Red Flag Raised for Post-Op Muscle Relaxants in Older Adults

Mary Chris Jaklevic

May 12, 2022

Dr Tasce Bongiovanni

As doctors shift to non-opioid pain relievers in response to the opioid epidemic, the results of a small but illuminating study raise concerns that one type of opioid alternative — muscle relaxants — may pose serious risks to some older adults.

Roughly one in eight (13%) of 1718 geriatric patients who received muscle relaxants to ease pain after surgery filled prescriptions for the drugs 3 months later, according to an analysis of Medicare data to be presented this week at the American Geriatric Society 2022 scientific meeting in Orlando, Florida.

The drugs are meant to be used for short-term spans of 2 to 3 weeks. Prolonged use in the elderly increases the risk of cognitive impairment, falls, and fractures. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults strongly recommends that muscle relaxants be avoided in older adults.

"It's important that we're fighting the opioid crisis," principal investigator Tasce Bongiovanni, MD, an acute care and trauma surgeon at the University of California, San Francisco, told Medscape Medical News. But doctors should be "really, really thoughtful about what types of medications we give older adults," she said.

"If someone's still having pain far out after surgery, then there may be more of a workup to be done, as opposed to just continuing the pain medication," Bongiovanni added.

Bongiovanni and colleagues examined a sample of 51,151 Medicare beneficiaries 66 years and older who underwent one of 15 common surgical procedures, such as total knee replacements and lumbar spine procedures, between 2017 and 2018. They then looked for patients who received a muscle relaxant 7 days before or after surgery, totaling 1718. Patients were excluded if they had been prescribed a muscle relaxant in the previous 3 months.

The 13% — or about 223 patients — who had prescriptions refilled past 90 days were younger (71.7 vs 72.7 years), more often women (66% vs 57%), had higher Charlson comorbidity scores (2.4 vs 2.0), and spent more time in the hospital (8 vs 5 days).  

Sixty percent of patients with refills after 90 days also had prolonged use of opioids, compared with 21% of those who didn't refill the order after 90 days. The combined use of an opioid and a muscle relaxant may increase the risk of adverse events, the researchers note.

Why muscle relaxants continue to be prescribed months longer than necessary is unclear, but stronger communication among surgeons, primary care physicians, patients, and caregivers might help, Bongiovanni said. The researchers wrote that "robust strategies" are needed to prevent prolonged use.

Kenneth Boockvar, MD, a geriatrics professor at the Icahn School of Medicine at Mount Sinai, New York City, who studies de-prescribing, told Medscape Medical News that "it's important to shed light" on the use of muscle relaxants, given the risks they pose to older patients.

Further research should explore how the opioid crisis has influenced prescribing in the elderly and why opioid use is a predictor of prolonged use, according to Boockvar, who was not involved in the new research.

The study was funded by the Agency for Healthcare Research and Quality and the UCSF Pepper Center. Bongiovanni and Boockvar have reported no relevant financial relationships.

American Geriatrics Society 2022. Abstract A170. Presented May 12, 2022.

Mary Chris Jaklevic is a healthcare journalist in the Midwest.

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