Medication Summary for Intractable Pain, CRPS/RSD

Published on November 15, 2016 under Guest Blogger for RSDSA

Nancy Sajben, MD discusses the medication summary for intractable pain (CRPS RSD) as discussed at an RSDSA conferenceThe following blog post was written on 11/6/16 by Nancy Sajben, MD for her website. Shared with permission.

I spoke only briefly this morning at the RSDSA conference but there is so much to add. Most importantly, thanks to RSDSA for helping so many people with CRPS. They fund pain research, they are starting a free children’s camp, and now offer physicians one hour free CME teaching about CRPS.

Holistic view, 36 points – that’s how I view caring for brain and nerves, very similar to the details used by UCLA Alzheimers Research Unit. In June 2015, I posted on their work on memory loss, dementia. We know chronic pain means inflammation in the brain, excess of proinflammatory cytokines. CT scans show memory loss and brain atrophy in those with chronic low back pain.  Can this inflammation lead to Alzheimers? Even if it doesn’t, why not maximize what we know we can do to help brain. As I view it, simply be meticulously detailed in giving the central nervous system (CNS) the best chance to relieve or prevent pain or disease.

Below is a brief list.

To find detail and sometimes depth, check the alphabetical lists on either side column [on Nancy Sajben’s website] until you see the category or tag when I first posted on that. Or simply plow through 7.5 years of detail with references. You do the work to check the side columns as I have no time to embed links below, taken from throughout this site.

For now just a list of medication players that may be strikingly important in trying to bring intractable pain into remission even after 20 years. Yes, even chronic for decades. The list applies to intractable pain of all causes. I omitted listing standard interdisciplinary approaches commonly used by every pain specialist around the world. My patients have failed all those.

Some patients with CRPS combine my medications with ketamine infusions.

For those who remain on opioids, ultra low dose naltrexone (10 to 60 mcg three times daily) can significantly reduce pain, reduce opioid induced hyperalgesia, reduce windup, and thus reduce the dose of opioid needed to give improved relief. Opioids cause pain and trigger pro-inflammatory cytokines that create more pain. I strongly recommend slowly, gently tapering off opioid, and remaining off for 3 weeks before the following is trialed:

  1. Vitamin D is anti-inflammatory. Important. Helps pain, depression. If bone loss is an issue, you will not absorb calcium from food if D is low. Mayo Clinic’s publication in 2012 showed more morphine is needed for pain if D is low. Huge literature of its benefit for depression. First topic I posted on – it is that important.74.
  2. Vitamin B6 can cause burning pain from scalp to toe, a toxic neuropathy. It can be toxic to brain. It is loaded in tons of soft drinks, “energy” drinks, supplements.
  3. MTHFR mutation may be present. Body cannot process  the B12 and folic acid you are eating or taking in supplement. A simple blood test, costly. Treatment is as simple as buying methyl folate and methyl B12 – no prescription needed. Folic acid in particular is profoundly important for one of the major energy cycles in the body. Can cause multiple conditions, some fatal, all from one single cause.
  4. Minocycline 100 mg/day is the dose I use but higher doses could be given. It is used daily for decades for acne. I may prevent spread of CRPS if given before surgery, dental work, even minor procedures. I start 24 hrs before, and continue for days after full recovery from surgery.
  5. Testosterone  in either male or female is depleted by opioids, it may be depleted by stress. Low T is a risk for depression, weakness and osteoporosis.
  6. Naltrexone low dose (LDN) – profoundly important. A glial modulator. Lifelong use.
  7. Dextromethorphan – reduces hyperexcitable glutamate
  8. Oxytocin
  9. Memantine – double the Alzheimers dose for CRPS. Like ketamine, it blocks the NMDA receptor.
  10. Lamotrigine
  11. Palmitoylethanolamide (PEA, PeaPure) a glial modulator, also acts on mast cells. A food supplement. No Rx. Your body makes it. Plants make it. Capsules & cream
  12. Ketamine via nasal spray, under tongue combined with IV or not, works on glutamate-NMDA receptor. Not an essential drug. Where ketamine has stopped working, patients have become pain free after years of CRPS.
  13. Creams combinations, so many. Most of my CRPS pts very much like   Mg++/guai  10% each. You may or may not trial various combinations lido/keto/keta, etc. Numerous. DMSO 50%.
  14. Medical Marijuana (CBD, THC, terpenes) Marijuana saves lives. Entire issue of Science, November 4, 2016, devoted to pain. NAC and alpha lipoic acid are noted by research from the Netherlands.


If it has not burst, treat it like the infection that it is. Surgery may never be needed. I posted details of publications early 2016 with a case report. That young man was being rolled into the OR, instead was discharged 100% better without surgery 2 days later.

Medications target 3 main systems, as discussed at the conference

The opioid receptor – opioids create pain. They trigger glia to produce pro-inflammatory cytokines. Opioid induced hyperalgesia may occur. Cannot be used with low dose naltrexone.

The glutamate NMDA receptor – ketamine, memantine.

Glia, the innate immune system – glial modulators.

Before they see me, my patients have failed all prior therapies even ketamine coma. I view it like football. You have one guy running down the field with one ball. Do you want to win the game? You’ve dealt with this for years. Let’s not prolong it. Hit it with my main choice of meds all at once. Jump on it. What if you get 10% relief – will you even notice 10% after many years of severe pain? But if you get 10% from each of 5 meds, then you are talking 50% relief as a start. Address those 3 main pain systems – even without ketamine – and I have posted a case report after 20 years and 3 suicide attempts before seeing me, she has been pain free for about 4 years as I recall. A surgeon nicked her sciatic nerve when she was 27. Two years ago, pain free, running on her treadmill, she twisted her ankle. She has permanent foot drop from the sciatic nerve injury, but even spraining her ankle did not flare her CRPS. Twenty years of CRPS, pain free for about 4 years. And ultimately, years ago, she was tapered off all the drugs with one exception: LDN lifelong.

Most importantly, I did not have time to relay a very special message from my patient in Brooklyn: “Surround yourself with friends and family who love you. Never give up hope.” She had her first 2 or 3 pain free days this week, as she slowly increases doses of medication. She’s not yet at maximal effect and even then there can be increases. Sending love and courage.


RSD support groups are essential and I am glad to see the RSDSA list of so many throughout the country.

There is so much more. Indeed, at least 36 points discussed on June 2015.



The material on this site is for informational purposes only.
It is not legal for me to provide medical advice without an examination.
It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.


  1. Dolores Green-Franklin

    I am 61 years old female that has been going through RSD for 25 years or more. On Monday I ended up in hospital overnight because I had severe pain in my left arm that I never experienced before I thought my arm was falling off. I have dealt with muscle spasms in my hands ,thighs both feet and also pain never had pain in left arm I also have the RSD that travels to my left breast and I have an morphine pain pump wit baclofen,dilaudid morphine and clondine inside ans I take oral pain medication, muscle relaxer the narcotics oral does work for me. Also I uses a ten units now that I have experienced that pain in left arm from the RSD I hoped I never has to any more. I had IV dilaudid morphine every 6 hours and tornado every 4 just to get the pain under control it has to be something that can be done more for RSD.

  2. Dolores Green-Franklin

    I am a 61 years old woman that has been dealing with RSD now for 25 years or more. On Monday of this week I have never had the pain in my left arm like it was about to exposed. I dealt with the muscle spasms, swelling on the right Hands, left leg also pain. Never had pain that I had to go to the hospital. I have a morphine pump. Never wants to go through that again what should I do the morphine pain with baclofen, clondine didn’t even touch the pain on the left side.

  3. Mark Wallenbrock

    I believe iVE BEEN WITH RSDS.ORG 20 YEARS ,i HAVE BEEN ON AND OFF oPIATES BUT oNLY opiastes work there is an actual disease it is when the hundreds and thousands of people comit suicide when taken off opiates.My Doctor wants me to take Suboxone but it only irritates my [pain even more I have been shot 3 times and also Methadone though Ive reduced my meds ,I’ll go once more but if it is still so horrid I will be gone Oregon allows Heroin and Speed but Iwould rather be dead Im 67 been taking Opiates ofgf and on 50 years it saddens me that this Doctor has no understanding of RSD full body in 67 yr old male I was an RN for many decades the abrupt cessation of opiates leads to suicide many times the amount to the vitamins etc for people I read about ,Im so sorryu it comes to this Mark

    1. Annette Edel

      Mark, I am the mom of someone with RSD. I am terribly worried about him. He has had thus monster for 26 years. He hasn’t been to a doctor since the beginning if covid. His pain management is pretty much non-existent. He has a wonderful wife and great support system but has become bitter and very difficult to live with. Have you found anything helpful. I know that he feels that we don’t understand and of course we can’t imagine the pain be is feeling. These Utube presentations can be helpful but most are a total waste of time.
      I am so sorry that you are going that the same thing.

  4. Jennifer

    Recently diagnosed earlier this year. It is just recently that the pain has started for me, being continual not really stopping. I’ve developed Trochanteric bursitis in my right hip. My right foot/ankle is where my injury occurred,in 2020 before Thanksgiving. I’ve been in physical therapy ever since. Any advice on what to do next?
    Thanks so much,

  5. Crystal Zona

    Hi recently diagnosed, from one yr ago, after a mammogram and having a non cancerous tumor in my breast, affected area is upper left chest wall and arm pit, looking for doctors in the Rochester ny area. Thank you

  6. Adam

    I have now had crps in my right leg for 8 years now.Its crazy how fast time flies even when your sitting around in pain. I have had many downs and a little progress. This disease is hell. Best thing to do is stay active. Aa much as possible.

  7. Valerie Khouri

    Hi Dr. Sajben,

    I just came avross your wonderful information on Face Book support Group. My 31 year old son is getting mor eand more debilitated by the dat from his CRPS 2. In fact it just recently started the hot burning pain in his head and jaw. It is now from head to toe. It is like he is dying befor my eys. He is a good boy always hardworking and kind.WE HAVE NO HELP IN BOSTON! Don’t let being in Boston with the best medical care fool you! His primary could care less, but it is hard to leave and just guess to find one that would be good and is aware of his disease or at least cares enough to read the info. we sent. The physiatrist, neourologist, neurosrsurgeon he all saw, simply are like, sorry and dismiss him, though I hear from other people what great kind and helpful doctors they have willing to treat them and try different methods. It’s a factory here. Please please help and archanoiditus can send you a list of doctors in MA , New England or I am willing to go anywhere. Tjank you and God Bless you for helping others!

  8. alene

    Very interesting. I am a nurse recently diagnosed with crps type 1 following a crushing ingury of my thumb. I have undergone 3 blocks and have had improvement with circulation and mobility. The only medication i am on is CBD oil and recently added THC AND CBD. it is helpng but i keep having to increase my dose. My pain specialist is considereing a 4 injection. I had concerns after my last injection i had issues with the anathesia dose and Dr lowered it the second and third time. This past injection i could feel it. 2 days after i felt fins and needles in my left ankle the following day in my right ankle. Now it is from both left and wright feet to my knees. I informed my Dr and he was unsure as to what was going on. I have been trying to educate myself on CRPS. Is it possible this has spread ? Also looking for best pain management.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.