STOP TAKING MUSCLE RELAXERS FOR LOW BACK PAIN

I am writing this blog because I am fed up. FED UP! I am sick and tired of hearing about people going to urgent care or the emergency department for acute low back pain, and subsequently walking away with a prescription for muscle relaxers and opioids. I have described my feelings towards opioids as a treatment for acute and chronic orthopedic pain in a previous blog I wrote, The U.S. Opioid Crisis: How Can Physical Therapy Help? Click HERE to read. So I will be specifically focusing on the prescription of muscle relaxers for acute low back pain in this blog. 

There is an overwhelming amount of statistics regarding low back pain, as it has been the leading cause of disability worldwide for the past 30 years (James SL, et al). In the US, low back and neck pain had the highest amount of healthcare spending in 2016 with an estimated $134.5 billion (Dieleman JL, et al). In summary, low back pain is a national and global epidemic.

Muscle relaxants, a broad class of drugs that include non-benzodiazepine antispasmodic and antispastics, are all too frequently prescribed in the US. In 2016, muscle relaxants exceeded more than 30 million prescriptions for ambulatory care visits in the US, and are the third most commonly prescribed drug for low back pain (Soprano SE, et al). What is incredibly interesting (or suspicious?) is the fact that recommendations for the use of muscle relaxants have conflicted between international clinical practice guidelines for low back pain. The US guidelines recommend non-benzodiazepine antispasmodics as the drug of choice for acute low back pain, however the Belgian guideline discourages such use, and the UK guideline does not make a recommendation (Cashin A G, et al). In conclusion, the US is one of the only modern countries that recommends muscle relaxers as a treatment for acute low back pain. Clearly this is an issue, as these medications and use of opioids have become a national crisis.

I have had multiple patients and friends share their experiences with me, almost all of them follow the same pattern. They have an episode of acute idiopathic low back pain, they are concerned it is something more serious, so they go to urgent care or the emergency department to rule out any red flags. If there is no injury involved, the clinicians rule out more serious conditions (non musculoskeletal related issues such as kidney related pain, etc). Then perform a quick assessment of myotomes and dermatomes, then maybe an hasty screening of movement. Once red flags are cleared, they are sent home with a prescription for muscle relaxers, and almost never a referral to physical therapy. However, there is little evidence that muscle relaxers actually work. 

Extensive uncertainty exists about the clinical effectiveness and safety of muscle relaxants. A recent study has found that “very low certainty evidence shows that non-benzodiazepine antispasmodics might provide small but not clinically important reductions in pain intensity at or before two weeks and might increase the risk of an adverse event in acute low back pain,” (Cashin A G, et al). Even beyond their skeptical clinical efficacy, is the concern for safety of the drugs, as there are significant increases in side effects with both short and long-term use.

There are numerous reasons not to utilize muscle relaxers as a treatment for low back pain, but I will focus on the main ones:

1) Side effects: Main side effects include drowsiness, dizziness, agitation, irritability, headache, nervousness, dry mouth, decreased blood pressure, and can affect vital organs such as the liver and heart. Symptoms like drowsiness and dizziness can make it dangerous to perform daily activities while under the influence of muscle relaxers, such as driving a car. Also, these symptoms can lead to an increased risk of falls and other injuries.

2) Potential for abuse and addiction: Prolonged use can lead to increased tolerance and physical dependence (Gonzalez LA, et al). Many individuals take muscle relaxers alone or in combination with other illicit drugs for nonmedical reasons, such as to produce or enhance feelings of euphoria and dissociation. In 2010 there were over 12,000 emergency room visits associated with Flexeril (a commonly prescribed muscle relaxer), and in 2016 over 10,000 calls to the Poison Control Centers had involved Flexeril (American Addiction Centers).

3) Global Effects: Muscle relaxers act as central nervous system depressants and cause a sedative effect, preventing your nerves from sending pain signals to your brain. Like most pain medications, muscle relaxers do not pinpoint their approach to a single muscle group affected. In reality, muscle relaxers can only attribute their effectiveness (if any) because of their ability to sedate the body globally and numb you to pain. If all muscles become relaxed, including the ones that caused the pain to begin in the first place, the root cause of the issue will only become aggravated. You will not be able to thoughtfully move in a way that will promote healing, and could potentially be causing more damage. 

4) Mask symptoms: Because muscle relaxers depress the central nervous system, they will most likely mask crucial feedback from your body that gives information about the movements that are causing the pain. Contrary to what you may think, pain isn’t always a bad thing. It is our body's way of communicating to us that something is wrong. This feedback is extremely important, so if we mask the pain we could be doing more damage than we realize. 

If you have made it this far in the blog, why do you think muscle relaxers are still prescribed as a treatment for low back pain? I’m baffled, especially when movement and exercise are proven to be a very effective treatment for low back pain. Yet, most of these individuals are not referred to physical therapy. Why? The healthcare system values quick fixes over long-term solutions. This REACTIVE system is not effective and ends up costing more in the long run. We need to educate individuals on how to be PROACTIVE about their health and wellness. 

In a study on physical therapy as the first point of care to treat low back pain, patients who received care from a physical therapist first experienced lower out-of-pocket, pharmacy, and outpatient costs after one year and reduced their likelihood of receiving an opioid prescription by 87% compared with patients who never visited a physical therapist (Frogner, Bianca K., et al). 

Please consider physical therapy as your first line of defense of low back pain. Your physical therapist is more than capable screening for red flags, and will refer you appropriately if they suspect something more sinister is occuring. If it is truly of musculoskeletal or neuromuscular origin, physical therapy should be your first option. If you have low back pain and don’t know where to go, please schedule a FREE phone consultation with one of our doctors of physical therapy. 

1. James SL, Abate D, Abate KH, et al., GBD 2017 Disease and Injury Incidence and Prevalence Collaborators Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet2018;392:1789-858. doi:10.1016/S0140-6736(18)32279-7. Pmid:30496104

2. Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863–884. doi:10.1001/jama.2020.0734

3. Soprano SE, Hennessy S, Bilker WB, Leonard CE Assessment of Physician Prescribing of Muscle Relaxants in the United States, 2005-2016. JAMA Netw Open2020;3:e207664. doi:10.1001/jamanetworkopen.2020.7664. Pmid:3257919

4. Cashin A G, Folly T, Bagg M K, Wewege M A, Jones M D, Ferraro M C et al. Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis BMJ 2021; 374 :n1446 doi:10.1136/bmj.n1446

5. Frogner, Bianca K.; Harwood, Kenneth; Andrilla, C. Holly A.; et al. “Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs.” Health Services Research, December 2018. https://pubmed.ncbi.nlm.nih.gov/29790166/

6. Gonzalez LA, Gatch MB, Forster MJ, Dillon GH. Abuse Potential of Soma: the GABA(A) Receptor as a Target. Mol Cell Pharmacol. 2009 Jan 1;1(4):180-186. PMID: 20419052; PMCID: PMC2858432.

7. Side effects of muscle relaxers (short & long-term side effects). American Addiction Centers. (2022, September 14). Retrieved October 27, 2022, from https://americanaddictioncenters.org/prescription-drugs/side-effects-of-muscle-relaxers

Dr. Samantha Benavides

Co-Owner

PT, DPT