Friday Tidbits: Interview #2 with my Fibro & Pain Specialist

Most definitely: tongue-in-cheek! NOT the med needed for knee pain!

Today I thought I'd talk to my rheumatologist about a seemingly never-ending question of mine - that is, regarding the intensely nightmarish experience I had with Cymbalta. Recently I happened to be present when my GP and my rheumy were talking about Cymbalta and something that was said struck me.  That is, that Cymbalta, an antidepressant, was OK'd by the FDA for treatment of chronic painful musculoskeletal conditions such as arthritis and low back pain. 

Before going on, let me give you the link to our guest's credentials (here!!).  It's simply too tedious to go through all of his qualifications.  And for background on my experiences with Cymbalta, you may go here through many other posts, here where I thought it had a been a good lesson to out-right anger through to suffering like I'd never done before, ending around here.  For those of you who are masochists, there is the search box which will give you more than you ever wanted to know, I'm afraid!   

Now for the interview.

Upa:  Hi, Doc. Thanks so much for agreeing to indulge me with an interview about some of your insight into Cymbalta.  I suppose I should make it clear that you never prescribed it for me, nor did my GP, but instead, a psychiatrist in the hospital did.  You and my GP seem to have been surprised with my reaction to getting off a medication which I'd only taken for three weeks.  Feel free to start wherever you'd like.

Doc:  Hello. It's my pleasure to talk to you. [Upa laughs, knowing better.]  Cymbalta is a psychotropic medication that inhibits the re-uptake of two important neurotransmitters in the brain, serotonin and norepinephrine.  It was first approved for the treatment of depression but that's not surprising since manipulation of those neurotransmitters can affect mood.  When Cymbalta was approved for the treatment of fibromyalgia, however, I was not too surprised because fibromyalgia is thought to be a pain condition that is intimately associated with brain neurochemicals.  I was, however, taken aback by the FDA approving this "mind drug" for patients with mechanical musculoskeletal problems like arthitis and lower back pain.  

Upa:  May I ask you, so we're on the same page here, what IS the difference between musculoskeletal pain and fibro?

Doc: With fibromyalgia, your elbow, for example, might hurt, but it is not swollen nor deformed.   With arthritis, on the other hand, the problem is localized to a particular joint or joints and there is inflammation, the joint is warm to the touch and is swollen.  I don't understand why someone would think that a psychotropic medication like Cymbalta would be the go-to medication for a condition like arthritis.  

Upa:  Can you explain this a bit more in detail?

Doc: In their zeal to find a non-narcotic medication for certain painful conditions, the pharmaceutical companies have tried many different types of medications to treat pain. We already have very effective ways to treat osteoarthritis knees, for example, including narcotic medications which, when taken as prescribed, are fairly safe and effective.  If the run-of-the-mill, not psychologically-impaired patient were to be put on Cymbalta, he might run the risk of such side effects as suicidal ideation, or behavior.  If Cymbalta were ineffective, the withdrawal from that drug may be much harder to tolerate than even withdrawal from narcotics.  

Upa: This answer leads me to want to ask so many questions that I barely know where to begin!  There's always the narcotic question, there's fibromyalgia vs musculoskeletal pain and there are the Cymbalta side effects and withdrawal - and that's just for starters. Perhaps you'd like to choose where to go! 

Doc: Let's talk a little bit about the medications.

Upa: Yes. And I do understand that you do prescribe Cymbalta to some patients.  How do you make that decision?  And what sort of luck have you found?

Doc:  I certainly am aware that Cymbalta is approved for fibromyalgia, however, when I prescribe Cymbalta it is typically for fibromyalgia patients who are depressed.  I am prescribing it more for the depression than for the fibromyalgia pain.  It works well for some patients but is not effective in everyone and I have noticed that when these patients stop the Cymbalta they have very odd symptoms such as palpitations, anxiety, numbness and tingling and the like.  The bottom line is, we simply don't know the long-term effects of Cymbalta nor do we have enough information on withdrawal symptoms, so this drug should be used with caution.  This is in contrast to what we know about narcotics.  They have been around a long time and their effects and withdrawal symptoms are well known.

Upa: So, you're not really surprised that I had that horrible and lengthy reaction to Cymbalta?  And I suppose you don't agree with the thinking of the shrink who said that at least I wouldn't care if I had pain or not? (Sorry: but you know I always have to push the line!)

Doc: No, I was not surprised you had such problems from Cymbalta and a lengthy withdrawal from it. Cymbalta is a VERY powerful medication which affects two brain neurotransmitters, as I stated previously. Why wouldn't you have potential problems from such a strong psychotropic medication?  I am flabbergasted that some individuals, including doctors, fear narcotics but embrace medicines like Cymbalta, proclaiming that the later medication is so much safer than the former.  Even among antidepressants, there seems to be a general feeling in the medical community that medicines like Prozac, Zofolt and Effexor don't have the same risks as Cymbalta.  However, this is my take on it.  I've not done a study but I've been in practice for 31 years and have seen a huge number of patients taking anti-depressants, but I have not seen such severe side effects as patients taking Cymbalta. 

Upa:  Thank you so much for taking this time to clear up some questions I've had on my mind. There are certainly more questions I do have but perhaps you'll return for another session?

Doc: It's always a pleasure.  Call me in the future if you need to. 

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And there you have it, the thoughts of an fibro specialist and pioneer with a very active and long-lived practice.  I hope this offers some of my readers insight and help.  It has for me.

As always, I hope everyone's doing their very best - only better!  Ciao and paka.



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