Depression in Fibromyalgia Patients May Require Low-Dose Naltrexone to Respond: A Case Report

Abstract

Fibromyalgia and depression are frequently comorbid. We propose a hormonal system model in understanding the underlying endogenous opioid system dysregulation in fibromyalgia with the utilization of the cold pressor test (CPT) in clinical practice to monitor treatment response to low-dose naltrexone (LDN) and the subsequent remission of major depressive disorder by restoring opioid tone.A 60-year-old professional on permanent disability presented with refractory depression and chronic widespread pain after years of multiple failed medication trials. Rating scales confirmed severe depression, Hamilton Rating Scale for Depression (HAM-D) of 20, a short cold pressor test (CPT) time of 21 seconds, and a face pain scale (FPS) of 8/10. Physical examination assessing for fibromyalgia was diagnostic, with 18/18 positive tender points.LDN, a minor increase in trazodone, and transference-focused psychotherapy were employed. The patient's CPT time increased modestly. The patient achieved remission of both conditions in 10 weeks when both disorders were treated at once (FPS and HAM-D of zero), restoring the quality of life, relatedness, and motivation. Some fibromyalgia patients may achieve remission of comorbid depression with concomitant low-dose naltrexone (LDN) treatment that is widely used "off label" to treat pain. LDN is a promising alternative for the treatment of chronic pain in fibromyalgia with its safety profile, high tolerability, and absence of abuse potential. Our unique finding is that without successful LDN treatment of fibromyalgia, remission of depression may be unlikely.

The Safety and Efficacy of Low-Dose Naltrexone in Patients with Fibromyalgia: A Systematic Review

“… N/A. Siembida 2022 16 10 weeks (0.1 mg twice a day and is gradually increased over 11 days to a maximum of 4.5 mg twice a day thereafter. Follow up 15 months.)…”

“…Characteristics of the included studies are summarized (Table 1). All studies were published between 2009 and 2022, with eight studies being conducted in the USA [16][17][18][19][20][21][22]24 and one in Denmark. 23 Trial participants consisted mainly of women, age ranging between 14 and 89 years, and trial sample sizes ranging from 1 to 37.…”

“…In total, 431 study participants were included among all of the included studies, with 159 individuals with FM. Participants in seven of the nine studies were diagnosed according to the 1990 ACR diagnostic criteria, [16][17][18][19]21,22,24 one study used the 2010 ACR criteria, 20 and one study used a combination of 1990 and 2011 ACR criteria. 23 All the pilot trials and a case report assessed the efficacy of LDN in patients with FM.…”

“… 14 , 15 In contrast, the current FDA-approved medications (duloxetine, milnacipran, and pregabalin) have no effect on the endogenous opioid system. 16 …”

“…14,15 In contrast, the current FDA-approved medications (duloxetine, milnacipran, and pregabalin) have no effect on the endogenous opioid system. 16 Until now, there has been no dedicated systematic review solely focusing on the efficacy of LDN in patients with FM. Furthermore, the potential safety of LDN use in FM has never been systematically assessed or reported.…”