Thursday, December 13, 2012
A Neurologist's Approach
A Neurologist’s Approach Many neurologists sub-specialize in the treatment of pain. The Fibromyalgia Network asked several different experts to offer their strategies for treating fibromyalgia. Here is one neurologist’s viewpoint on how to address the pain: Benjamin Natelson, M.D. Neurologist New York, NY As a neurologist, I often use anti-epileptic drugs (AEDs) to help control pain. There appears to be an overlapping neurological system involved in epilepsy, depression, and pain, because similar medications seem to exert an impact on those same systems. AEDs are often good at relieving migraines and they are effective at reducing burning pain. However, their ability to treat the dull, achy, widespread pain of fibromyalgia is not easy to predict. I start a person on one AED, and if it helps but the pain is still bad, I will usually add a second AED with a different mechanism of action. If cost is an issue, gabapentin (Neurontin) and lamotrigine (Lamictal) are off-patent and relatively cheap. If a person has insurance, I may prescribe oxycarbazepine (Trileptal) or pregabalin (Lyrica) because they only have to be taken twice a day, while the others must be taken more frequently. AEDs may be sedating and can reduce nighttime pain—effects that can lead to improved sleep. Regardless of which AED I prescribe, I always start patients on the lowest possible dose, taken at night, and then they increase dose every four days as tolerated. It takes two to three months to reach the target dose of 2,400 mg/day of Neurontin (taken in four divided doses). The target dose for Lamictal is 100 mg three times a day, Trileptal is 600 mg twice a day, and Lyrica is 150 mg twice a day. If a patient does not receive any benefit, or the side effects are intolerable, I switch them to a different AED. Patients may benefit from a healthcare professional, or coach, whom they can communicate with about their abilities and illness concerns. Psychologists working at pain management centers/hospitals may be suitable coaches. Specify up-front that you want help coping with your physical symptoms, not just emotional-related counseling, and use the tips below by Dr. O’Reilly. -------------------------------------------------------------------------------- Finding a Therapist by Connie O’Reilly, Ph.D., Beaverton, OR How do you select a good psychologist, particularly one who understands fibromyalgia? Most psychologists are willing to do a brief consult by phone before you schedule an appointment. Others may be able to consult by email, although some are limited due to confidentiality issues. What to Ask a Prospective Psychologist: •What is your experience in working with patients with chronic pain? •Have you worked with patients that have fibromyalgia? •What is your approach in to helping with such patients? In general, it is important that your psychologist have experience with chronic and painful conditions. However, if you get any hint that the therapist feels fibromyalgia is a questionable diagnosis, keep searching. Listen for this: •Does this professional convey respect and empathy for people dealing with chronic medical conditions, including chronic pain and fatigue? •Does this person recognize that chronic illness disrupts multiple areas of your life, causes a tremendous amount of stress, and can result in concurrent depression and anxiety? •Does this person have expertise in specific areas of concern to you? Identify what you want from a therapist. The better you are at communicating what you want, the more likely you will get it. •Does this person sound like a good fit for you? If not, trust your intuition and keep calling. Evidence suggests the therapeutic relationship is the key to a client receiving satisfying results.