Chronic use of tramadol after acute pain episode: cohort study

Abstract

ObjectiveTo determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids.DesignObservational study of administrative claims data.SettingUnited States commercial and Medicare Advantage insurance claims (OptumLabs Data Warehouse) January 1, 2009 through June 30, 2018.ParticipantsOpioid-naive patients undergoing elective surgery.Main outcome measureRisk of persistent opioid use after discharge for patients treated with tramadol alone compared with other short acting opioids, using three commonly used definitions of prolonged opioid use from the literature: additional opioid use (defined as at least one opioid fill 90-180 days after surgery); persistent opioid use (any span of opioid use starting in the 180 days after surgery and lasting ≥90 days); and CONSORT definition (an opioid use episode starting in the 180 days after surgery that spans ≥90 days and includes either ≥10 opioid fills or ≥120 days’ supply of opioids).ResultsOf 444 764 patients who met the inclusion criteria, 357 884 filled a discharge prescription for one or more opioids associated with one of 20 included operations. The most commonly prescribed post-surgery opioid was hydrocodone (53.0% of those filling a single opioid), followed by short acting oxycodone (37.5%) and tramadol (4.0%). The unadjusted risk of prolonged opioid use after surgery was 7.1% (n=31 431) with additional opioid use, 1.0% (n=4457) with persistent opioid use, and 0.5% (n=2027) meeting the CONSORT definition. Receipt of tramadol alone was associated with a 6% increase in the risk of additional opioid use relative to people receiving other short acting opioids (incidence rate ratio 95% confidence interval 1.00 to 1.13; risk difference 0.5 percentage points; P=0.049), 47% increase in the adjusted risk of persistent opioid use (1.25 to 1.69; 0.5 percentage points; P<0.001), and 41% increase in the adjusted risk of a CONSORT chronic opioid use episode (1.08 to 1.75; 0.2 percentage points; P=0.013).ConclusionsPeople receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids. Federal governing bodies should consider reclassifying tramadol, and providers should use as much caution when prescribing tramadol in the setting of acute pain as for other short acting opioids.

Trends in opioid prescribing in Estonia (2011‐2017)

“…Tramadol is not classified under controlled substances in Estonia. However, its abuse potential cannot be underestimated …”

<p>The Persistence of Opioid Use Following Surgical Admission: An Australian Single-Site Retrospective Cohort Study</p>

“…However, this study was unable to determine the utilisation of tramadol or combination analgesics containing codeine following hospital discharge and this is likely to result in an underestimate of the likelihood of opioid persistence, with a previous study identifying patients commenced on tramadol following surgery were as likely, if not more likely to persistent taking opioids long term. 20 There are some limitations with this study, including the use of only one site (albeit the largest hospital in Tasmania) and a short (2 months) recruitment period. Two months were selected as one of the follow-up time points to be reviewed because the Poisons Act 1971 defines this as the time when opioid use becomes chronic.…”

Tramadol is not "opioid-lite"

“…This modern day scourge, killing 130 Americans a day,1 is a health catastrophe, but just as its antecedents and evolution are infinitely complicated, broad brush comments and solutions are unhelpful in turning the tide of opioid related deaths in North America and in mitigating against disaster in other countries where opioids are liberally prescribed 2. In the linked paper (doi:10.1136/bmj.l1849), Thiels and colleagues should be applauded for their focused and cautiously interpreted study of the relation between opioids prescribed after surgery and long term use 3…”