Can a healthcare provider prescribe muscle relaxers, such as cyclobenzaprine, long term?

Long-Term Muscle Relaxer Prescribing: Not Recommended

Healthcare providers should not prescribe muscle relaxers like cyclobenzaprine for long-term use, as the FDA explicitly states that cyclobenzaprine "should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available." 1

FDA-Approved Duration and Evidence Base

• The FDA label for cyclobenzaprine clearly limits use to 2-3 weeks maximum, noting that "muscle spasm associated with acute, painful musculoskeletal conditions is generally of short duration and specific therapy for longer periods is seldom warranted." 1
• All clinical trials of skeletal muscle relaxants were 2 weeks or less in duration, meaning there is literally no evidence supporting chronic use. 2, 3
• The American College of Physicians guidelines emphasize that skeletal muscle relaxants are "an option for short-term relief of acute low back pain" only, with insufficient evidence for chronic use. 4

Risks of Long-Term Use

Withdrawal and Dependence Issues

• With long-term cyclobenzaprine use, patients experience withdrawal symptoms (malaise, nausea, headache) for 2-4 days after discontinuation, requiring tapering over 2-3 weeks to prevent these symptoms. 4, 3
• Carisoprodol, another muscle relaxant, is classified as a controlled substance due to abuse potential and can cause severe withdrawal symptoms requiring slow tapering over 4-9 days. 4
• Tizanidine carries risk of withdrawal with rebound tachycardia, hypertension, and hypertonia if discontinued abruptly after long-term use. 4

Adverse Effects Profile

• Skeletal muscle relaxants are associated with significantly increased risk of any adverse event (RR 1.50) and central nervous system events including sedation (RR 2.04) compared to placebo. 4
• Cyclobenzaprine causes significant anticholinergic effects including hallucinations, confusion, drowsiness, constipation, urinary retention, and dry mouth due to its structural similarity to amitriptyline. 4, 3
• The medication has potential for dangerous drug interactions with sedatives, anesthetic agents, and can cause serotonin syndrome when combined with monoamine oxidase inhibitors or other serotonergic agents. 4, 3

Special Populations at Higher Risk

Elderly Patients

• The American Geriatrics Society recommends discontinuing cyclobenzaprine entirely rather than switching to another muscle relaxant, due to lack of evidence for chronic use and significant adverse effect burden. 5
• The Society for Perioperative Assessment and Quality Improvement contraindicates tizanidine (often considered as an alternative) in elderly patients due to significant sedative and hypotensive effects. 5
• Muscle relaxants are identified in the American Geriatrics Society Beers Criteria as potentially inappropriate medications for older adults due to significant sedation and fall risk. 5

Clinical Approach When Long-Term Use Has Occurred

Discontinuation Strategy

• If a patient has been on cyclobenzaprine long-term, taper gradually over 2-3 weeks to prevent withdrawal symptoms rather than stopping abruptly. 4, 5, 3
• Do not switch to alternative muscle relaxants (like tizanidine or baclofen) as these also lack evidence for chronic use and carry similar or worse adverse effect profiles. 2, 5, 3

Alternative Management

• Insufficient evidence exists for chronic use of any muscle relaxant for musculoskeletal pain, so focus should shift to non-pharmacologic approaches and physical therapy. 4, 2, 3
• For chronic pain conditions, consider evidence-based alternatives such as tricyclic antidepressants for chronic low back pain (which have demonstrated efficacy unlike chronic muscle relaxant use). 4

Common Pitfalls to Avoid

• Do not continue prescribing muscle relaxants beyond 2-3 weeks simply because a patient reports subjective benefit—this exceeds FDA-approved duration and evidence base. 1
• Do not assume that switching from one muscle relaxant to another addresses the fundamental problem of lack of efficacy data for chronic use. 2, 3
• Avoid combining muscle relaxants with other sedating medications or alcohol, as this significantly increases central nervous system depression risk. 4
• Do not prescribe muscle relaxants for spasticity from cerebral or spinal cord disease, as cyclobenzaprine "has not been found effective in the treatment of spasticity associated with cerebral or spinal cord disease." 1