Jail Medicine



Prescribing Guideline Skeletal Muscle RelaxantsIntroduction. Skeletal Muscle Relaxants (SMRs) are a group of structurally unrelated medications commonly used to treat acute musculoskeletal pain and to reduce the spasticity of upper motor neuron lesions.Definitions. Skeletal Muscle Relaxants are generally divided into two categories:Antispasmotics refers to the group of SMRs prescribed for acute and chronic musculoskeletal pain. Antispasmotics include cyclobenzaprine (Flexeril), metaxalone (Skelaxin), carisoprodol (Soma), chlorzoxazone (Parafon forte), carisoprodol (Soma), methocabamol (Robaxin), and orphenadrine (Norflex) Antispastics refers to SMRs used to treat the spasticity of spinal cord lesions. Antispastics include baclofen and dantrolene.Tizanidine (Zanaflex) is both an antispasmotic and an antispastic.Mechanism of Action. Despite being named Skeletal Muscle Relaxants, the antispasmotic SMRs act as sedatives rather than by relaxing skeletal muscles. Providers should properly view these medications as sedatives. “Most (SMRs) don’t directly relax muscles. Any benefit is likely due to a sedative effect.” Prescriber’s Letter, February 2017Efficacy. There is limited evidence for the efficacy of some SMRs in reducing the symptoms of pain and spasm in acute musculoskeletal conditions. The evidence is best for short term treatment of acute low back pain. Cyclobenzaprine is the most studied of the SMRs.Abuse Potential. SMRs all have moderate abuse potential in correctional settings. Carisoprodol (Soma) is a DEA Schedule IV drug. Correctional practitioners should take the abuse potential of these drugs into account when making a decision to prescribe them.Principles of Prescribing. Many prescribing guidelines for SMRs have been published. These generally agree with the following principles:SMRs are second line agents for the treatment of acute low back pain When used, SMRs should be prescribed as PRN drugs for a short period of time SMRs should not be prescribed long termSince SMRs are sedatives, they have many potential drug interactions. In general, they should not be prescribed with other sedating drugsBaclofen should be used only to treat the spasticity of central nervous system conditions. Baclofen should not be prescribed for non-spastic conditions such as low back pain or non-spastic chronic pain syndromes.References:Choosing a Skeletal Muscle Relaxant. American Family Physician. 2008; 78(3):365-370Considerations for the Appropriate Use of Skeletal Muscle Relaxants for the Management of Acute Low Back Pain. P&T Vol. 39 (6). June 2014.Therapeutics Initiative. Is Cyclobenzaprine Useful for Pain? March-April 2017.Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain. JAMA 2015: 314(15):1572-1580The Prescriber’s Letter. Muscle Relaxants. Feb. 2017 ................
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