hormone doesn’t do anything in the bloodstream. It only works when it gets in the cell. Blood tests don’t show us if thyroid hormone is in the cell. Therefore we must make an educated guess that if “x” amount of thyroid hormone is seen in the blood then “x” amount must be in the cell. However, chronic stress not only reduces thyroid function it also increases a hormone known as reverse T3 which blocks thyroxine, or T4, from becoming the more active triiodothyroxine (T3). It’s not unusual for me to see my patients who take T4 medications, including Synthroid, benefiting little from their prescription, while their low thyroid symptoms actually become worse over the years. They return to their doctor to have their blood tested and dose adjusted only to feel no better than they did before starting the medication.
INT – If blood tests may be inaccurate, what can patients do to see if they have low thyroid?
DR. M I recommend they monitor their body temperature, which was one of the original ways used to diagnose hypothyroid. Body temperature is determined by our metabolism (cellular energy) and thyroid hormones control metabolism. A temperature taken under the arm or under the tongue of 97.8 or below is a sign of low thyroid and should be treated no matter what the blood test shows.
INT- Thank you Dr. Murphree, I look forward to your upcoming presentation.</>
There is quite a bit of information in this interview. I didn’t have time to go into all the details and didn’t get to address digestive disorders like reflux, bloating, gas, and indigestion, which are common in fibromyalgia patients.
Here are some excellent resources for you and links to many of the items I talked about in this interview.
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