Prescription of nonsteroidal anti-inflammatory drugs and muscle relaxants forback pain in the United States.

Secondary analysis of the 2000 Medical Expenditure Panel Survey(MEPS). OBJECTIVE.: To examine national prescription patterns of nonsteroidalanti-inflammatory drugs (NSAIDs) and muscle relaxants among individuals withback pain in the United States. SUMMARY OF BACKGROUND DATA: There is a lack ofinformation on national prescription patterns of NSAIDs and muscle relaxantsamong individuals with back pain in the United States. METHODS: TraditionalNSAIDs, cyclooxygenase-2-specific (COX-2) inhibitors, and muscle relaxants wereinvestigated. Individuals with back pain were stratified by socio-demographiccharacteristics and geographic regions. For each medication category, overallprescribing frequency was compared across different strata and individual drugprescription was analyzed. RESULTS: Traditional NSAIDs, COX-2 inhibitors, andmuscle relaxants, respectively, accounted for 16.3%, 10%, and 18.5% of totalprescriptions for back pain in 2000. Among individual drugs, ibuprofen andnaproxen accounted for most of the prescriptions for traditional NSAIDs (60%),whereas two thirds of the prescriptions for muscle relaxants were attributableto cyclobenzaprine, Carisoprodol ( Soma ), and methocarbamol. Prescription of COX-2inhibitors or muscle relaxants demonstrated wide variations across differentregions. Several individual characteristics including age, race, and educationallevel were associated with the prescription of some of the medications.CONCLUSIONS: Neither traditional NSAIDs, nor COX-2 inhibitors, nor musclerelaxants dominated prescriptions for back pain. However, a small number ofindividual drugs were attributable to most of the prescriptions for traditionalNSAIDs or muscle relaxants. The prescription of some of the medicationsdemonstrated wide variations across different regions or different racial andeducational groups. More studies are needed to understand the source of thevariations and what constitutes optimal prescribing.

Carisoprodol ( Soma ), meprobamate, and driving impairment.

This paper considers the pharmacology of the centrally acting muscle relaxantCarisoprodol ( Soma ), and its metabolite meprobamate, which is also administered as ananxiolytic in its own right. Literature implicating these drugs in impaireddriving is also reviewed. A series of 104 incidents in which these drugs weredetected in the blood of drivers involved in accidents or arrested for impaireddriving was considered, with respect to the analytical toxicology results,patterns of drug use in these subjects, the driving behaviors exhibited, and thesymptoms observed in the drivers. Symptomatology and driving impairment wereconsistent with other CNS depressants, most notably alcohol. Reported drivingbehaviors included erratic lane travel, weaving, driving slowly, swerving,stopping in traffic, and hitting parked cars and other stationary objects.Drivers on contact by the police displayed poor balance and coordination,horizontal gaze nystagmus, bloodshot eyes, unsteadiness, slurred speech, slowresponses, tendency to doze off or fall asleep, difficulty standing, walking orexiting their vehicles, and disorientation. Many of these cases had alcohol orother centrally acting drugs present also, making difficult the attribution ofthe documented impairment specifically to Carisoprodol ( Soma ) and meprobamate. In 21cases, however, no other drugs were detected, and similar symptoms were present.Impairment appeared to be possible at any concentration of these two drugs;however, the most severe driving impairment and most overt symptoms ofintoxication were noted when the combined concentration exceeded 10 mg/L, alevel still within the normal therapeutic range.

Carbidopa-levodopa overdose.

A 57-year-old woman ingested 15 to 17 tablets of carbidopa-levodopa 10/100tablets (carbidopa 150 mg and levodopa 1,500 mg) along with ibuprofen,Carisoprodol ( Soma ), hydrocodone, and acetaminophen. The patient developed choreiformmovements that persisted despite obtundation and attempts to extinguish themwith naloxone, morphine, and diazepam. When the patient developed a rising levelof creatine phosphokinase and myoglobinuria, she was treated with ventilatorysupport and pancuronium. She required paralysis for 60 hours, when her chorearesolved.

Comparative efficacy and safety of skeletal muscle relaxants for spasticity andmusculoskeletal conditions: a systematic review.

Skeletal muscle relaxants are a heterogeneous group of medications used to treattwo different types of underlying conditions: spasticity from upper motor neuronsyndromes and muscular pain or spasms from peripheral musculoskeletalconditions. Although widely used for these indications, there appear to be gapsin our understanding of the comparative efficacy and safety of differentskeletal muscle relaxants. This systematic review summarizes and assesses theevidence for the comparative efficacy and safety of skeletal muscle relaxantsfor spasticity and musculoskeletal conditions. Randomized trials (forcomparative efficacy and adverse events) and observational studies (for adverseevents only) that included oral medications classified as skeletal musclerelaxants by the FDA were sought using electronic databases, reference lists,and pharmaceutical company submissions. Searches were performed through January2003. The validity of each included study was assessed using a data abstractionform and predefined criteria. An overall grade was allocated for the body ofevidence for each key question. A total of 101 randomized trials were includedin this review. No randomized trial was rated good quality, and there was littleevidence of rigorous adverse event assessment in included trials orobservational studies. There is fair evidence that baclofen, tizanidine, anddantrolene are effective compared to placebo in patients with spasticity(primarily multiple sclerosis). There is fair evidence that baclofen andtizanidine are roughly equivalent for efficacy in patients with spasticity, butinsufficient evidence to determine the efficacy of dantrolene compared tobaclofen or tizanidine. There is fair evidence that although the overall rate ofadverse effects between tizanidine and baclofen is similar, tizanidine isassociated with more dry mouth and baclofen with more weakness. There is fairevidence that cyclobenzaprine, Carisoprodol ( Soma ), orphenadrine, and tizanidine areeffective compared to placebo in patients with musculoskeletal conditions(primarily acute back or neck pain). Cyclobenzaprine has been evaluated in themost clinical trials and has consistently been found to be effective. There isvery limited or inconsistent data regarding the effectiveness of metaxalone,methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo inpatients with musculoskeletal conditions. There is insufficient evidence todetermine the relative efficacy or safety of cyclobenzaprine, Carisoprodol ( Soma ),orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone.Dantrolene, and to a lesser degree chlorzoxazone, have been associated with rareserious hepatotoxicity. Copyright 2004 U.S. Cancer pain relief Committee