Chronic use of tramadol after acute pain episode: cohort studyBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1849 (Published 14 May 2019) Cite this as: BMJ 2019;365:l1849
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Our country is in the midst of an opioid crisis, and I fear that well-intentioned authors have made a misguided recommendation that will further harm the public. The conclusion that tramadol presents a similar or greater risk of opioid dependence is neither supported by the study design nor clinical practice. In fact, the findings of the study may support the opposite conclusion to the one made.
While I welcome the advancement of epidemiologic data around opioid use, the suggestion that tramadol confers greater risk to patients struck me in particular since it is inconsistent with clinical experience among fellow psychiatrists involved in the spectrum of addiction care.
I suggest critical thinking around the following two study limitations:
1. The groups were not matched. The data presented for the groups at baseline does not allow meaningful interpretation except that there were more women receiving tramadol, and that the prescriptions for tramadol vs other short-acting or long-acting opioids varied widely by type of surgery. It is highly likely that the patient groups differed in significant and relevant ways. Authors attempted to use logistic regression to account for potential confounders but this is recognized to be inferior to other methods.1
Critical thinking: It remains entirely plausible that tramadol was prescribed preferentially for patients with histories of opioid dependence or substance use disorder since it is considered less addictive than standard opiates.
2. Persistent treatment for pain may be appropriate and should not be considered synonymous with abuse or addiction. The reason for continuing the medication is not provided, and the study did not evaluate whether persistent pain was the driver for continued treatment. The study would have benefited from inclusion of a non-addictive control group such as an NSAID. Without that, it is not appropriate to assume that addiction or abuse is responsible for the findings with tramadol.
Critical thinking: It remains entirely plausible that tramadol was prescribed preferentially for patients (with or without substance use disorder concerns) who require ongoing pain management since it is considered less addictive than standard opiates.
My field’s experience is more consistent with the existing body of evidence that has shown tramadol to be of lesser risk for abuse and dependence than other opiods.2,3,4 We must pay attention to the very population this study aims to protect and take note: among opiates, tramadol has the lowest street value and is seldom a “drug of choice.” Said another way: addictive drugs always have high street value/demand, and tramadol does not.
While I am open to questioning old notions, this study is neither designed to refute current notions, nor is it supported in clinical practice. Using these potentially confounded results to group tramadol with conventional opiates may be misleading, and may wrongly influence prescribers to ignore a reasonable alternative to these highly addictive drugs.
Prior to my submission of this response, I spoke with several patients about the study. Some laughed because of how shocked they were. Anecdotally, they shared three agreed upon facts about their experience:
1. Tramadol has little to no “nod” effect (a high).
2. Tramadol is most commonly used as a matter of convenience, or as a last option.
3. It is common to drug seek tramadol first briefly in order to appear to be a genuine patient, prior to stepping up requests for any other opiate.
Ultimately my patients voiced genuine concern: “What if physicians who read the study are led away from prescribing safer opiates and towards risker ones?” We need to be careful.
Daniel Hochman, MD
Supervisor, University of Texas Dell Medical School, Department of Psychiatry
1Stürmer T, T, Wyss R, Glynn RJ, Brookhart MA. Propensity scores for confounder adjustment when assessing the effects of medical interventions using nonexperimental study designs. J Internal Med 2014; 275: 570-580
2Dart RC, Cicero TJ, Surratt HL, Rosenblum A, Bartelson BB, Adams EH. Assessment of the abuse of tapentadol immediate release: the first 24 months. J Opioid Manag. 2012 Nov-Dec;8(6):395-402.
3Mojtabai R, Amin-Esmaeili M, Nejat E, Olfson M. Misuse of prescribed opioids in the United States. Pharmacoepidemiol Drug Saf. 2019 Mar;28(3):345-353
4World Health Organization (WHO). Critical Review Report: Tramadol. 2018. Available at: https://www.who.int/medicines/access/controlled-substances/Tramadol.pdf?....
Competing interests: No competing interests
The present and recent issues of the BMJ have highlighted some of the stock crazies of the medical-pharmacological-corporate world. For example, the marketing of opiates including Tramadol. If you promote opiates like Sackler and Purdue Pharma did in the United States you get 130 opiate deaths a day - marketing works.1 If you give female hormones (contraceptive pill, HRT) to widespread populations you get three things: 1. An epidemic of breast cancer, 2. Plummeting birth rates, 3. Pollution of the water tables with feminization of fish and aquatic life (all documented in national databases with correlations).2 If you promote a TV series detailing teenage suicide like "Thirteen Reasons Why", you get teen suicides and mental health issues in teens. If you legalise cannabis (despite its unproven efficacy in any medical condition save intractable epilepsy in childhood) you fill psychiatric units with psychosis (33% of acute units in London were occupied by skunk users) and do untold harm to developing brains of young people who need to be motivated to achieve their potential (amotivational effect of cannabis). You also make money for manufacturers. Finally if you release Ketamine on the market as the new panacea for depression and let marketing take over you will probably get an epidemic of addiction and side effects. All these interventions are backed by corporate interest. The medical authorities and government were and are no match for vested interest and corporate greed and muscle.
There is urgent need for another voice for the people, an advocate that will protect them from pseudo medicine and the corporate machine. This advocate should be similar to NICE or Cochrane with independence, resources and most of all a guarantee that its primary aim is for the benefit of the health of the community. It needs to have teeth to block expensive industry driven interventions that are unnecessary of doubtful efficacy and are even harmful. This is not happening based on the above debacles and upcoming possible debacles. Complicity, money and absolute silence on behalf of those responsible for safe and intelligent healthcare has allowed health budgets to soar (20% of GDP in USA, averages of 10-12% in Europe), creating the medicalization of many aspects of life and a spawning industry serving the share holders. Medicine is big business and has gone from being a service to the state to being serviced by the state at the expense of ordinary taxpayers. The realistic position for health is in education, prevention, healthy lifestyle and behaviours, good housing and green spaces and employment. Expensive corporate medicine should be way down somewhere like 10th position after a host of other societal needs have been satisfied - instead it is in pole position dictating what health is.
1. Preying on Prescribers (and Their Patients) — Pharmaceutical Marketing, Iatrogenic Epidemics, and the Sackler Legacy. Scott H. Podolsky, M.D., David Herzberg, Ph.D., and Jeremy A. Greene, M.D., Ph.D. NEJM 2019;380: 1785-1787.
2. Breen EG. The Screech Owls of Breast Cancer. AuthorHouse 2013.
Competing interests: No competing interests