Fibromyalgia, Catastrophizing, and a Request for Opioids
42-year-old woman with 3 years of widespread pain, fatigue, unrefreshing sleep, and difficulty concentrating. She meets clinical criteria for fibromyalgia. Pain is 7/10 and she has stopped working as a teacher. She has tried duloxetine (nausea) and gabapentin (dizziness) without benefit. She has catastrophizing on the Pain Catastrophizing Scale and reports 4/10 depression. She asks for oxycodone because “nothing else works.” Examination is notable for diffuse tenderness without synovitis or focal neurologic deficit. Laboratory studies including CBC, CMP, TSH, and CRP are normal. She has no history of substance use disorder.
1. How would you respond to the opioid request and build a multidisciplinary plan?
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Explain that opioids are not recommended for fibromyalgia because evidence shows limited benefit and risks of hyperalgesia, sleep-disordered breathing, and functional decline. Validate her suffering and set functional goals rather than chasing a pain score. Build a plan around pain neuroscience education, CBT, graded exercise (starting low and progressing slowly), sleep hygiene, and treatment of depression. Consider nonpharmacologic modalities such as tai chi or aquatic therapy. For pharmacologic options, review why prior agents failed and consider low-dose tricyclic or a different SNRI only with attention to side effects; avoid combining sedatives. Refer to an interdisciplinary pain program and vocational rehabilitation. Offer shared decision-making and a follow-up interval.
2. What would you do if she becomes tearful and says her life is not worth living?
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Screen directly for suicidal ideation, plan, intent, and means, and assess for depression. If she is at imminent risk, arrange emergency evaluation; if not, same-day mental health follow-up and a safety plan. Do not simply increase analgesics. Reassure her that her pain is believed and that the plan will address mood and sleep. Involve her primary care clinician and a psychologist. Document the risk assessment. This is a pivotal moment to integrate behavioral health rather than label her as drug-seeking.
3. How would you measure whether the multidisciplinary plan is working over 3 months?
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Use functional and patient-centered outcomes: work participation or volunteer activity, walking tolerance, sleep quality, pain interference, depression score, catastrophizing, and patient global impression of change. A reduction in pain intensity is not required for success; improved function and coping are adequate. Track attendance and adherence to CBT and exercise. If there is no improvement, reassess for untreated sleep apnea, endocrine disease, or depression, and adjust the plan rather than adding opioids. Coordinate care among primary care, psychology, physical therapy, and vocational services.