Neurologists have observed through review of muscle relaxants for chronic back pain relief that the use of Cyclobenzaprine, a muscle relaxant, may have harmful side effects that cause cardiac problems and sedation. This medicine had failed in the scientific tests for being used as an antidepressant, but it was subsequently used as a muscle relaxant. Another drug named Carisoprodol was banned by the European Medicines Agency for the emotional and physical dependence of the users taking it.
 
Doctors have been advised not to prescribe Carisoprodol as it has been found to be a sedative hypnotic agent and subject to misuse by many. There are older types of medication in the form of Methocarbamol, also known as Robaxin, and Mataxalone, also known as Skelaxin. Although they have been found to have the side effect of sedation, they are more preferred as drugs for the treatment of back pain because the amount of sedative effect is negligible. Orphenadrine, commonly known as Norflex, is another drug that is prescribed for back pain relief, but it has a high sedative effect, which can be compared to Benadryl.
 
The use of this drug may lead to physical impairment among motorists that is similar to the consumption of alcohol at a certain level. Tizanidine is a drug recommended for treatment of spasticity, but it has a good effect on reducing back pain. Although not approved as a pain reliever, this medicine can be quite useful for both spastic patients and those with chronic back pain.

Review Of Muscle Relaxants For Chronic Back Pain Relief

Muscle relaxants can be helpful when severe muscle spasms follow the start of low back pain.

This is Dr. Charles Argoff. I’m Professor of Neurology and Director of the Comprehensive Pain Center at Albany Medical College and Albany Medical Center in Albany, New York. I would like to present a pretty common situation for all of us, which is addressing the role of muscle relaxants for patients who might need them for management of chronic pain.

 

I want to review some of the more commonly prescribed muscle relaxants to get an understanding of what is available and what to be cautious about. Let’s look at cyclobenzaprine. The brand name of cyclobenzaprine is Flexeril. Cyclobenzaprine is a tricyclic antidepressant that failed in its development as an antidepressant and was subsequently redeveloped as a muscle relaxant. It is marketed in several forms, not only as Flexeril but also as Amrix. It is so structurally similar to amitriptyline that they differ by only a single double-bond. This is important because both amitriptyline and cyclobenzaprine share very important side effects, including the risk for sudden cardiac death, anticholinergic side effects, sedation, and others. It is very important to realize that when you prescribe cyclobenzaprine, you are prescribing a medication that is truly in the tricyclic antidepressant category. Keep that in mind when thinking about what other medications that patient may be using.

 

Another commonly prescribed muscle relaxant is carisoprodol, also known as Soma. It should be made clear that carisoprodol is now banned by the European Medicines Agency, the equivalent of the Drug Enforcement Administration, due to concerns about physical and emotional dependence on that medication. For those of you who do prescribe this drug, I would caution you that these risks are very real. One of the active metabolites of carisoprodol is meprobamate, which is a sedative-hypnotic agent that was sold under the name Miltown many years ago. Miltown was found in emergency department surveys to be frequently associated with misuse and overuse. Therefore, it is important to realize that what used to be fairly commonly prescribed as a muscle relaxant has some serious issues to consider.

 

Let’s look at 2 older medications. One is methocarbamol, also known as Robaxin. The other is metaxalone, also known as Skelaxin. These agents were developed over 30 years ago and are the least likely among the commonly prescribed medications to produce sedation, although they can produce sedation. These agents are very reasonable to consider. They do have side effects that you should look for, including sedation, but they are not as likely to cause sedation as some of the others. These are reasonable medications to consider.

 

Another very commonly prescribed medication is orphenadrine, sold under the brand name Norflex. One should be aware of the fact that orphenadrine is actually a diphenhydramine, a Benadryl look-alike in terms of its activity and mechanism of action. This is extremely important to realize, not only because you should know what you’re prescribing, but also because of the side-effect profile of this medication. As you are probably aware, diphenhydramine and orphenadrine can both produce sedation and motoric impairment that is comparable to using alcohol at certain levels. This is important if our goal in treating someone like this 42-year-old gentleman is to establish a regimen that will allow him to continue to function during the day.

 

Before ending this particular segment, I would like to turn to 2 medications that are not officially FDA-approved as muscle relaxants for acute or other care but which are used very frequently to treat spasticity because that is what they are approved for. The antispasticity medication tizanidine is sold under the brand name Zanaflex. What is neat about tizanidine is that, more than 20 years ago, it was shown in a study published in a British medical journal to be very effective in reducing pain associated with acute low back pain and acute musculoskeletal pain when combined with ibuprofen.[1] This is important because, although it is sold in this country and marketed as an antispasticity medication, there is very robust evidence for its use in chronic pain, chronic and acute musculoskeletal pain, and even chronic pain syndromes such as neuropathic pain. Tizanidine is an alpha-adrenergic agent similar to clonidine and has analgesic activity that you should be aware of. It is a sedating medication with a half-life of about 1.5 hours, so when given at night, it can help people wake up with much less spasm, much less tone, and not necessarily cause a “hangover effect” during the day. From a clinical perspective, I would only consider using Tizanidine at night to help a patient sleep more comfortably with less muscle-related spasm pain and wake up more refreshed without a hangover effect.

 

The other medication that is marketed for spasticity is baclofen, brand name Lioresal. Baclofen can also be used for the treatment of musculoskeletal-related pain in an off-label manner. I have done that, and sometimes the other muscle relaxants are not particularly effective. Side effects, including sedation and others, need to be very carefully monitored because, especially for this 42-year-old gentleman, patients want to be as fully active as possible and work to their full potential. We don’t want to prescribe medications that an individual may perceive as causing sedation.

 

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Analysing the side effects of most muscle relaxants in contrast to their efficacy as a relief for back pain, review of muscle relaxants for chronic back pain relief suggest to select a few of them where the benefits significantly outweigh the risks, and use the best ones that are actually recommended that can be less misused as sedatives.

Learn how natural herbs can relieve back pain and more in this health care video on chiropractic care taught by a pack pain expert Dr. Eric Sayer.

 
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