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Pain medications and muscle relaxants

Pain is a symptom of Th1 disease and can be exacerbated by immunopathology. Marshall Protocol (MP) patients should always use 40mg of olmesartan (Benicar) every four hours before resorting to pain medications. There are also other strategies for managing pain.

When the usual strategies for managing immunopathology are not enough to control pain, Marshall Protocol (MP) patients rely upon pain medications. Except for corticosteroids, there is no pain medication contraindicated specifically because a patient is on the Marshall Protocol. Opioids are the preferred method of dealing with extreme pain in the MP cohort.

The effects of pain medications drugs on the immune system are not known. At present, it can't be said to what extent these drugs interfere with immunopathology. While it's strongly possible that some pain medications might temper immune system activity, patients taking them have made progress while taking them. As long as patients feel they're still experiencing immunopathology and that the medications are taken for reasons of necessity, pain medications are not contraindicated.

In conjunction with their physician or a pain management specialist, patients may want to experiment with different pain killers to see if any of them seem to lower not just pain but other disease symptoms. If they feel a particular pain medication is lowering immunopathology they are able to tolerate, they may want to ask their physician to change to a medication that does not elicit such an effect.

Types of pain medications

Listed below are common varieties of pain medications. Note that the substance names are in lower case and that any brand names are capitalized.

  • acetaminophen (Tylenol) – Tylenol dosage should be limited to a total of 3 grams (3,000mg, six 500mg tablets) in each 24 hour period for patients with healthy livers.
  • aspirin – not recommend in the routine use of aspirin for its touted preventative characteristics; see NSAIDs
  • celecoxib (Celebrex) – a COX-2 inhibitor; not recommended
  • corticosteroidscontraindicated - may cause IP instablity
  • diazepam (Valium) – okay for patients to take; only the brand name, Valium, has seemed to work for patients with Th1 inflammation; half the 2mg (white tablet, the one with the V cut from the center) seems to often be enough to reduce anxiety and calm restless muscles; stay away from the generic diazepam and the higher strengths; make sure your doctor orders Valium 2mg to use “as directed” and writes “no substitutions” on the prescription; Valium is usually taken 1-4 times per day.
  • hydrocodone-acetaminophen (Lortab, Norco, Percocet, Vicodin, Xodol) - Generally reported OK
  • ibuprofen (Motrin, Advil) – of Motrin and Advil, Advil is preferred: Motrin has two times the additives a Motrin – 18 versus 9 – and the additives are some very difficult substances for the body to break down; see NSAIDs
  • ketamine – An anesthetic drug commonly used in Lyme disease and chronic fatigue syndrome. Reports suggested that Ketamine doesn't work very well at palliation, and it loses efficacy quickly as the months go by. Also, Ketamine may damage bladder function.1
  • morphine – avoid if possible - shown to be immunosuppressive in a study2
  • naltrexone – an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. Naltrexone would certainly appear to affect the ability of the MP to return the human immune system to full function again. Lymphocytes express opioid receptors, probably for a good reason. Even though that reason is not fully understood, it is not a good idea to block those opioid receptors (with naltrexone) if one expects to be able to return your immune system to normal.

Low dose naltrexone (LDN) is palliative. It doesn't help the innate immune system in any significant way. If it were helping the immune system to kill the microbiota then your immunopathology would increase, not decrease. However, I have looked into whether it is likely to stop healing, and it does not seem to interfere with the known actions of Olmesartan on the VDR. So it seems a “safe” palliative. There was a thread on CureMyTh1.org where these issues were briefly discussed.

LDN is special because it is a very low dose drug, and it must therefore be targeted tightly towards whatever it affects. Science is still not completely sure what LDN does, which is why there is this myth about it helping the immune system. However, it doesn't seem to get in the way of olmesartan, especially at low doses.

Speaking of that, has Doc allowed you to try even smaller doses to see if the extra symptoms are less of a problem for you? As a palliative, it should be able to be used p.r.n. (as you need it), every other day, or even every other week, if it helps you.

Naltrexone is suspected to operate via a similar pathway to Ketamine, known to have pain-killing powers, and therefore any relief you get from idiopathic pain should not be unexpected.

Trevor Marshall, PhD, MarshallProtocol.com

  • naproxen (Aleve, Anaprox, Miranax, Naprogesic, Naprosyn, Naprelan, Synflex)
  • oxycodone (Oxycontin) - Generally reported OK
  • oxycodone-acetaminophen (Oxycocet, Percocet) - Generally reported OK
  • pregabalin (Lyrica) – a “small” molecule, one which is very non-specific in what it targets in the body; there are tens, probably hundreds of potential targets for a molecule that small; not recommended
  • propoxyphene-acetaminophen (Darvocet, Propox-N)
  • tramadol (Ultracet, Ultram, Ultram ER, Zytram XL) – possibly okay for patients to take; an atypical opioid and centrally acting analgesic used for treating moderate to severe pain. There have been reports of severe reactions from MP members - best to avoid this and use oxycodone or hydrocodone, which tend to have more positive than negative reports.

Opioids

Opioids are the preferred method of dealing with extreme pain in the MP cohort.

An opioid is any agent that binds to opioid receptors, found principally in the central nervous system and gastrointestinal tract. Opioids work to relieve pain in two ways. First, they attach to opioid receptors, which are specific proteins on the surface of cells in the brain, spinal cord and gastrointestinal tract. These drugs interfere and stop the transmission of pain messages to the brain. Second, they work in the brain to alter the sensation of pain. These drugs do not take the pain away, but they do reduce and alter the patient’s perception of the pain.

Many physicians are hesitant to prescribe what they feel is a lot of pain medication. Patients may need to demand that they give you enough pain medication to take care of their pain; Patients have a right to have their pain relieved. Opioids used to treat existing pain are not addicting.

I would suggest regularly changing around opioids so as to make sure that only the pain was being affected by them. There are opioid receptors on lymphocytes. In general terms, if your doctor prescribes opioids for your pain, they seem to have less interaction with Th1 disease than some of the other pain medications (aspirin, for example). This has to be a decision between you and your licensed physician.

I am generally comfortable with opioids, they are definitely the preferred pain killer, after higher-dose olmesartan. If the olmesartan doesn't control the pain then you should discuss opioids with your doctor. Talk with your doctor about more than one type. Try three weeks on one, three weeks on another or some other regime with which your doctor is comfortable with. That is really the only way to observe cause and effect.

Trevor Marshall, PhD

Opioids do suppress the immune system,3 so it is important not to use them more than necessary. Patients should work with their physician to find an appropriate dose.

NSAIDs

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) are commonly used for mild to moderate pain. The most commonly used members of this group are over the counter drugs: aspirin, ibuprofen, and naproxen. Taken regularly, NSAIDs can lead to stomach upset and prolonged bleeding. NSAIDs should only be taken with a physician's say so. NSAIDs can inhibit the excretion of sodium and lithium as well as interfere with other medications.

NSAIDS and COX-2 inhibitors can inhibit antibody production in human cells, thus lowering host defense.4 NSAIDs can also increase the risk of life-threatening heart or circulation problems, including heart attack or stroke. This risk will increase the longer they are used. A recent study indicated that Naproxen may pose less risk to the circulatory system than the others.5

NSAIDs are not the way to [best treat pain]. Pain should be treated with acetominophen/paracetamol (Tylenol, Panadol) or one of the [preferred] opioids, none of which significantly affect the immune system [as NSAIDs do]

Trevor Marshall, PhD

Patients with liver disease should use all over the counter pain medications, including ibuprofen, aspirin and acetaminophen (Tylenol), with caution. Any pain medication can jeopardize an already struggling liver, as many patients with Th1 inflammation have subclinical liver inflammation. One's physician is the best source of information regarding the safety of pain medication.

Topical pain relief

For localized pain, topical pain relievers may provide some temporary relief. Patients are advised to avoid those with salicylates such as Ben-Gay.

Over the counter topical creams with capsaicin, a component in hot peppers, in them work well. They produce a sensation of heat which fools the nerve endings into not noticing the pain. This might work well on joints.

Patients should be careful to wash their hands well after applying it as it can be very painful if it gets in one's eyes.

Muscle relaxants

A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia (overresponsive reflexes). The term “muscle relaxant” is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics. Neuromuscular blockers are used during surgical procedures and in intensive care. Spasmolytics, also known as “centrally-acting” muscle relaxants, are used to alleviate musculoskeletal pain and spasms and to reduce spasticity in a variety of neurological diseases. As with pain medications, it is okay for MP patients to take muscle relaxants in order to help manage intolerable symptoms.

Muscle relaxants include:

  • baclofen (Kemstro, Lioresal, and Gablofen)
  • bentazepam (Thiadipone)
  • carisoprodol (SOMA, Sanoma, Carisoma)
  • chlormezanone (Trancopal)
  • chlorphenesin (Maolate, Musil)
  • chlorzoxazone (Muscol, Parafon Forte)
  • cyclobenzaprine
  • diazepam (Valium)
  • donepezil (Aricept)
  • eperisone (Myonal)
  • febarbamate
  • flopropione (Compacsul, Cospanon, Ecapron, Pellegal, Argobyl, Floveton, Saritron, Spamorin, Labrodax, Tryalon, Mirulevatin, Padeskin, Profenon)
  • lorazepam (Ativan, Temesta)
  • mephenesin
  • mephenoxalone (Dorsiflex, Moderamin)
  • meprobamate (Equanil, Miltown, Meprospan)
  • metaxalone (Skelaxin)
  • methocarbamol (Robaxin)
  • nitrazepam (Alodorm, Arem, Insoma, Mogadon, Nitrados, Nitrazadon, Ormodon, Paxadorm, Remnos, Somnite)
  • orphenadrine
  • phenprobamate (Gamaquil, Isotonil)
  • phenyramidol
  • pridinol
  • promoxolane (Dimethylane)
  • quinine (Qualaquin)
  • styramate
  • tetrazepam (Clinoxan, Epsipam, Myolastan, Musaril, Relaxam, Spasmorelax))
  • thiocolchicoside (Muscoril, Myoril, Neoflax)
  • tizanidine (Zanaflex, Sirdalud)
  • tolperisone (Biocalm, Mydeton, Mydocalm, Myolax, Myoxan, Viveo)
  • trazodone (Desyrel, Oleptro, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico, Mesyrel)
  • tybamate

Patients experiences

I didn't relish speaking with my doctor about the possibility of prescribing opioids to help manage my pain while on the MP. I've had a bad experience with a physiological addiction to Ativan at low levels (used as a sleep aid) in the past and I wasn't sure who would be more reticent about the use of opiods.

I figured I would wait until after I experienced intolerable pain to speak with my doctor. I mean, I'm pretty good with pain.

Wrong move. During one 12-day period about a week into beginning the antibiotics, I had about five different body pains occurring at the same time (ranging from a 5 to a 9 in pain on a scale of ten) and a migraine with little relief throughout. It was intolerable. I was bereft. Speaking to my doctor about opiods over the phone was not what I wanted to do, and so I toughed it out.

At my next appointment, I got a prescription for oxycodone. I took just half the dose at the next mega-pain attack and the overall pain level was dropped to about a four, which was not only tolerable, but allowed me to know that I was still killing the bacteria and also when the response stopped. Thankfully, unlike the 12-day bout, it stopped after 8 hours. I went from feeling like a big wimp to feeling like I could manage my pain and therefore survive the MP.

I encourage everyone to talk with your Doctor about pain management in advance no matter how well you think you have managed the various pains you've had in the past.

Claire, MarshallProtocol.com

I have been taking 2mg Valium for muscle cramping associated with rheumatoid arthritis (I take it perhaps once or twice a week). As Jeannine advised, the brand name version of this drug usually works much better and at lower doses than the generic diazepam. I have followed this advice and used the brand name Valium with good results.

Until recently, when I attempted to refill my prescription at a new pharmacy in a remote location. I was told they could not obtain brand name Valium and that no pharmacy that they knew of within several hundred miles carried the brand name version. I accepted the generic, and very quickly found out that Dr. Marshall was right (as usual). Even when I took double the dose, I got no relief from my muscle cramps and in fact, my joint and muscle pain was worse.

Carol, MarshallProtocol.com

I took a low dose of LDN (Low Dose Naltrexone) last night (I think prescribed at my request, as I was trying to think of different meds to try so I could stop the Tramadol and I've already taken Vicodin) and had one of the worst experiences of my life. It's a little pill, 3.5mg.

It made me feel like I had drank paint thinner. It made my insides burn, gave me a terrible headache, caused my organs to burn. That horrible feeling went on for more than 5 hours. I took it at 8 pm, felt absolutely horrible for hours, couldn't read or watch TV, finally fell asleep about 1:15 am. I don't think it was an allergic reaction, so I wonder why it made me feel so horrible. It was a really, really awful experience. Worst med I've ever taken. I've had a couple make me feel way too drowsy before but nothing like this.

SanDiegoJoy, MarshallProtocol.com

Notes and comments

  • Legacy Content

Excellent article re: "the MS Hug"

More than 20 studies, including a large analysis of data on more than 200,000 children, have produced results that link acetaminophen use to an increased risk of asthma. http://nyti.ms/u9ZxHZ

Ibuprofen and other widely used non-steroidal anti-inflammatory drugs inhibit antibody production in human cells

Bancos S, Bernard MP, Topham DJ, Phipps RP.

Department of Environmental Medicine, Lung Biology and Disease Program, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.

The widely used non-steroidal anti-inflammatory drugs (NSAIDs) function mainly through inhibition of cyclooxygenases 1 and 2 (Cox-1 and Cox-2). Unlike Cox-1, Cox-2 is considered an inducible and pro-inflammatory enzyme. We previously reported that Cox-2 is upregulated in activated human B lymphocytes and using Cox-2 selective inhibitors that Cox-2 is required for optimal antibody synthesis. It is not known whether commonly used non-prescription and non-Cox-2 selective drugs also influence antibody synthesis. Herein, we tested a variety of Cox-1/Cox-2 non-selective NSAIDs, namely ibuprofen, tylenol, aspirin and naproxen and report that they blunt IgM and IgG synthesis in stimulated human peripheral blood mononuclear cells (PBMC). Ibuprofen had its most profound effects in inhibiting human PBMCs and purified B lymphocyte IgM and IgG synthesis when administered in the first few days after activation. As shown by viability assays, ibuprofen did not kill B cells. The implications of this research are that the use of widely available NSAIDs after infection or vaccination may lower host defense. This may be especially true for the elderly who respond poorly to vaccines and heavily use NSAIDs.

PMID: 19345936

Common pain relief medications may influence cancer growth: http://news.uchicago.edu/news.php?asset_id=1780

NSAIDs actually inhibit immune tolerance/suppression. Prostanoids are highly immuno-suppressive, in particular PGE2, which is also associated with pain perception, fever and tissue healing. NSAIDs inhibit the cyclo-oxygenases and in this manner limit the conversion of arachidonic acid into PGE2. Thus, NSAIDs can alleviate pain and fever but can also lead to further joint destruction, for example.

On the other hand, they are associated with a lower of rate of alzheimers and a strikingly reduced rate of cancers, particularly the COX2 inhibitors. The smoker/celebrex user lung cancer rates are super low compared to non-COX inhibitor users.

The angiotensin receptors increase the expression of COX-2. I suspect this is one of the pathways that the ARBs work on, amongst others, which lead to a reduction in cancers and neurodegenerative disease.

Phillyguy, MarshallProtocol.com

I also googled Fentanyl, and searched the MPKB for it. I know it's a newer pain med, a synthetic opioid. I seem to remember seeing something suggesting it is not recommended on the MP, but I can't lay hands on where I saw that–or whether I made it up! It would be the most questionable of the meds you asked about.

From Titta:

the term anticonvulsant is used only for medications used against seizures, epilepsy.

Baclofen is a so called muscle relaxant. It acts at (in?) the spinal part of the nervous system. So it is a main medication used against spasticity (too high muscle tension caused by cerebral or upper spinal lesions) but used for other causes, too.

Tetrazepam (relative to diazepam) is a muscle relaxant, too, with actions at different structures.

Chininsulfat acts as a muscle relaxant, too, with peripheral action only. It is mostly used against so called crampi or Charley horse.

I think muscle relaxants are important for many patients with neurological diseases and often used additionally to pain medication.

I have used Keltican frequently in my neurological practice when I had to deal with pain caused by radiculopathies, slipped discs and other neuropathic pain. I could not find much about it in English either. It is produced by a former German manufacturer, so it might be quite local.

“Is it OK to take Robaxin (Methocarbamol) Muscle relaxer for the back ache. Just to get over this hump.”

Yes, it is okay to take Robaxin for your intolerable pain due to muscle injury.

Hope you feel better soon….:)

I also found a post here: http://www.marshallprotocol.com/view_topic.php?id=12488&forum_id=35&highlight=robaxin

When searching methocarbamol and muscle relaxant I found many posts about MP'ers taking a muscle relaxant. I don't recall finding any info on the MPKB site. It would be helpful to have info about muscle relaxants added to the MPKB site if not already there.

Since it has imprecise modes of action I will have Kritter stop taking it. I will also note any change in symptoms.

Trevor: Muscle relaxant or pain killer? Medicine is unsure about the category of robaxin

References

1 Mak SK, Chan MT, Bower WF, Yip SK, Hou SS, Wu BB, Man CY Lower Urinary Tract Changes in Young Adults Using Ketamine. J Urol. 2011;:.
2 Sacerdote P, Manfredi B, Mantegazza P, Panerai AE Antinociceptive and immunosuppressive effects of opiate drugs: a structure-related activity study. Br J Pharmacol. 1997;121:834-40.
3 Roy S, Loh HH Effects of opioids on the immune system. Neurochem Res. 1996;21:1375-86.
5 Ray WA, Varas-Lorenzo C, Chung CP, Castellsague J, Murray KT, Stein CM, Daugherty JR, Arbogast PG, García-Rodríguez LA Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease. Circ Cardiovasc Qual Outcomes. 2009;2:155-63.
Last modified: 09.01.2012
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