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Carisoprodol Withdrawal Syndrome
 

Carisoprodol Withdrawal Syndrome

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Presentation done by Pallav Pareek M.D. indicating the withdrawal phenomenon seen with the use of carisoprodol. Presented at Sinai Grace Research day May 2011.

Presentation done by Pallav Pareek M.D. indicating the withdrawal phenomenon seen with the use of carisoprodol. Presented at Sinai Grace Research day May 2011.

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    Carisoprodol Withdrawal Syndrome Carisoprodol Withdrawal Syndrome Presentation Transcript

    • Carisoprodol withdrawal syndrome
      • Pallav Pareek M.D.
      • Acknowledgements
      • Gerald. A. Shiener M.D.
      • Leonard L. Lachover M.D.
      • RP Rajarethinam M.D.
    • What on earth is Carisoprodol?
      • a.k.a SOMA, available as 250 and 350 mg white round tablets.
      • 1959: Pharmacologists convened @ Wayne State University
      • N -isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate
      • MOA not known, believed to act through GABA A receptor
      • Carisoprodol also has weak anticholinergic and antipyretic properties
      • Half life: 2-3 hrs
      • Used -> primary care settings for musculoskeletal pain relief esp. lower back
    •  
    • Why Worry?
      • Easily available, and is not controlled in most US states.
      • An active metabolite meprobamate: schedule IV controlled substance in U.S.
      • Mebrobamate risk of addiction potential equal (if not greater) to benzo’s
      • Carisprodol is not a controlled substance at federal level and in MI
      • DAWN: Soma -> ER visits ↑300% (94-05)
    • Case Report
      • Identifying data: SS is a 55 yo AASF, lives with boyfriend, never married, no children, unemployed, SSD(705$/mo)
      • Chief complaint: Per patient “I don’t know why Iam here” psychiatry consulted for “dystonic reactions”
      • Day 1: Presented to ER with rhythmic jerky abnormal movements in both U&LE, presumed by ER as manifestation of a psychiatric illness.
      • Complete neurological work-up including a CT scan performed. No focal deficits found. Seizures ruled out.
      • Did not have any manifestation of any psychiatric illness -> cleared by psychiatry
      • No neurological or medical etiology of her manifestation was found -> Patient d/c home
      • Day 2: Patient again presented to the ER with similar presentation, this time with altered mental state, anxiety, tremulousness, muscle twitching, unsteady gait and abnormal movements in U&LE
      • Past Psychiatric Hx: Hx of Bipolar disorder vs. schizoaffective disorder. 4-5 previous inpatient admissions. Current O/P Psych Rx: Risperdal 4 mg QHS
      • Substance abuse:
      • - Smoking: quit 2 yrs ago.
      • - Alcohol : abstinent for last 2 years
      • - Marijuana : 50 $/week
      • - Tylenol #3: as much as she can get a hold of from Physicians or from street.
      • - Soma: Gets 60-90 pills from a PCP, sinusoidal pattern of use.
      • Medical Hx: osteoporosis, arthritis, chronic low back pain, s/p polypectomy. No active ongoing medical problems.
      • Family Hx: non-contributory
      • Mental Status: 55 yo f, appeared ↑ stated age. Fair grooming and hygiene, mild tremors in b/l UE, speech soft, ↑ latency, mood euthymic, affect constricted, -A/VH, thought process linear and goal directed, intact remote memory, no memory for recent events including her being in hospital, fair calculation, abstraction & reasoning
    • Labs
      • Most: WNL
      • CPK :1890
      • UDS: + for cannabinoids and opioids
      • Urinalysis: 1+ blood
      • EKG: Sinus tachycardia
      • EEG: No epileptiform activity or focal features seen
    • Management
      • Neurology, Psychiatry, Toxicology were consulted
      • Maintained on minimal possible medications.
      • Symptomatically managed
      • Day 4 : Patient returned to baseline, no active symptoms, no recollection of the episode. D/C home
    • Why is Soma abused?
      • Clinical effect/abuse: from carisoprodol v/s metabolite meprobamate not known
      • Per se : sedative and relaxant effect
      • Augments other drugs e.g. : ↑ sedative effect of alcohol or benzos
      • Alter other drugs: prevent jitteriness due to cocaine (or other stimulant) use
      • Combination : carisoprodol + tramadol: significant relaxation and euphoria
    • Reeves RR 2009:Pattern of use
      • Study of 40 pts, with use > 3mo
      • N=20 (other drugs)
      • 40% use ↑ prescribed
      • 30% other than the effects for which prescribed
      • 10% : for augmentation
      • 5%: to counter other drugs
    • Physician awareness
      • 2009 study N=100
      • 95% aware: meprobamate is controlled vs. 39% felt: carisoprodol has abuse potential vs. 18% aware: C ->M
      • PDR: no wdrwl in dogs 1g/kg/d
      • Kentucky: physician guidelines “should be prescribed with same caution as opioid and other controlled subs..”
      • DEA: hearing pending 3/26/10
    • More Worries, including www…
      • Is still a scheduled drug in just 14 states
      • Physicians often choose this as a less harmful/addictive option
      • Internet is a boon…
      • Attractive and unmonitored means of procuring carisoprodol
    • Conclusions
      • Several case reports suggest withdrawal potential of soma
      • Important but under recognized syndrome
      • Appropriate caution in cases with hx drug abuse
      • Cautious : if needed chroninc/long term
      • Can often masquerade as a psychiatric or neurological illness
      • Is it time to make it a controlled substance at federal level?
    • Conclusions….contd
      • Slow taper over 2-4 wks is recommended
      • Withdrawal: No standard protocol
      • Carisoprodol levels (through DMC lab)
      • Benzodiazepines may be used for anxiety, myoclonus, ataxia and seizures
      • Flumazenil has been used to counter the intoxications of carisoprodol
      • Consensus on symptomatic management
    • Thank You!!!
      • “ If it's your job to eat a frog, it's best to do it first thing in the morning. And If it's your job to eat two frogs, it's best to eat the biggest one first.” Mark Twain