Fibromyalgia is a difficult medical condition. Treatment success is rare. Patients feel they are not taken seriously and frustrated physicians become unhelpful. As treatment involves medications that are often ineffective, the patient becomes frantic, seeing multiple physicians, who prescribe more and more medications that eventually lead to more harm than good.

Recently in Canada, physicians from McGill University in Montreal and the University of Calgary in Alberta published updated guidelines on the diagnosis and treatment of fibromyalgia in the Canadian Medical Association Journal. They make a strong case that fibromyalgia patients should be treated by a primary care physician who has significant expertise in the complex factors involved in diagnosis and treatment. They discourage referring patients to rheumatologists because they are typically less available; they have a limited time, and long-term outcomes are less than ideal.

Fibromyalgia is diagnosed clinically by identifying a constellation of symptoms that include severe pain that waxes and wanes and is accompanied by chronic fatigue, insomnia, cognitive changes, depression and abdominal pain associated with constipation, diarrhea or both. The disease is four times more common in women.

A careful history, a physical examination and appropriate laboratory tests should be obtained. Apart from some joint stiffness and muscle pain, the examination will be normal and all laboratory tests will be negative. It is important to exclude conditions that mimic fibromyalgia, including rheumatoid arthritis, lupus, chronic infections (HIV and hepatitis), multiple sclerosis and certain medications (statins to lower cholesterol, aromatase inhibitors to treat breast cancer, bisphosphonates to treat osteoporosis or bone cancer).

Once a diagnosis has been made, a primary-care physician working with an interdisciplinary team (which might include social workers, pharmacists, a psychologist, nurses and physical therapists) should direct treatment. The team must be knowledgeable about fibromyalgia, recognize that the patient is suffering and understand how best to approach treatment.

The central and most effective approach is cognitive behavioral therapy aimed at improving coping skills. The most pressing and important symptoms must be identified, and realistic treatment goals should be set; the patient must buy in to the plan and work with a therapist. The goals are to encourage improved self-esteem, develop a robust social support system and focus on developing healthy lifestyle habits. There is compelling evidence that exercise can significantly relieve symptoms, as can relaxation techniques and massage therapy.

Proficiency and experience are required in prescribing medications to relieve pain and improve quality of life. Patients and physicians must understand that fibromyalgia is a chronic condition that interferes in the way nerves perceive pain.

What may be a minor irritation to someone without the disease manifests with severe symptoms in the fibromyalgia patient.

If pain is the major problem and persists despite cognitive behavioral therapy and psychotherapy, medications should be titrated slowly upward, starting with generic Tylenol (which is given on schedule three times daily). As a general rule, it is far easier to prevent than relieve pain. Thus early treatment is more effective than delaying until pain is severe. Even if unsuccessful alone, taking acetaminophen makes the addition of other pain medications more effective.

Narcotics (hydrocodone, morphine) should be avoided if possible. While they do provide initial relief, tolerance develops, requiring higher doses to relieve pain that is perceived as more severe by the patient. Demands for higher doses lead to dependency, serious side effects and even overdose.

As a complement to pain medications, antidepressants have been shown to help alleviate pain while simultaneously improving mood. Two (Cymbalta and Savella) are approved for fibromyalgia by the Food and Drug Administration, but many antidepressants are effective, particularly if combined with psychotherapy. In addition, anticonvulsants are prescribed. The most frequently used are Lyrica and Neurontin, which "soothe nerves" and assist in improving the way patients with fibromyalgia perceive pain.

It is very important that the patient fully understands the purpose of therapy, which has a main goal of pain relief and not improved mood or seizure prevention.

To be successful, treatment of fibromyalgia must be multimodal. Without appropriate psychotherapy, education and support groups, the medical treatment has little hope of success. And because symptoms wax and wane, so, too, can response to treatment. Often medication adjustment or change is needed to assure continued relief. If possible, the patient must find a receptive, trusted physician and understand that moving from one doctor to another is rarely successful.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." To find out more about Dr. David Lipschitz and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com. More information is available at:

www.drdavidhealth.com