Carisoprodol withdrawal Carisoprodol withdrawal syndromesyndrome

Pallav Pareek M.D.Pallav Pareek M.D.AcknowledgementsAcknowledgements Gerald. A. Shiener M.D.Gerald. A. Shiener M.D. Leonard L. Lachover M.D.Leonard L. Lachover M.D. RP Rajarethinam M.D.RP Rajarethinam M.D.

What on earth is What on earth is Carisoprodol?Carisoprodol?

a.k.a SOMA, available as 250 and a.k.a SOMA, available as 250 and 350 mg white round tablets.350 mg white round tablets.

1959: Pharmacologists convened @ 1959: Pharmacologists convened @ Wayne State University Wayne State University

N-isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate

MOA not known, believed to act through GABAA receptor

Carisoprodol also has weak Carisoprodol also has weak anticholinergic and antipyretic anticholinergic and antipyretic propertiesproperties

Half life: 2-3 hrsHalf life: 2-3 hrs Used Used → → primary care settings for primary care settings for

musculoskeletal pain relief esp. musculoskeletal pain relief esp. lower backlower back

Why Worry?Why Worry? Easily available, and is not Easily available, and is not

controlled in most US controlled in most US states.states.

An active metabolite An active metabolite meprobamate: schedule IV meprobamate: schedule IV controlled substance in controlled substance in U.S.U.S.

Mebrobamate risk of Mebrobamate risk of addiction potential equal addiction potential equal (if not greater) to benzo’s(if not greater) to benzo’s

Carisprodol is not a Carisprodol is not a controlled substance at controlled substance at federal level and in MIfederal level and in MI

DAWN: Soma DAWN: Soma →→ER visits ER visits ↑300% (94-05)↑300% (94-05)

02000400060008000

100001200014000160001800020000

94 '01 '04 '05

ER Visits

Case ReportCase Report Identifying data: SS is a 55 yo AASF, lives Identifying data: SS is a 55 yo AASF, lives

with boyfriend, never married, no children, with boyfriend, never married, no children, unemployed, SSD(705$/mo)unemployed, SSD(705$/mo)

Chief complaint: Per patient “I don’t know Chief complaint: Per patient “I don’t know why Iam here” psychiatry consulted for why Iam here” psychiatry consulted for “dystonic reactions”“dystonic reactions”

Day 1:Day 1: Presented to ER with rhythmic jerky Presented to ER with rhythmic jerky abnormal movements in both U&LE, abnormal movements in both U&LE, presumed by ER as manifestation of a presumed by ER as manifestation of a psychiatric illness.psychiatric illness.

Complete neurological work-up including a Complete neurological work-up including a CT scan performed. No focal deficits found. CT scan performed. No focal deficits found. Seizures ruled out. Seizures ruled out.

Did not have any manifestation of any Did not have any manifestation of any psychiatric illness psychiatric illness →→ cleared by psychiatry cleared by psychiatry

No neurological or medical etiology of her No neurological or medical etiology of her manifestation was found manifestation was found → → Patient d/c homePatient d/c home

Day 2:Day 2: Patient again presented to the ER Patient again presented to the ER with similar presentation, this time with with similar presentation, this time with altered mental state, anxiety, altered mental state, anxiety, tremulousness, muscle twitching, unsteady tremulousness, muscle twitching, unsteady gait and abnormal movements in U&LEgait and abnormal movements in U&LE

Past Psychiatric Hx: Hx of Bipolar disorder vs. Past Psychiatric Hx: Hx of Bipolar disorder vs. schizoaffective disorder. 4-5 previous inpatient schizoaffective disorder. 4-5 previous inpatient admissions. Current O/P Psych Rx: Risperdal 4 admissions. Current O/P Psych Rx: Risperdal 4 mg QHSmg QHS

Substance abuse: Substance abuse: - Smoking: quit 2 yrs ago.- Smoking: quit 2 yrs ago. - Alcohol : abstinent for last 2 years- Alcohol : abstinent for last 2 years - Marijuana : 50 $/week- Marijuana : 50 $/week - Tylenol #3: as much as she can get a hold of from - Tylenol #3: as much as she can get a hold of from

Physicians or from street.Physicians or from street. - Soma: Gets 60-90 pills from a PCP, sinusoidal - Soma: Gets 60-90 pills from a PCP, sinusoidal

pattern of use. pattern of use.

Medical Hx: osteoporosis, arthritis, chronic Medical Hx: osteoporosis, arthritis, chronic low back pain, s/p polypectomy. No active low back pain, s/p polypectomy. No active ongoing medical problems. ongoing medical problems.

Family Hx: non-contributoryFamily Hx: non-contributory Mental Status: 55 yo f, appeared Mental Status: 55 yo f, appeared ↑ stated ↑ stated

age. Fair grooming and hygiene, mild age. Fair grooming and hygiene, mild tremors in b/l UE, speech soft, tremors in b/l UE, speech soft, ↑ ↑ latency, latency, mood euthymic, affect constricted, mood euthymic, affect constricted, -A/VH, -A/VH, thought process linear and goal directed, thought process linear and goal directed, intact remote memory, no memory for intact remote memory, no memory for recent events including her being in recent events including her being in hospital, fair calculation, abstraction & hospital, fair calculation, abstraction & reasoningreasoning

LabsLabs

Most: WNLMost: WNL CPK :1890CPK :1890 UDS: + for UDS: + for

cannabinoids and cannabinoids and opioidsopioids

Urinalysis: 1+ bloodUrinalysis: 1+ blood EKG: Sinus tachycardiaEKG: Sinus tachycardia EEG: No epileptiform EEG: No epileptiform

activity or focal activity or focal features seenfeatures seen

ManagementManagement

Neurology, Psychiatry, Toxicology Neurology, Psychiatry, Toxicology were consultedwere consulted

Maintained on minimal possible Maintained on minimal possible medications.medications.

Symptomatically managedSymptomatically managed Day 4Day 4: Patient returned to baseline, : Patient returned to baseline,

no active symptoms, no recollection no active symptoms, no recollection of the episode. D/C homeof the episode. D/C home

Why is Soma abused?Why is Soma abused? Clinical effect/abuse: from Clinical effect/abuse: from

carisoprodol v/s metabolite carisoprodol v/s metabolite meprobamate not knownmeprobamate not known

Per sePer se: sedative and relaxant effect: sedative and relaxant effect AugmentsAugments other drugs e.g. : other drugs e.g. : ↑ ↑

sedative effect of alcohol or benzossedative effect of alcohol or benzos AlterAlter other drugs: prevent other drugs: prevent

jitteriness due to cocaine (or other jitteriness due to cocaine (or other stimulant) usestimulant) use

CombinationCombination: carisoprodol : carisoprodol ++ tramadol: significant relaxation tramadol: significant relaxation and euphoriaand euphoria

Reeves RR 2009:Pattern of Reeves RR 2009:Pattern of use use

Study of 40 pts, with Study of 40 pts, with use > 3mouse > 3mo

N=20 (other drugs)N=20 (other drugs) 40% use ↑ prescribed40% use ↑ prescribed 30% other than the 30% other than the

effects for which effects for which prescribedprescribed

10% : for 10% : for augmentationaugmentation

5%: to counter other 5%: to counter other drugsdrugs

0

5

10

15

20

25

30

35

40

HD OE Aug Alt

N=20

Physician awarenessPhysician awareness 2009 study N=1002009 study N=100 95%95% aware: meprobamate aware: meprobamate

is controlled vs. is controlled vs. 39%39% felt: felt: carisoprodol has abuse carisoprodol has abuse potential vs. potential vs. 18%18% aware: aware: CC→M→M

PDR: no wdrwl in dogs PDR: no wdrwl in dogs 1g/kg/d1g/kg/d

Kentucky: physician Kentucky: physician guidelines “should be guidelines “should be prescribed with same prescribed with same caution as opioid and other caution as opioid and other controlled subs..”controlled subs..”

DEA: hearing pending DEA: hearing pending 3/26/103/26/10

0102030405060708090

100

Ctrl Abs C-M

Doctors

More Worries, including More Worries, including www…www…

Is still a scheduled Is still a scheduled drug in drug in justjust 14 states 14 states

Physicians often Physicians often choose this as a less choose this as a less harmful/addictive harmful/addictive optionoption

Internet is a boon…Internet is a boon… Attractive and Attractive and

unmonitored means unmonitored means of procuring of procuring carisoprodolcarisoprodol

ConclusionsConclusions

Several case reports suggest withdrawal Several case reports suggest withdrawal potential of somapotential of soma

Important but under recognized syndromeImportant but under recognized syndrome Appropriate caution in cases with hx drug Appropriate caution in cases with hx drug

abuseabuse Cautious : if needed chroninc/long term Cautious : if needed chroninc/long term Can often masquerade as a psychiatric or Can often masquerade as a psychiatric or

neurological illnessneurological illness Is it time to make it a controlled substance Is it time to make it a controlled substance

at federal level?at federal level?

Conclusions….contdConclusions….contd

Slow taper over 2-4 wks is recommendedSlow taper over 2-4 wks is recommended Withdrawal: Withdrawal: No standard protocolNo standard protocol- Carisoprodol levels (through DMC lab)Carisoprodol levels (through DMC lab)- Benzodiazepines may be used for Benzodiazepines may be used for

anxiety, myoclonus, ataxia and seizuresanxiety, myoclonus, ataxia and seizures- Flumazenil has been used to counter the Flumazenil has been used to counter the

intoxications of carisoprodolintoxications of carisoprodol- Consensus on symptomatic managementConsensus on symptomatic management

Thank You!!!Thank You!!!

““If it's your job to eat a frog, it's best to do it first thing in the 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 morning. And If it's your job to eat two frogs, it's best to eat the biggest one first.” the biggest one first.” Mark TwainMark Twain