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From the Townsend Letter
November 2014

Effective Treatment of Pain and Fibromyalgia:
Treating the Root Causes

by Jacob Teitelbaum, MD
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With pain medications causing over 45,000 preventable US deaths a year, it is time to recognize that there are far more effective, and safer, ways to get rid of pain!
And 45,000 deaths is a conservative estimate. Arthritis medications cause over 16,500 deaths a year from bleeding ulcers, along with a massive 40% to 300% increased risk of heart attack and stroke.1,2 Meanwhile, over 15,000 people a year die from overdoses of prescribed codeine medications.
It is important to recognize that, like the flashing red oil light on your car's dashboard, pain is your body's way of saying that something needs attention. If you have your hand on a hot stove or have a broken leg, the cause is obvious. But most of the time with arthritis, migraines, fibromyalgia, or other common pains, the cause is less obvious. So what do most doctors do? Simply throw an often-toxic pain medication at the person!
Simply giving a pain medication without treating the cause of the pain is like putting a Band-Aid over a flashing red oil light. It looks better, but then you burn your motor out a few miles later. In the same way, if you give the person's body what it needs, the pain goes away – just like the oil light goes out when you put oil in the car. This has been shown in our research, using fibromyalgia as one pain model.3,4
In addition to the personal costs of pain, the financial costs are also staggering. A study in the August 2012 issue of the
Journal of Pain showed that the economic costs of pain in the US are about $600 billion dollars a year, a huge figure that is more that the total costs of cancer and heart disease combined!5 Yet most physicians are very poorly trained in treating pain, while being indoctrinated with a dogmatic belief that any holistic or non-MD practitioners who can help pain patients must be quacks. It's no surprise then that around ¼ of adult Americans suffer unnecessarily with poorly treated pain.

Let's begin by looking at how to treat the root causes of pain to get relief, using fibromyalgia (FMS) and myofascial pain syndrome (MPS), or muscle pain, as a model. These same principles also appy to treating fatigue and chronic fatigue syndrome (CFS). FMS, CFS, and MPS are common names for an overlapping spectrum of disabling syndromes. It is estimated that FMS alone affects 3 to 6 million Americans, and as many as 12 million in milder form, causing more disability than rheumatoid arthritis. Myofacial pain syndrome (MPS) affects many millions more. Although we still have much to learn, effective treatment is now available for the large majority of patients with these illnesses.3,4 CFS/FMS/MPS represents a syndrome, a spectrum of processes with a common end point, and I will often refer to the three together.

Research has implicated mitochondrial and hypothalamic dysfunction as common denominators in these syndromes.6 Dysfunction of hormonal, sleep, and autonomic control (all centered in the hypothalamus) and energy production centers can explain the large number of symptoms and why most patients have a similar set of complaints.

Essentially, these three conditions represent an energy crisis in one's body. Treating the root causes requires treating the underlying problems that deplete energy or interfere with energy production.

To make it easier to explain to patients, we use the model of a circuit breaker in a house: if the energy demands on your body are more than it can meet, your body "blows a fuse." The ensuing fatigue forces you to use less energy, protecting you from harm. On the other hand, although a circuit breaker may protect the circuitry in the home, it does little good if you do not know how to turn it back on or that it even exists.
This analogy actually reflects what occurs in CFS/FMS. As energy stores are depleted, hypothalamic dysfunction occurs early on, resulting in the disordered sleep, autonomic dysfunction, low body temperatures, and hormonal dysfunctions commonly seen in these syndromes. In addition, inadequate energy stores in a muscle results in the muscle shortening (think of rigor mortis) and pain that is further accentuated by the loss of deep sleep. Therefore, restoring adequate energy production, and eliminating the stresses that overutilize energy, restores function in the hypothalamic "circuit breaker," and also allows muscles to release – allowing pain to resolve. Our placebo-controlled study showed that when this is done, 91% of patients improve, with an average 90% improvement in quality of life, and the majority of patients no longer qualified as having FMS by the end of three months.4
In addition to muscle pain, about half of those with FMS have a secondary neuropathy called small fiber neuropathy (SFN). Chronic pain in general can trigger SFN, and in my experience most with FMS begin with muscle pain and MPS, which then progresses in some cases to SFN. Interestingly, SFN also is being commonly seen in association with antibody deficiencies (mostly IgG1 and -3) in clinical work being done by Dr. Mark Sivieri, and may supply a "missing link" connection between the nervous system, immunity, and even autonomic dysfunction. More on this in future articles and in an upcoming webinar (see below).

Common Causes of the Energy Crisis that Leads to Fibromyalgia May Include

  • infections
  • nutritional deficiencies
  • disrupted sleep
  • pregnancy
  • hormonal deficiencies
  • stress
  • toxin exposures
  • injury (especially brain and neck)

The criteria for diagnosing FMS/CFS are readily available elsewhere. There is a simpler approach to diagnosis that is very effective clinically. If patients have the paradox of persistent widespread pain and severe fatigue combined with insomnia (if one is exhausted, one should sleep all night), they likely have an FMS related process.

Two studies (including our RCT) have shown an average 90% improvement rate in FMS/CFS when using the "SHINE" protocol.3,4 SHINE stands for Sleep, Hormonal support, Infections, Nutritional support, and Exercise as able. Using the acronym SHINE will simplify treatment of these patients. This article will give you an excellent start in treating CFS/FMS/MPS, and there are other tools available for simplifying and improving treatment of these complex conditions.

Tools to Simplify Care of these Complex People
1.  Free treatment tools. These include:

A.   intake questionnaires that elicit symptoms by diagnosis (e.g., thyroid, adrenal, candida) so that you can quickly determine the underlying contributing conditions;
B.   treatment checklists. Are you repeatedly (and illegibly) writing down the same treatment recommendations over and over? Instead, simply check off the treatments that you want. They include detailed recommendations such as dosing, side effects, etc. Simply e-mail me at and ask for the free treatment tools, and I will send them to you.

2.  Our free Practitioners Alliance Network (PAN). This is a free membership organization for health-care practitioners. Our mission is to provide a common platform for bringing together health-care professionals from widely diverse backgrounds in order to foster communication and to help practitioners grow their practices.
PAN members participate chiefly through a private, members-only website where practitioners gain access to many free benefits that include:

A.   membership in the PAN Forum, a practitioners-only social website and discussion forum where members can ask and answer questions – including questions for Dr. Teitelbaum;
B.   access to the PAN Buyers Club, a group of companies that offer PAN members special discounts on nutritional supplements and office supplies for their practices (typically at rates of 7.5%–15% below wholesale);
C.   opportunities for cross-referrals through a growing community of PAN members;
D.   access to free live webinars conducted by Dr. Teitelbaum and guest presenters on health topics of interest to practitioners;
E.   opportunities to help suggest, design, and participate as study authors in PAN-sponsored research studies. PAN has just launched a study on Alzheimer's treatment using a holistic protocol. There will be many more.

3.  Online training. There is an 8-hour online training that you can take at your leisure which will make you an expert on treating FMS/CFS/MPS and also get your name on our patient referral list. See for info.

4.  Our free online Energy Analysis Program (at, which will analyze the person's symptoms and even pertinent labs if available, determine the factors contributing to the person's energy crisis, and tailor a program to optimize that person's energy. The questionnaire that the person fills out is the same as the one in the treatment tools, so your staff can enter the info if you like and have the detailed analysis and treatment protocol come from you instead of the online program. That allows you to be "the Wizard"!
All involved in the healing arts in any and all forms are invited to come and share what you know while learning from each other. Let's come together to heal our health-care system!

Treating the Root Causes of Pain with SHINE
S – Sleep: Sleep is when tissue repair occurs, and is critical for the resolution of most types of chronic pain. A foundation of FMS/CFS is the sleep disorder. Using treatments that increase deep restorative sleep, so that the person gets 7 to 9 hours of solid sleep each night, is critical. Start treatment with natural therapies or with a low dose of sleep medications that do not decrease stage 3–4 sleep. Continue to adjust the treatments each night until the patient is sleeping 8 hours a night without a hangover.

The natural remedies that I recommend you begin with include the following:

1.  Herbal preparations containing a mix of valerian root, wild lettuce, Jamaican dogwood, passionflower, hops, and theanine. These are all combined in an excellent product called "The Revitalizing Sleep Formula" by Integrative Therapeutics. Patients can take 1 to 4 caps at bedtime. These six herbs can help muscle pain and libido as well as improving sleep.
2.  Melatonin: ½–1 mg at bedtime.
3.  5-HTP (5-hydroxytryptophan): 200 to 400 mg at night. Limit to 200 mg if on antidepressants or other serotonin-raising medications.
4.  Magnesium at bedtime. A hot bath with 2 cups of Epsom (magnesium) salts and some lavender oil can be very helpful.

If natural remedies are not adequate to result in at least 8 hours a night of sleep, consider these medications:

•   Zolpidem (Ambien): 2.5 to 10 mg q.h.s.
•   Gabapentin (Neurontin): 100 to 900 mg h.s. can help sleep, pain, and restless leg syndrome (RLS) as well.
•   Cyclobenzaprine (Flexeril): 3 mg.
•   Trazodone (Desyrel): 50 mg. Use a half to 1 tablet q.h.s.

There are over 30 other helpful natural and prescription sleep aids.
Most people with insomnia do well just with the natural sleep support. In those with CFS/FMS, the added medications may be needed. Because of next-day sedation and each medication's having its own independent half-life, FMS/CFS patients do better with combining low doses of several medications than with a high dose of one.
Although less common, three other sleep disturbances must be considered and, if present, treated. These are sleep apnea, UARS (upper airway resistance syndrome), and RLS, which is also fairly common in fibromyalgia.7

H – Hormonal support: Hormonal imbalances are associated with FMS. Sources of imbalance include hypothalamic dysfunction, adrenal exhaustion from chronic stress, environmental toxins, and autoimmune processes such as Hashimoto's thyroiditis. Most blood tests use two standard deviations to define blood test norms. By definition, only the lowest or highest 2.5 % of the population is in the abnormal (treatment) range. This does not work well if over 2.5 % of the population has a problem.

The goal in pain management is to restore optimal function while keeping labs in the normal range for safety. One way to convey the difference between the "normal" range based on 2 standard deviations and the optimal range which the patient would maintain if he/she did not have FMS is as follows:
Pretend that your lab test uses 2 standard deviations to diagnose a "shoe problem." If you accidentally put on someone else's shoes and had on a size 12 when you wore a size 5, the normal range derived from the standard deviation would indicate that you had absolutely no problem. You would insist the shoes did not fit although your shoe size would be in the normal range. Similarly, if you lost your shoes, the doctor would pick any shoes out of the "normal range pile" and expect them to fit you.

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