Marijuana: Well isn't this just fun. Maybe the Government well get the hell out of the way.

https://community.breastcancer.org/forum/73/topics/840463?page=1#post_4617216

Leslie, your's is an important post for many reasons. Pain isn't just one thing/area/type in a chronic situation. Those of us with chronic pain would love to have 'just one area'. My joke when they ask me my pain level is 'which body part'. They laugh, I laugh. They want a number because it's required. They have one box. I'm serious, but know it's one box. They don't get that that's real re: which body part. Cynically, I know they're isn't much caring. They want to finish the interview and move on.

Let's get to your post. You have much to teach us. Your words. " I had my L4/L5 disc rupture in my early 30's and couldn't walk. The pain was so bad that if I couldn't get relief I would have killed myself. That's my measure of level 10. I had to wait three days to get into surgery and they were the longest days of my life.". This is over for you and I'm sorry that you had to experience this. You are an example of what I refer to as aggressive pain management in the hospital setting.

You should have been on several modalities to control your pain

1. Patient Controlled Analgesia PCA. It can be set at a maintenance dose with order for boluses at intervals if pain not controlled. That takes team work between the nurse and patient to make control happen.

2. Benzodiazipine muscle relaxer Valium. Has to be used carefully with a PCA because respiratory depression is a potential. General order is '5-10 mg every 6 hrs prn' This is a weakness generally on the nurses part. It's written as a prn( as necessary). The prn part is that they are to use 'judgement/critical analysis' to determine when to give. Not sure if in 2016 nurses have come to understand the beauty of Valium in skeletal muscle spasm. They can talk of it's antianxiety characteristics, but our generally 'brain void' of it's skeletal muscle action.

What happens when a bone causes pain, is the muscles around it go into protective mode. Spasm. This may have been protective in Neolithic times, now it's counterproductive. Spasming causes pain in and of itself. Causes a system response of increasing stress chemicals. Increases the inflammatory response. The whole body suffers.

Breaking the spasms associated with orthopedic problems helps with reducing pain. Judicious use of valium is important. Sadly, to many practitoners, don't understand this. This is something that should be carefully addressed with the doc preop and ask that direct instructions be given to the nurses.

I believe you went to the block thread. Ask your doc to determine what kind of localized blocks can be used. They're many. Injection of Marcaine directly into the incisional area. Localized infusing balls that deliver a 'caine' that directly affect the tissue. Generally used for 24-48(72) hours. They're may be more blocks that I don't know of.

The key is ask for a discussion. The beauty of these localized modalities allow you less use of systemic drugs. Safer approach.

Do you have a different orthopedic doc? Your words " The left was botched in 2010, and left me with Meralgia Parasthetica. It was revised 2013 and the stem hadn't integrated into the bone as it was too small and retroverted" I've been in the OR I've watched how they measure for the prosthesis. Too small, perhaps shouldn't have happened? Not familiar with the word retroverted in this context, but seems the sizing and placement wasn't done well. Hope a new doc is involved.

My description of a 4-6 in chronic pain is a middle ground. Us chronics learn to live there. For someone new to pain, they might describe it as greater. i.e. ten. Not to diminish them, but rookie painers (just made that up) have no reference and it is awful to them. If they get back to zero because every thing went right, they will always perceived it a 10. If they don't get back to zero, they will eventually slide into the 4-6 as the mind learns how to deal with it and become a chronic

For completeness, they're those that 10 is an issue as in Reflexive Sympathetic Dystrophy-RSD, now know as Chronic Regional Pain Syndrome-CRPS. Regretfully, these folks are in the 10 range. This an unusual pain syndrome. Hopefully discussed later.

With your pain doc that has a problem with people appearing to walk and sit comfortably and call themselves a ten. Ask him to review what is written here regarding the pain scale. Perhaps teaching them the basics of the scale will help.

But he is very right. They're are physical signs of pain that went put together with the pain scale can quide how pain is managed. I often just observe people walking across a parking lot and I can pick out hip, knee, back problems just by how they walk. There deliberateness of how they walk gives me a clue how much pain they are in.

Leslie Your words again " Distraction tops the list." Please, describe in detail the situations that cause you to use distractions and what they are besides warm water. Thanks, don't think your stories long. You never know when a description triggers in another a recognition that it applies to them. Thanks.

Oh well, Thank you LadyB appreciate your appreciation !

Magic Hi welcome here, Saw your post and been mulling it over. You make allot of great points. Eventually it will happen here. I can say that with surety because I've done it before on several threads. My approach is to lay the groundwork. Then once it's done, move on to conversation. The groundwork here is to describe a historical perspective on pain management. Then the tools to get someone going on how to document their pain and communicate the info to their care team.

The historical look is important b/c even now in 2016 the average doc and nurse does not help manage pain as good as it can be done. Unless folks/patients understand this, they won't know this weakness is pervasive. Then we can learn how to train our docs & nurses to manage our pain well. They're has been great advancements since the 1980's, but we can do better.

Take a look at the Constipation thread. 30 some pages talking poop. I started with the technical and then it took off from there. It incorporates Evidenced Based material, Complimentary/ Alternative, and punning.

I'm starting off slow, b/c I'm slowing down these days. Would welcome you to stay and post material too. On the constipation thread they're several that mentor on that thread. Same with the Toradol thread, and Pinktober. In each place members have an interest.

https://community.breastcancer.org/forum/6/topics/781867?page=1 constipation thread

https://community.breastcancer.org/forum/73/topics/833612?page=1 Toradol thread.

Ah reminded me they're should be a poop column on the pain chart

Hi Rosieo, nice to see you Anything you need help with?

Workup Approach Considerations

The physician should inform the patient that no cure exists for fibromyalgia but that education, lifestyle changes including regular physical activity, and proper medications can help the individual to regain control and achieve significant improvement.^[95] When patients with fibromyalgia fully understand the nature of the disease, they are more likely to comply with treatment and to take an active role in managing the disease.

At the initial visit, give patients educational materials about fibromyalgia, including a list of resources, such as Web sites, books, videotapes, newsletters, and brochures, related to the disease. Some authors recommend encouraging patients to attend their local fibromyalgia support group. Provide education and support to the patient's significant family members.

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Therapeutic recommendations for fibromyalgia can now be based almost entirely on evidence from well-designed randomized controlled trials. Models of pain behavior that interrelate biologic, cognitive, emotional, and behavioral variables form the basis for cognitive-behavioral and operant-behavioral approaches to pain management. Wood published a useful summary of therapeutic approaches to central sensitivity syndrome (CSS) comorbidities in fibromyalgia.^[96]

The first crucial element in the treatment of pain, fatigue, and other diverse symptoms in patients with fibromyalgia is for the clinician to validate the patient's illness through empathetic listening and acknowledgment that the patient is indeed experiencing pain.^{[26, 32, 97, 98, 99, 100, 101, 102, 103]} Comments such as "it's all in your mind" or "I cannot find anything wrong with you" only add to the patient's frustration.

Avoid excessive use of physical therapy modalities after minor trauma, excessive activity limitation, and overly liberal work release. Be aware of confounders to recovery, such as pending litigation or compensation claims.

The overall approach for chronic pain in fibromyalgia involves a multifaceted treatment plan that incorporates various adjuvant medicines, aerobic and resistance exercise, and psychological and behavioral approaches to reduce distress and promote self-efficacy and self-management (eg, relaxation training, activity pacing, visual imagery, distraction).

If significant nociceptive pain coexists with the diffuse chronic pain of fibromyalgia, manage it pharmacologically with non-narcotic medications such as antidepressants, anticonvulsants, or muscle relaxers. For associated regional chronic pain syndromes (eg, temporomandibular disorder), referral to an experienced specialist who advocates nonsurgical approaches is recommended.

In a systematic review by Häuser of 1119 patients in 9 randomized controlled trials, multicomponent treatment (at least 1 form of educational or other psychological therapy plus at least 1 form of exercise therapy) yielded short-term benefits for the symptoms of pain, fatigue, depression, and quality of life. They found no evidence that these symptomatic benefits were durable in the long term, but strong evidence suggested that multicomponent therapy conferred a long-term benefit to maintenance of physical fitness.^[104]

Poor sleep is virtually universal in fibromyalgia and contributes importantly to pain, depression, and fatigue. Accurate diagnosis and pharmacologic and nonpharmacologic management are essential.^{[105, 106, 107]}

Trigger point injections, acupuncture, chiropractic manipulation, and myofascial release are usually well received by patients and can be beneficial, but results are not long lasting. In addition, patients may not be able to afford long-term therapy since these are sometimes not covered my insurance.

A possible etiologic link between Chiari malformation and fibromyalgia has been suggested. However, no generally accepted evidence indicates that skull surgery for correction of Chiari malformation is of benefit in patients with fibromyalgia and

Approach Considerations continued

Patients with fibromyalgia do not have characteristic or consistent abnormalities on laboratory testing. However, routine laboratory and imaging studies are important to help rule out diseases with similar manifestations and to assist in diagnosis of certain inflammatory diseases that frequently coexist with fibromyalgia. In addition to complete blood cell (CBC) count and differential count, basic metabolic panel, and urinalysis, the following limited evaluation is reasonable.

• Thyroid-stimulating hormone: Hypothyroidism shares many clinical features with fibromyalgia, especially diffuse muscle pain and fatigue
• 25-Hydroxy vitamin D level: Low levels can cause muscle pain and tenderness
• Vitamin B-12 level: Very low levels can cause pain and fatigue
• Iron studies including iron, total iron binding capacity, percent saturation, and serum ferritin: Low levels can cause fatigue and can lead to poor sleep and depressive symptoms; for patients with restless legs syndrome, percent saturation should be maintained above 20% and serum ferritin should be kept above 50 ng/mL
• Magnesium: Low levels can lead to muscle spasms, which are common in fibromyalgia patients; magnesium supplementation can also improve symptoms in some fibromyalgia patients; recommended magnesium levels in fibromyalgia patients are at least 2 mEq/L

The erythrocyte sedimentation rate (ESR) is often recommended as a routine laboratory test in fibromyalgia patients to rule out the presence of inflammatory disorders that may mimic symptoms. While the ESR is usually normal in patients with fibromyalgia, it is a nonspecific measure of inflammation and mild elevations may not be meaningful. The upper limit of normal for the ESR in women is half their age (eg, a level of 40 in an 80-year-old women is normal),and in men is half their age minus 10. The ESR can also be mildly elevated in obese patients. However, a high ESR may be indicative of an inflammatory disorder or occult malignancy that should be thoroughly evaluated.

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Routine antinuclear antibody (ANA) or rheumatoid factor (RF) testing in not recommended unless patients have signs or symptoms concerning for systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). A low-titer positive ANA or RF level is common in the general population, so these findings may be of no clinical significance in a fibromyalgia patient.

Formal sleep studies may be useful in patients whose sleep does not improve with the usual conservative measures (eg, elimination of caffeine, prescription of hypnotics or nighttime tricyclics). These studies can be performed as part of a formal assessment by a neurologist or pulmonologist experienced in sleep disorders.

Serum transferrin saturation and serum ferritin screening can be useful for detecting the unusual cases of hemochromatosis in which patients present with diffuse arthralgias and myalgias. Consider screening with a serum transferrin saturation and a serum ferritin concentration in patients aged 40-60 years, especially those with small-joint arthropathy in the hands and/or calcium pyrophosphate dihydrate deposition disease (CPPD).

The antipolymer antibody assay is a blood test. Antipolymer antibodies are present in approximately 50% of patients with fibromyalgia. This biologic marker may provide conclusive evidence for a subgroup of people with fibromyalgia.

There are no histologic abnormalities seen in fibromyalgia syndrome. Earlier belief that fibromyalgia was associated with inflammation in muscle fascia has been disproven.

Carefully assess all possible causal or perpetuating factors. Investigate psychological and sociocultural factors and identify any specific regional sources of ongoing nociceptive pain (eg, degenerative spondylosis, bursitis).

Medication Summary

Medication summary

Always combine pharmacologic approaches with nonpharmacologic therapy in the treatment of fibromyalgia (FM), especially stress management, aerobic exercise, and, in some cases, psychotherapy. Aggressively treat comorbid depression.

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Tricyclic antidepressants (TCAs) are of proven benefit. Certain anticonvulsants and antidepressants clearly decrease pain sensitivity. Corticosteroids and nonsteroidal anti-inflammatory medications are useful only as management for coexisting inflammatory processes. Pharmacologic and nonpharmacologic treatment of poor sleep is crucial for improving the patient's overall sense of well-being.

Anecdotally, dextromethorphan, an N -methyl-D-aspartate (NMDA) receptor antagonist available as an over-the-counter (OTC) antitussive, is beneficial as adjunctive therapy in patients with fibromyalgia. Topical capsaicin, obtained from red chili peppers, is essentially free of toxicity, other than mild burning at the site of application, and is useful as adjunctive therapy in combination with gentle massage.

Beta-blockers and/or increased fluid and sodium/potassium intake may benefit a subset of patients with fibromyalgia who have orthostatic hypotension, palpitation, and vasomotor instability. Growth hormone and cytokine therapies are still experimental.^[119]

Patients with fibromyalgia have difficulty tolerating regular doses of most medications and supplements. They are sensitive to medications, and adverse effects are common. To avoid these problems, use the lowest dose available or perhaps one half to one quarter of the lowest recommended dose.

The US Food and Drug Administration (FDA) has approved three drugs for use in fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). Pregabalin is used to reduce pain and improve sleep. The antidepressants duloxetine and milnacipran, which are used to relieve pain, fatigue, and sleep problems, are generally used at lower doses than for treatment of depression.

Several medications should be avoided or used carefully. Opioids, hypnotics, anxiolytics, and certain skeletal-muscle relaxants must be used with caution because of the potential for abuse.

A trial of tramadol may be considered for second-line therapy in patients with moderate to severe pain that is unresponsive to other treatments.^{[95, 120]} In a 12-month observational study of opioid use in 1700 adult patients with fibromyalgia, tramadol proved superior to other opioids for improving pain-related interference with daily living, functioning, depression, and insomnia.^[121]

Avoid complications and confusion by providing written instructions and drug information. These instructions need to be easy to understand. Patients should be instructed to consult their physician before starting any over-the-counter (OTC) medications or supplements, to avoid potentially harmful drug interactions.

Integrative medicine

Integrative medicine (complementary and altenative medicine [CAM]) is popular in patients with fibromyalgia, in part due to medical skepticism (ie, doubt in the ability of conventional medical care to appreciably alter health status).^[122] Many physicians are ignorant of, if not overtly hostile toward, integrative medicine, and patients are often reluctant to inform their physician about their use of it. This can be dangerous because of unsuspected drug-to-drug interactions.

A practical approach is to inquire about integrative medicine usage, to refrain from expression of negative opinions if a particular integrative treatment is relatively inexpensive and appears to be safe, and to encourage whatever works in the context of the power of the placebo effect and promotion of self-efficacy for pain control.

Analgesics

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are of limited efficacy in reducing pain due to fibromyalgia but are important adjuncts for nociceptive pain generators, such as osteoarthritis and degenerative spondylosis.^[123] Topical anesthesia with lidocaine (5% Lidoderm patch) can also be helpful in this regard. Tramadol, a weak opioid agonist with additional effects on serotonin and norepinephrine receptors, improves pain associated with fibromyalgia.

Opioid analgesics with more potency (eg, hydrocodone, oxycodone, fentanyl, morphine), although frequently prescribed in patients with fibromyalgia, appear to be of limited efficacy in most patients with this disorder and are generally not recommended. However, in addition to utility in the treatment of severe nociceptive pain (eg, radicular pain, advanced osteoarthritis of the knee), opioid analgesics may reduce pain, improve quality of life, and occasionally restore function in a patient with fibromyalgia who has severe allodynia and who has not responded to other approaches.

More often, rheumatologists discover that patients with fibromyalgia are already taking very high doses of opioids prescribed by their family physician. The task is then to gradually withdraw opioids, if possible, or perhaps switch therapy to reasonable doses of methadone (eg, 5-10 mg tid). Tapering takes 2-3 weeks; clonidine, 0.2-0.4 mg/day, is helpful for controlling withdrawal symptoms. Remember that opioid-induced hyperalgesia can be a paradoxical complication of high-dose opioid therapy.

Monitoring of patients receiving opioid medications requires frequent reevaluation for efficacy, improvement in daily functioning, and adverse effects during initiation, titration, and maintenance therapy, especially in older patients. The patient should sign a "narcotics contract" that specifies the following:

• One prescribing physician
• One dispensing pharmacy
• Acceptance of no early prescription of opioids if the medication runs out early or is lost or stolen
• Agreement for random urine testing

Other medications

The selective estrogen receptor modulator raloxifene (Evista), 60 mg every other day, is effective in improving pain, improving fatigue, reducing tender-point count, and improving daily functioning in postmenopausal women with fibromyalgia.^[124] Modafinil (Provigil), approved for narcolepsy and shift-work sleep disorder, 100-200 mg in the morning, improves fatigue and cognitive disturbances.^{[125, 126]}

Preliminary data suggest that the synthetic cannabinoid nabilone (Cesamet) in doses escalating from 0.5 mg daily to 1 mg twice daily improves pain and anxiety in fibromyalgia.^[127] Beta-adrenergic antagonists such as pindolol or propranolol (Inderal), given in low doses at bedtime, can also improve pain and agitation.^[117]

Other medications used in fibromyalgia may include the following:

• Vitamins and minerals
• Malic acid and magnesium combination
• Antioxidants
• Amino acids
• Herbs and supplements

Fibromyalgia

Corky, Your welcome on the pain info. It was from WebMD.I didn't reinvent the wheel. It's appropriate to bring it here rather than clicking back and forth. Easy for us to talk about the different sections.

The advent of pain management was a good thing. But they're were people, docs and patients, that abused the system. The tight controls you've seen at the pain docs office are now the standard because of that abuse. Rather than thinking they are treating you as an addict, think of them as trying to protect the majority from those that would wreak the system if they could by abusing.

Yes it's important to be as educated about your problem as possible. You will then know how well your doc is systematically evaluating you. Docs know when your educated. Some dislike it. That's okay if they are still doing their job. If they aren't ditch them fast.
A really good doc will see you as a partner in trying to solve this.

Important that you start journaling. Use the pain chart. Yours will be different however. With Fibro we have so many body parts that hurt. I laugh when asked my pain level. I usually respond with "which part". The intake person laughs and generally says "I need just one number". They have one box. Right there you know that person hasn't a clue, AND the computer program was developed by clueless people.

What would be more appropriate is to be able to give a score for each body part. What that would allow is to see trends of each area. Once trends were identified, then extend that to evaluating activity that occurred just previous to the trend change(1-4 days). Much Pain & Effect or no Pain &Effect could be seen. If P&E is seen, we change the activity. If no P&E is doesn't mean that there is no reason or the info is useless. We just don't know how to use it yet. Journal. Consider at a big part of your care that will lead to an answer. It will be boring as hell and after a week or so you will want to quit it. Don't, please.

Also, journal what you are eating and type of drink. Again boring, but they're is a connection between food and food intolerances that can lead to pain. With the food journal also document how much total fluids you are drinking. Dehydration can cause pain. Just a note about alcohol it can cause pain.

Next box I will make a pain chart for a fibro person. Then the box after a diet chart.

Hugs Cory. Remind me to reread your post for the micro details. I read it in the Macro sense the first read through.

Corky, had the longest most thorough post to you. Damn gone twice. Irony I was saving it b/c I get nervous with long posts being lost.

Thanks Mags will get to it with the next brain discharge

Corky. The office scope is a piece of cake and you will get the results immediately, unless your doc was different than mine. Ask your Gyn doc if an Endocrine doc would run any different tests than they are running?

CORKY OMD, sounds like a drug den, pill mill. Awful. Please, if you can start the pain record. Problem with Fibro is it's primarily Women's disease and it's still not clearly understood. Which I know you know. Meant for readers that don't know that. I haven't read Mags article yet, but she described it. there has been some success with Rituxin. OH so hope it plays out that way.

Corky, That was my knee jerk reaction about the facility you were in. Florida was notorious for pill mills. Part of why there was a crack down nationally. Every news video that I saw when a raid was shown on TV, the pill mill was in a shady part of town. looked decrepit with people lined up outside. Views of licensed from out of state "patients". It wasn't a good time.

Haven't read the rituxan article yet, likely won't get to it till next week. Big family gathering this weekend. Shoulda been preparing before this.