564 - Muscle Relaxants for Pain, Antibiotic Duration, Anatomy of Trust
From the Literature
1) Use of Muscle Relaxants for Chronic Pain
Chronic pain is commonly defined as pain that lasts > 3 months and/or extends past normal tissue healing time and has a prevalence for US adults of >20%. Guidelines such as the Centers for Disease Control and Prevention’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain emphasizes a multimodal approach to pain management, incorporating nonpharmacologic and nonopioid pharmacologic treatment options, but leaving considerable latitude as to recommended treatment. In 2017, the American College of Physicians published a Clinical Practice Guideline (which was endorsed by the American Academy of Family Physicians) on the treatments for acute, subacute, and chronic low back pain, emphasizing non-opioid treatment including
nonsteroidal anti-inflammatories (NSAIDs) and muscle relaxant medications for acute low back pain.
However, with the emphasis in guidelines (and the evidence) to avoid the prescribing of opioid medication for chronic low back pain, there has been an increase in the use of skeletal muscle relaxants (SMRs) for chronic pain. The centrally acting SMRs are a pharmacologically diverse category of medications that include antispasticity and antispasmodic medications, such as baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, and tizanidine. They are indicated for acute musculoskeletal conditions including spasms and low back pain but are commonly used off-label for numerous other pain and non-pain conditions. This includes approximately one-third of patients being prescribed SMRs who do not have a preceding musculoskeletal disorder diagnosis.
A recently published systematic review investigated the long-term use of SMRs for chronic pain, focusing on their efficacy and safety. The study reviewed 44 clinical trials and cohort studies and found that SMRs may be beneficial in treating certain painful chronic conditions such as trigeminal neuralgia, painful cramps, and neck pain but were not significantly more effective than placebo for fibromyalgia, low back pain, or other chronic pain syndromes.
This indicates that the benefits of SMRs are condition specific. Side-effects are quite common and include sedation and dry mouth. Given these findings, the authors recommend that clinicians consider deprescribing SMRs if pain relief goals are not met, especially due to the potential for central nervous system side effects. Additionally, the guidelines referenced above have shown that non-pharmacological approaches, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation are all modalities that should be considered as part of a customized, comprehensive approach for most patients who have chronic low back pain rather than relying on pharmacologic therapy alone.
Mark’s Comments:
For we in primary care, the review underscores the importance of individualized treatment strategies and the careful monitoring of SMRs' effectiveness and side effects, remembering that there are many modalities that can help these patients, and pills of any sort are only one of them. Without the incorporation of some of these non-pharmaceutical modalities, optimal control of this pain for most patients will likely not occur. From the perspective of caring for our elderly patients, this review appears to call us to even greater vigilance when using this medication class. Note that the American Geriatrics Society 2023 updated Beers Criteria® for potentially inappropriate medication use in older adults lists this class of medications as “Avoid” with a strong strength of recommendation.
Reference:
Oldfield B et al. Long-Term Use of Muscle Relaxant Medications for Chronic Pain: A Systematic Review. JAMA Netw Open. 2024;7(9):e2434835. Link
From the Literature
2) Antibiotic Duration for Respiratory Infections
There has been a move to shorter durations of antibiotic therapy for many infections over the last 20 years or so. These changes are inherently hard to get used to for clinicians trained with the longer durations (or maybe it just seems so to me), so knowing that the recommendations are based on solid evidence is important. The authors of a recent “umbrella” systematic review sought to lay out the evidence for shorter antibiotic durations for the following infections: community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), hospital-acquired pneumonia (HAP), acute sinusitis, and streptococcal pharyngitis/tonsillitis.
The researchers performed a good search, had explicit questions to answer, and graded the quality of the systematic reviews they found. They made use of an interesting artificial-intelligence-based approach that sounded overall reasonable as there were multiple human checkpoints used by the researchers. They limited their search for evidence to adults only but included both inpatient and outpatient settings of treatment. They found a total of 40 systematic reviews, but unfortunately graded them as low or very low quality. They could not combine most of the data by meta-analysis, so had to present the results narratively.
· CAP: 14 reviews were found. They defined short course antibiotics as 1 to 8 days, and longer course as 3 to 14 days. The included reviews varied as to whether they excluded studies with azithromycin (which has long had a shorter recommended course). Some did, some just analyzed azithromycin data separately. Overall, the reviews favored short course therapy for delivering a higher proportion of clinical cures, settling on an average of five days of therapy as the most effective. Shorter antibiotic courses also had similar microbiologic cure rates, and fewer adverse events.
· ACOPD: 8 reviews were found. Clinical and microbiological cure rates were similar between short and long courses, but adverse events were fewer in the short course groups. Again, five days seemed to be the optimum duration of therapy for these infections.
· HAP: 3 reviews were found, but there was so much variation between reviews (mainly ventilator-associated pneumonias vs. not) that no useful conclusions could be reached.
· Sinusitis: 4 reviews were found, but only two provided useful data. Short course antibiotics produced similar clinical and microbiologic cure rates as longer courses. Adverse events were similar also, but when a sub-analysis specifying 5 days of treatment compared with 10 days of treatment was performed, the 5 day course led to fewer events.
· Pharyngotonsillitis: Eight reviews were found, all of which required microbiologic confirmation of the infection, but still assessed clinical cure outcomes. Interestingly, shorter courses of cephalosporin antibiotics were better than longer course penicillin. Short courses of penicillins were not effective compared to longer courses.
In addition to the concerns about the quality of the evidence, the authors note that these findings should not be applied to immunocompromised patients.
John’s Comments:
Remember when 10 days of antibiotics was the rule for almost all infections? Simpler times…but antibiotic overuse is a known threat. The quality of evidence leaves a lot to be desired here, but there does seem to be consistency in the findings. For CAP, AECOPD, and sinusitis, a five-day course seems like a reasonable routine choice, but extending therapy to 10 days also seems very reasonable for a patient who is not responding well. For pharyngotonsillitis, confine short courses to cephalosporins, while penicillins still need a 10-day course.
Reference:
Kuijpers SME, Buis DTP, Ziesemer KA, et al. The evidence base for the optimal antibiotic treatment duration of upper and lower respiratory tract infections: an umbrella review. The Lancet Infectious Diseases. Published online September 2024:S1473309924004560. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Trust Me, I’m a Doctor: The Anatomy of Trust
“The best way to find out if you can trust somebody is to trust them.” ― Ernest Hemingway
Consider for a moment the qualities of someone you would say you “trust fully,” and someone whom you “don’t trust.” How did you establish these judgments? Though we don’t talk about it often, trust is certainly foundational in our work; trust in ourselves, our care team, our colleagues, the systems we work in, the medications we prescribe, and the equipment we use. And trust in healthcare is fragile these days.
The establishment of trust is also necessary in our relationships with patients. As a Family Medicine resident, I was often struck by the trust patients placed in me, even when making life-or-death decisions. Despite being a trainee, my opinion was sometimes valued even more than my attending’s or a consultant. This prompted me to become a “student” of trust.
During my research, I came across a “trust equation” that has continued to resonate:
Trust = Connection x Competence
Risk
In this equation, “connection” is built through empathy and caring (“I sense you care about me”), while “competence” speaks to demonstrated skill and knowledge (“you appear to know what you’re doing”). The “risk” factor underscores that trust isn’t absolute but varies depending on the perceived vulnerability involved. When someone feels exposed or dependent on another’s judgment, the stakes—and the importance of trust—are higher.
How can we strengthen these pillars in our daily work? Consider starting with small, actionable steps. For example, spend an extra minute explaining the rationale behind a treatment plan or decision. Listen without interrupting when someone shares their concerns. Acknowledge uncertainties openly, showing that you’re committed to working through them together. These actions help build the “relationship” side of the equation, while our regularly honing fundamental skills fortifies the “competence” component.
Ultimately, trust requires more than credentials, clinical skills, or a title; it demands a willingness to engage, communicate, and make oneself vulnerable. Rebuilding trust in healthcare isn’t a quick fix but an ongoing commitment. Continuously revisiting these fundamentals, not just as a theoretical exercise but as a practical approach to our interactions, will help us together find our way forward with our patients and with each other. Let’s give it a try. Trust me, I’m a doctor …
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Mark and John
Carilion Clinic Department of Family and Community Medicine