[@PeterAttiaMD] Chronic Pain & Muscle Relaxants: Neurontin and Baclofen | Sean Mackey, M.D., Ph.D.

Link: https://youtu.be/B4Ilh8xKGoc

Short Summary

Key Quotes

Detailed Summary

Here's a detailed summary of the YouTube video transcript, presented in bullet points:

Key Topics:

• Muscle Relaxants (specifically Baclofen/Blephin)
• Neuropathic Pain Management (specifically Gabapentin/Neurontin and Pregabalin/Lyrica)
• Chronic Pain Definition and Management
• Context Specific Approach to Pain Management

Muscle Relaxants (Baclofen/Blephin):

• Benefits of Baclofen (Blephin):
  • Not particularly potent but offers a gentler alternative to stronger medications like Valium (benzodiazepines) or Flexeril (cyclobenzaprine).
  • Does not carry the same baggage of drowsiness or nausea that other muscle relaxants might cause.
  • Effective for acute muscle spasms or flare-ups (e.g., kink in the neck, lower back pain).
  • Considered a relatively safe medication.
• Baclofen vs. Other Muscle Relaxants:
  • Not habit-forming, unlike some muscle relaxants (e.g., Somas).
  • Flexeril has tricyclic antidepressant properties that can cause sedation, while Baclofen is more benign.
• Use Cases and Dosage:
  • Effective for acute or subacute conditions. Can be used as a trial for chronic conditions.
  • Typical oral dose: Up to 20 mg three times a day (up to 80 mg max).
• Intrathecal Baclofen:
  • Used for severe spasticity (e.g., spinal cord injury).
  • Delivered via an intrathecal pump (catheter into the CSF).
  • Allows for lower doses and fewer side effects compared to oral administration.
• Long-Term Use Considerations:
  • Careful evaluation of benefit vs. cost (side effects) is necessary.
  • Ongoing monitoring is crucial to determine if the medication should be adjusted or discontinued.
  • The individual cost and benefits need to be weighed.

Neuropathic Pain Management (Gabapentin/Neurontin and Pregabalin/Lyrica):

• Gabapentin and Pregabalin: Similar Mechanisms:
  • Work on the alpha 2 delta subunit of calcium channels in the spinal cord and brain.
  • Reduce pain signals being processed in the central nervous system (spinal cord and brain).
  • Do not directly impact peripheral nerves.
• Safety Profile:
  • Both have a high safety profile; no lethal dose.
  • Side effects: Drowsiness, risk of falls (especially in elderly patients), peripheral edema (water retention), weight gain (more prominent with pregabalin).
  • The need to avoid operating heavy machinery is stressed.
• Use Cases and Benefits:
  • Effective for reducing neuropathic pain, especially in cases that are difficult to treat.
  • Can help with sleep, especially pregabalin, by promoting appropriate sleep architecture.
  • Daytime dosing helps with pain, and nighttime dosing promotes sleep.
• Dosage and Considerations:
  • Gabapentin: Maxes out at around 900-1000 mg per dose due to active transport limitations in the small intestine.
  • Pregabalin: Linear kinetic profile (the more you take, the more gets into your system).
  • Switching from Gabapentin to Pregabalin: Consider switching to pregabalin if the patient benefits from gabapentin but maxed out on the dose.
• Stanford context: They are tertiary referral center, seeing patients with recalcitrant pain.

Chronic Pain Definition and Management:

• Definition of Chronic Pain:
  • Pain that persists beyond the expected time of tissue healing.
  • Context-specific; dependent on the nature and extent of the injury or surgery.
• Context-Specific Pain Management:
  • The appropriate timeline for pain resolution varies depending on the specific condition.

In essence, the video discusses the appropriate use of muscle relaxants and medications for neuropathic pain, emphasizing the importance of individualized treatment plans and careful consideration of benefits vs. risks. The speakers also highlight the challenges of defining and managing chronic pain, particularly in patients who have not responded to standard treatments.