Re: Chronic use of tramadol after acute pain episode: cohort study
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