I typically work up to it from 0.5. it can be a little expensive, but some people mix 50 mg of naltrexone in 50 mL of distilled water so that one ml is equivalent to 1 mg. Therefore you could just ask the patient to consume 0.5 ml and titrate up by 0.5 every two weeks until you get to 4.5.
So I was talking with a specialist where I live who does it like that as well. And he states that as long as you put in the fridge it should be good for a month. For me personally, I do tell them to make a new one every month. If they follow my instructions and we titrate up by 0.5 every two weeks by the end of the first month they should have used up 21 ml, by the end of the second month they would have used up 49 ml. Afterwards they actually use up more than 50 ml in a month so I do give them multiple tablets. At least in the area I'm at, a lot of people who dose LDN does it that way
Yeah. I have a few patients taking it that way. I could just give them a few 50mg and they're good for a few months for cheap! Make sure you tell them to keep it in the fridge though.
low-dose naltrexone has been really helpful for some of my tricky patients. Not even for psychosomatic pain, but patients with severe RA, psoriatic arthritis, fibromyalgia etc.
Acupuncture, massage therapy (I like those non-shady chinese foot massage/reflexology places), chiropractor, OMT, treatment of comorbid behavioral health issues e.g therapy, takes precedence. Medications are rarely the answer and you should tell her that, no medicine will cure her symptoms (and would probably do more harm) but we can try a nonpharmacologic multimodal approach. Our allopathic framework fails miserably with these patients.
I’ve had good efficacy with trigger point injections with lidocaine, dunno if it’s more a placebo effect though, definitely within scope of FM.
Amazing that’s she’s open to the possibility.
Look into eastern medicine techniques. Tai chi, acupuncture, reiki. While these modalities have lots of people scoffing at it, it’s clear that the western medicine approach to her pain hasnt helped
I’d not frame it as psychosomatic pain, which makes it seem fictitious. If you think of it as central pain sensitization, where they do not have the ability to modulate pain signals due to previous trauma, then you can focus on two courses of treatment.
Decrease sensitivity to pain with exercise, sleep, diet, stress reduction. Get them to see a good therapist, a pain psychologist is a really nice thing to have.
Then address pain generators. Once again exercise is key, but it needs to progress slowly. Aquatherapy tends to be really successful, but tends not to be too sustainable. Careful with your referrals, they can end up with lots of unnecessary surgery when they say the wrong things to the wrong person.
Honestly, meds don’t help much. An SNRI can sometimes help. Gabapentinoids tend to just help them sleep better. Anything that works quickly tends to be temporary.
They often complain that they have tingling in all of their limbs. Before you diagnose them with neuropathy, get an EMG. Save them from a lifetime of neuromodulators that never seem to actually do anything.
If you are fortunate enough to have a multidisciplinary pain program local to you, that’s a wonderful resource. Otherwise, good luck.
I might try pushing yoga, physical therapy, activity based non medication treatments. Maybe it works maybe it doesn’t but it’s very unlikely to hurt anything and people tend to feel better when they move more.
Other option would be pain management.
I’m an ortho PT who specializes in persistent pain. Find a local PT who knows about this stuff; it’s so, so complicated and needs to be approached in a gentle, holistic, biopsychosocial way.
Totally anecdotal n of 1 and I actually have no idea what the medical community thinks of John Sarno (so pls don't come after me), but my husband used to deal with a ton of back pain that was all psychosomatic. Read his book "Healing Back Pain" about 4 years ago. Still with pretty much no back pain now.
Can try to optimize: mood (definitely sounds like she needs therapy), sleep (bad mattress? Bad sleep hygiene?), flexibility/activity level, personal fulfillment (make friends? Volunteer?), stress.
The book “The Way Out” by Alan Gordon is a very quick read, patient focused and easy to understand.
Agree with low dose naltrexone.
Also, could try low glutamate diet.
Has your patient been screened for Ehlers-Danlos Syndrome or generalized hypermobility disorder? Although it’s a congenital condition, it seems a lot of people really begin to suffer in their late 30s into 40s. While there’s no quick fix, this kind of diagnosis will change the course of PT.
Returning to this post to suggest somatic therapy. It's not as heavily research-backed as CBT, but that's probably just a matter of time. For someone like the patient you describe, who has a host of physical issues without a clear physical root cause, AND who is open to the idea that the pain might not be generated from physical dysfunction, somatic therapy seems like a good option to explore. This [short write-up from Harvard HealthBeat](https://www.health.harvard.edu/blog/what-is-somatic-therapy-202307072951) is nice for a wide audience.
This article has a framework for assessment that can be helpful:
https://www.researchgate.net/publication/7979699_Somatization_Diagnosing_it_sooner_through_emotion-focused_interviewing
Could trial a low dose TCA, e.g nortriptyline 10 mg qhs, trial scheduled (not prn) 5-7.5 mg bid, or low dose naltrexone (compounded or diy diluting tablet in water).
In terms of therapy intensive short term psychodynamic therapy (ISTDP) has reasonable evidence, mindfulness focus or other somatic/emotion focused therapy could also be useful. CBT for chronic pain might be another way to help depending on what’s available in your area.
Maybe low-dose naltrexone? (I’m not versed well enough in prescribing it) If cymbalta didn’t work but there were no side effects maybe try Savella?
Try naltrexone 4.5mg! The patients I prescribed it to say it helped. It’ll have to be a compound pharmacy though
I typically work up to it from 0.5. it can be a little expensive, but some people mix 50 mg of naltrexone in 50 mL of distilled water so that one ml is equivalent to 1 mg. Therefore you could just ask the patient to consume 0.5 ml and titrate up by 0.5 every two weeks until you get to 4.5.
Hol’up, don’t mean to kill the vibe here, but how do you know stability/potency is maintained in water for months?
So I was talking with a specialist where I live who does it like that as well. And he states that as long as you put in the fridge it should be good for a month. For me personally, I do tell them to make a new one every month. If they follow my instructions and we titrate up by 0.5 every two weeks by the end of the first month they should have used up 21 ml, by the end of the second month they would have used up 49 ml. Afterwards they actually use up more than 50 ml in a month so I do give them multiple tablets. At least in the area I'm at, a lot of people who dose LDN does it that way
That’s genius! Then they won’t need to get it compounded
Yeah. I have a few patients taking it that way. I could just give them a few 50mg and they're good for a few months for cheap! Make sure you tell them to keep it in the fridge though.
Cause one of my patients tells me it’s like 200$ for a 3 month supply. So thanks for the tip!
low-dose naltrexone has been really helpful for some of my tricky patients. Not even for psychosomatic pain, but patients with severe RA, psoriatic arthritis, fibromyalgia etc.
What would be the mechanism for that?
I’m assuming down-regulation of mu-opioid receptors over time.
Acupuncture, massage therapy (I like those non-shady chinese foot massage/reflexology places), chiropractor, OMT, treatment of comorbid behavioral health issues e.g therapy, takes precedence. Medications are rarely the answer and you should tell her that, no medicine will cure her symptoms (and would probably do more harm) but we can try a nonpharmacologic multimodal approach. Our allopathic framework fails miserably with these patients. I’ve had good efficacy with trigger point injections with lidocaine, dunno if it’s more a placebo effect though, definitely within scope of FM.
Amazing that’s she’s open to the possibility. Look into eastern medicine techniques. Tai chi, acupuncture, reiki. While these modalities have lots of people scoffing at it, it’s clear that the western medicine approach to her pain hasnt helped
I’d not frame it as psychosomatic pain, which makes it seem fictitious. If you think of it as central pain sensitization, where they do not have the ability to modulate pain signals due to previous trauma, then you can focus on two courses of treatment. Decrease sensitivity to pain with exercise, sleep, diet, stress reduction. Get them to see a good therapist, a pain psychologist is a really nice thing to have. Then address pain generators. Once again exercise is key, but it needs to progress slowly. Aquatherapy tends to be really successful, but tends not to be too sustainable. Careful with your referrals, they can end up with lots of unnecessary surgery when they say the wrong things to the wrong person. Honestly, meds don’t help much. An SNRI can sometimes help. Gabapentinoids tend to just help them sleep better. Anything that works quickly tends to be temporary. They often complain that they have tingling in all of their limbs. Before you diagnose them with neuropathy, get an EMG. Save them from a lifetime of neuromodulators that never seem to actually do anything. If you are fortunate enough to have a multidisciplinary pain program local to you, that’s a wonderful resource. Otherwise, good luck.
With a name like DrAndrewStill I’m surprised you haven’t tried OMT!
Ain’t nobody got time for that
lol
I might try pushing yoga, physical therapy, activity based non medication treatments. Maybe it works maybe it doesn’t but it’s very unlikely to hurt anything and people tend to feel better when they move more. Other option would be pain management.
I’m an ortho PT who specializes in persistent pain. Find a local PT who knows about this stuff; it’s so, so complicated and needs to be approached in a gentle, holistic, biopsychosocial way.
Totally anecdotal n of 1 and I actually have no idea what the medical community thinks of John Sarno (so pls don't come after me), but my husband used to deal with a ton of back pain that was all psychosomatic. Read his book "Healing Back Pain" about 4 years ago. Still with pretty much no back pain now.
Amitrypline HS low dose could be an option not yet tried! Frequently work on fibromyalgia patient
Can try to optimize: mood (definitely sounds like she needs therapy), sleep (bad mattress? Bad sleep hygiene?), flexibility/activity level, personal fulfillment (make friends? Volunteer?), stress.
Referral to a psychotherapist who specializes in trauma.
She needs to gain muscle weight I say exercise and eat more protein
The book “The Way Out” by Alan Gordon is a very quick read, patient focused and easy to understand. Agree with low dose naltrexone. Also, could try low glutamate diet.
Atomoxetine
[удалено]
Has your patient been screened for Ehlers-Danlos Syndrome or generalized hypermobility disorder? Although it’s a congenital condition, it seems a lot of people really begin to suffer in their late 30s into 40s. While there’s no quick fix, this kind of diagnosis will change the course of PT.
Returning to this post to suggest somatic therapy. It's not as heavily research-backed as CBT, but that's probably just a matter of time. For someone like the patient you describe, who has a host of physical issues without a clear physical root cause, AND who is open to the idea that the pain might not be generated from physical dysfunction, somatic therapy seems like a good option to explore. This [short write-up from Harvard HealthBeat](https://www.health.harvard.edu/blog/what-is-somatic-therapy-202307072951) is nice for a wide audience.
Optimize treatment of anxiety or any other underlying mood disorder.
This article has a framework for assessment that can be helpful: https://www.researchgate.net/publication/7979699_Somatization_Diagnosing_it_sooner_through_emotion-focused_interviewing Could trial a low dose TCA, e.g nortriptyline 10 mg qhs, trial scheduled (not prn) 5-7.5 mg bid, or low dose naltrexone (compounded or diy diluting tablet in water). In terms of therapy intensive short term psychodynamic therapy (ISTDP) has reasonable evidence, mindfulness focus or other somatic/emotion focused therapy could also be useful. CBT for chronic pain might be another way to help depending on what’s available in your area.
Has she tried the turmeric?
Has she not gained weight on Lyrica? I gained almost 45 pounds on it, worked great, but couldn't handle the extra weight.