opinions on muscle relaxants

[masterofmonkeys]

hello everyone. I'm a pgy-1 psychiatrist with a strong interest in MSK dysfunction (not PAIN darnit, the causes of pain). Anyway one of the problems I deal with a lot is the fact that back pain/fibromyalgia/borderline/depression/anxiety patients are often on a slew of pain medications that are also bigtime CNS depressants and/or have euphoric/abuse potential.

Not good side effects, especially in this population.

Needless to say I stay the heck away from Soma and d/c it when the patient agrees.

I usually schedule them on cyclobenzaprine, but it's pretty weak as muscle relaxants go.

I'll use robaxin if there aren't going to be significant drug/drug interactions and I know they've got an upcoming appointment with a pain/back/whatever specialist.

Don't have a lot of experience with skelaxin, good or bad.

Curious what you guys would suggest.

---

Members don't see this ad.

 

[PMR 4 MSK]

hello everyone. I'm a pgy-1 psychiatrist with a strong interest in MSK dysfunction (not PAIN darnit, the causes of pain). Anyway one of the problems I deal with a lot is the fact that back pain/fibromyalgia/borderline/depression/anxiety patients are often on a slew of pain medications that are also bigtime CNS depressants and/or have euphoric/abuse potential.

Not good side effects, especially in this population.

Needless to say I stay the heck away from Soma and d/c it when the patient agrees.

I usually schedule them on cyclobenzaprine, but it's pretty weak as muscle relaxants go.

I'll use robaxin if there aren't going to be significant drug/drug interactions and I know they've got an upcoming appointment with a pain/back/whatever specialist.

Don't have a lot of experience with skelaxin, good or bad.

Curious what you guys would suggest.

Muscle Relaxers are best for acute muscle sprains and strains, and are usually of little benefit when used chronically. Pts who find benefit are usually experiencing the sedative side effects and using that more than anything. In fact, most of the MRs mechanism of action is via the descending reticular system, and hence, mainly work through sedation.

The exceptions are the anti-spasticity meds such as baclofen or tizanidine, or dantrolene. The have vastly different mechanisms of action and work best on CNS-induced spasticity, such as SCI, TBI, CVA, etc.

Sometimes I use them as a sleep aid. Cyclobenzaprine is quite sedating for many people, but a few can take it with no side effects (5 mg will stone me for several hours). The others tend to be less sedating.

I D/C Soma even if the pt doesn't agree, except for acute strains. I will not use it chronically.

 

[ampaphb]

Soma was just placed in the Schedule IV of the Louisiana Uniform Controlled Substance Law.

 

[masterofmonkeys]

Muscle Relaxers are best for acute muscle sprains and strains, and are usually of little benefit when used chronically. Pts who find benefit are usually experiencing the sedative side effects and using that more than anything. In fact, most of the MRs mechanism of action is via the descending reticular system, and hence, mainly work through sedation.

sedation is one thing. Getting high is another. Which is why I hate Soma so much.

There've been a few trials with cyclobenzaprine in longer-term use for fibromyalgia. I know it mostly helps with sleep and doesn't help a ton with tender points, but it does seem to have a decent amount of symptom reduction without getting you high.

And there are quite a few chronic back and neck pain patients for whom a significant component of their pain is due to spasm (not that I'm telling you anything you don't know), usually due to involuntary guarding.

With these patients, we go through some stretching and light strengthening, as well as breathing-relaxation and mindfulness exercises. The goal is to wean off the muscle relaxants as they develop more muscle control and awareness. They're usually pretty far along the process by the end of a 1 week inpatient stay.

The exceptions are the anti-spasticity meds such as baclofen or tizanidine, or dantrolene. The have vastly different mechanisms of action and work best on CNS-induced spasticity, such as SCI, TBI, CVA, etc.

Agreed.

I D/C Soma even if the pt doesn't agree, except for acute strains. I will not use it chronically.

Good. The only patients I don't fight with too hard are the ones that are getting it prescribed by their rheumatologists, etc. Usually I win after a short attempt at a convincing argument. Sometimes I don't. And I know it's a lost cause if their 'back pain' doc is just going to put them right back on it even if I do manage to d/c.

Basically I'm in a situation where its damned if you do, damned if you don't. It's hard to get a patient who's on opiods, muscle relaxers, and benzos off of all of those things. Especially in the acute settings I'm currently in (and may stay in after residency...who knows). And with so many physicians out there who don't mind prescribing the things, to the detriment of their patients needs (not wants), you have to pick your battles.

I consider it a victory if i can get them off the opioids, benzos, and soma.

 

[Hemisphere]

well don't claim victory yet... just by getting them off the meds.
patient needs and 'wants' really aren't all that much different.

if you think your patients just ask the back pain doctor for the meds after you take them off it because they 'want' them, there are probably underlying psychiatric needs that havent been met. if they really do have a physical source of pain, they might find themselves unable function off the meds. think about an 80 year old man who cant get up and walk unless he takes a few percocet a day for severe arthritis and didn't start taking meds until later in life.

ideally you are right getting off the meds is a victory, but think of having them restarted not as a defeat or as the back pain doctors fault for restarting them. if you feel the needs are purely psychiatric and upset the meds were prescribed - call the back pain doctor and discuss it with him!
maybe he can shed some light on his physical exam or imaging findings that there might be something physical underlying the pain as well.

 

[masterofmonkeys]

well don't claim victory yet... just by getting them off the meds.

I don't. But it's the first step in them taking an active role in managing their disorders. Getting them off meds is the first step in better body awareness, better psychological pain control, better outlook, and better adaptive behaviors.

patient needs and 'wants' really aren't all that much different.

I bet to differ on that. My experience is colored by the fact that I'm pretty much a walking textbook example of spine and peripheral nerve problems with a fair amount of education in neurological and MSK dysfunction.

My last visit to a doctor:
"so why are you here?"
"scapulothoracic dysfunction"
"so shoulder pain?"
"no. scapulothoracic dysfunction CAUSING shoulder pain."
"so you want your pain treated"
"no you don't treat pain, you manage it. I want help decreasing the amount of scapulothoracic dysfunction present."
"ummm. sooo. Roid shot or opioid?"
"argh! i'm leaving!!!"

What I need is help managing the sequelae of peripheral nerve damage by addressing muscle imbalances, joint health, and spasm through multiple treatment modalities. How many patients vocalize things that way though? Most just say 'stop the pain!!!'

if you think your patients just ask the back pain doctor for the meds after you take them off it because they 'want' them, there are probably underlying psychiatric needs that havent been met.

I don't think they just ask for them because they 'want' them. But I see a lot of patients with unaddressed muscle imbalances, etc. Often they've been through physical therapy but didn't put in much effort. In the case of the patients with fibromyalgia, they won't engage in the physical activities (like water aerobics and light weight-training) that can significantly reduce pain and improve function. Because it hurts. And they don't want to hurt.

When a patient can do something to increase their health and quality of life but is struggling with what are essentially psychological blocks (fear of pain, negative worldview, poor motivation), then it's my job as a psychiatrist to wear down those blocks. Sometimes certain meds get in the way of it. Sometimes the meds are an easy way out. Sometimes the meds directly get in the way of it (getting high and sedation are too easy ways to avoid dealing with pain).

if they really do have a physical source of pain, they might find themselves unable function off the meds. think about an 80 year old man who cant get up and walk unless he takes a few percocet a day for severe arthritis and didn't start taking meds until later in life.

Agreed. For some this is true.

ideally you are right getting off the meds is a victory, but think of having them restarted not as a defeat or as the back pain doctors fault for restarting them. if you feel the needs are purely psychiatric and upset the meds were prescribed - call the back pain doctor and discuss it with him!

I do when I can. When the 'back pain' doctor is a rheumatologist, family doctor, or pain physician with limited respect for and/or understanding of the contribution of MSK dysfunction to the pain, and how physical therapy, TENS/MENS, stretching, postural training, and exercise can reduce the pain, I'm somewhat limited though.

maybe he can shed some light on his physical exam or imaging findings that there might be something physical underlying the pain as well.

Note I am not talking about somatization, but rather real physical pain, for which psychological factors play a role in perception of severity, motivation for rehabilitation, etc.

 

[RUOkie]

Note I am not talking about somatization, but rather real physical pain, for which psychological factors play a role in perception of severity, motivation for rehabilitation, etc.

If I am understanding you, you are discussing the role that symptom magnification plays in the manifestation of pain. In clinical pracitce, it is nearly ubiquitous. Think about it. What is pain? In reality, it is the emotional and psychological response to a noxious stimulus. If you look at it that way, either all or no pain is "somatization". In my opinion it is somewhere in between.

In the old days, pain clinics involved psychologists, PT/OT physicians and social workers. Those clinics were overused however, and now don't exist (except in a few locations).

What I do, is use medications, injections and modalities to help treat symptoms. When I see pts. in the office I try to get them to own their symptoms. If they are passive and waiting for a cure, they will not improve. I explain to the patients that I WILL NOT CURE THEM. Sometimes the patients cure themselves, but usually "learn to live with it". I use a lot of catch phrases like: "There is a difference between pain and injury" or " you are going to need to make yourself hurt in order to get better". By empowering the patient, they learn to FUNCTION better. That is what it is all about.

 

[PMR 4 MSK]

What is pain? In reality, it is the emotional and psychological response to a noxious stimulus.

It is also often the perceived notion of noxious stimuli, or in the now-popular definition of pain, the perceived or actual threat of tissue damage.

That perception that something is broken and needs to be fixed is one of the biggest hurdles in many patients.

Often, just altering the perception, via chemical, physical or psychological therapy can make all the difference. To be, that's what painm management is - altering the perception of pain.

 

[RUOkie]

It is also often the perceived notion of noxious stimuli, or in the now-popular definition of pain, the perceived or actual threat of tissue damage.

That perception that something is broken and needs to be fixed is one of the biggest hurdles in many patients.

Often, just altering the perception, via chemical, physical or psychological therapy can make all the difference. To be, that's what painm management is - altering the perception of pain.

Exactly what I was trying to say, But you said it much more succinctly!

 

[masterofmonkeys]

If I am understanding you, you are discussing the role that symptom magnification plays in the manifestation of pain. In clinical pracitce, it is nearly ubiquitous. Think about it. What is pain? In reality, it is the emotional and psychological response to a noxious stimulus. If you look at it that way, either all or no pain is "somatization". In my opinion it is somewhere in between.

Agreed.

What I do, is use medications, injections and modalities to help treat symptoms. When I see pts. in the office I try to get them to own their symptoms. If they are passive and waiting for a cure, they will not improve. I explain to the patients that I WILL NOT CURE THEM. Sometimes the patients cure themselves, but usually "learn to live with it". I use a lot of catch phrases like: "There is a difference between pain and injury" or " you are going to need to make yourself hurt in order to get better". By empowering the patient, they learn to FUNCTION better. That is what it is all about.

Exactly.