Cyclobenzaprine, better known by the brand name Flexeril, is a skeletal muscle relaxant. Its primary medicinal use is to treat pain and stiffness that is associated with muscle spasms and disorders that are musculoskeletal as opposed to pain and stiffness associated with central nervous system conditions.
The mechanism of action of Flexeril is believed to be primarily involved in increasing the release of the neurotransmitter norepinephrine as a result of stimulating the area in the brain known as the locus coeruleus. The use of Flexeril is most often accompanied with physical therapy, and its use is not designed for long-term treatment. Because issues with tolerance develop very quickly, the drug becomes ineffective after only a few weeks of regular use. Instead, the drug is most often prescribed for a week or two and then discontinued while physical therapy and other forms of treatment may continue. Flexeril is not as an effective treatment option for pain and muscle spasm issues that arise from involvement of the central nervous system, such as for individuals who have multiple sclerosis, spinal cord injuries, or brain injuries.
Cyclobenzaprine is available in several different forms, but it is most often used as tablets or capsules. There is an extended-release form of the drug (brand name Amrix). Cyclobenzaprine is usually administered in small doses several times a day (e.g., 5 mg three times a day with potential increases to 10 mg three times a day). The drug has lost favor for use in elderly individuals because one of the side effects of the drug is confusion and even hallucinations in this group of individuals.
The drug is not listed as a controlled substance by the United States Drug Enforcement Administration (DEA) and therefore is not considered by the federal government to be a significant potential drug of abuse. This could be because the drug is not designed for long-term use and is typically only prescribed for a few days to a few weeks at a time. The development of physical dependence takes longer than the timeframe for which Flexeril is usually prescribed medicinally.
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The Addiction Potential of Flexeril
The Substance Abuse and Mental Health Services Administration (SAMHSA) expends considerable resources to accurately conduct surveys to estimate the use and misuse of various types of prescription medications, illicit drugs, and alcohol in the United States on a yearly basis. Data for the previous year’s results are typically published in the fall of the following year. According to the data from SAMHSA released in the fall of 2017:
- In 2015, it was estimated that 4.8 million individuals used Flexeril; in 2016, the estimation was 5.2 million.
- In 2015, it was estimated that 255,000 individuals engaged in at least one misuse of Flexeril; in 2016, this estimate was 256,000 individuals.
- Estimates are made for individuals over the age of 12 years of age.
The misuse of a drug is not quite the same thing as abuse of a drug. Misuse simply means that the individual has used the drug in a manner that is inconsistent with its prescribed purposes, whereas the abuse of a drug represents chronic misuse of the drug that can also result in a diagnosis of a substance use disorder in certain circumstances. As can be seen based on the information provided by SAMHSA, misuse of Flexeril is not a major issue in the United States in terms of its breadth of misuse. This would suggest that Flexeril abuse (or developing a substance use disorder to Flexeril) is a not major concern in the same way that the abuse of other types of prescription drugs, such as narcotic pain medications, is. However, serious attention should be given to the abuse of any prescription drug, and efforts to educate the public regarding safe use of any prescription medication should be undertaken.
Abusing Flexeril in the context of other central nervous system depressant drug abuse can increase the potential for overdose on any of the drugs a person takes.
Although cyclobenzaprine is classified as a sedative or mild central nervous system depressant, its chemical structure is quite similar to a class of antidepressants known as tricyclic antidepressants. Most of the information regarding abuse of cyclobenzaprine products from SAMHSA, the DEA, and other sources indicates that its abuse is primarily in conjunction with abuse of other drugs, particularly alcohol, narcotic pain medications, and benzodiazepines. Most often, its abuse is involved in attempting to increase the psychoactive effects of these drugs.
Whenever one combines drugs with similar mechanisms of action, there is a potential for serious issues, including significant side effects and overdose. Most likely, an overdose on a combination of drugs involving Flexeril would be concerning due to the primary drug of abuse, such as alcohol or a narcotic pain medication, and not an overdose of Flexeril itself.
According to the available information, the half-life of Flexeril is estimated to range from 8 hours to 37 hours in most individuals. This means that the drug should be completely eliminated from the system of most people who take it within 4-5 days; however, using Flexeril in conjunction with alcohol might extend this time period slightly because alcohol is metabolized by the liver before any other substances in the system.
Nonetheless, the research on the withdrawal process associated with Flexeril indicates that any person who does exhibit a withdrawal syndrome from Flexeril will experience mild discomfort that is similar to the withdrawal symptoms that occur in individuals who use antidepressants. Withdrawal from Flexeril most likely does not require direct intervention other than using a simple tapering strategy in cases where the symptoms are discomforting. The withdrawal timeline from Flexeril can be estimated to be as follows:
- Within 1-2 days after stopping Flexeril, a person may begin to feel mild symptoms that are often associated with the common cold or the flu, such as headaches, body aches, irritability, some nausea, anxiety, fever, chills, insomnia, and general feelings of malaise.
- The symptoms will most likely peak within 2-4 days and then subside.
- Symptoms may last 1-2 weeks after discontinuation but will be mild in nature. Withdrawal symptoms from Flexeril will exacerbate the withdrawal process from other drugs or alcohol, but they are not considered to be potentially dangerous on their own.
Withdrawal from Flexeril probably occurs in far less than 20 percent of all individuals who use the drug. Many of the individuals who experience symptoms do not seek treatment for withdrawal, and the biggest danger associated with Flexeril abuse is its use in conjunction with other central nervous system depressant drugs. Individuals who chronically abuse more than one substance and develop a polysubstance use disorder may experience very complicated withdrawal syndromes.
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Abuse of Flexeril alone is probably very rare. Treatment for Flexeril abuse would follow the general overall plan for treating any substance use disorder. This blueprint for recovery includes the following:
- Detox: A physician-assisted withdrawal management program (still often referred to as medical detox) targets the main drugs of abuse and may use opiate replacement medications or benzodiazepines on a tapering schedule. The detox program allows the individual to slowly be weaned off their drugs of choice without experiencing significant withdrawal symptoms, lowering the potential for relapse during the early stages of recovery.
- Comprehensive care: Once the withdrawal management program is completed, the person should be involved in a solid treatment program that includes:
- A personalized program that is individualized to meet the specific needs of the person
- Continued medical management of issues as identified in the initial assessment
- Heavy involvement in substance use disorder therapy
- Involvement in peer support groups
- Long-term involvement in treatment-related activities
- Use of other interventions and alternative treatments as deemed useful in the specific case
- Aftercare: A continued objective process that monitors and tests for continued abstinence in the individual (scheduled or random drug or alcohol screens) is recommended. The individual’s progress should be continually evaluated.
Individuals who are formally diagnosed with substance use disorders need to remain abstinent from drugs and alcohol for many years and need to be involved in treatment-related activities for many years before their relapse potential can be considered to be significantly decreased. However, individuals who have been in recovery from any substance use disorder are always at risk for relapse. A minimum of 5-7 years of abstinence and involvement in recovery is needed before an individual can be considered to be at a decreased risk of relapse.