Tramadol dispensing patterns and trends in Canada, 2007‐2016

Abstract

Purpose Opioid use and associated mortality and morbidity have substantially increased in Canada, which recent interventions have aimed to reduce. Tramadol is an atypical prescription‐only (but unscheduled under Canada's narcotics law) opioid analgesic and not subject to controls for other (eg, strong) opioids. Given experiences in different jurisdictions, tramadol may have been increasingly dispensed as a “substitute” drug during a period with increasingly restrictive controls for other (scheduled) opioids. Methods We examined the annual population‐level retail dispensing (as a proxy for use) of tramadol and (scheduled) “strong opioids” in Canadian provinces for 2007‐2016 based on data from a representative national sample of community pharmacies, covering the majority of episodes of opioid dispensing. Data for both aforementioned formulation categories were converted into defined daily doses (DDD)/1000 population/day and examined descriptively and by segmented regression analyses (to identify significant breakpoints in trends). Results Tramadol use strongly increased in all provinces until 2009. After 2009, tramadol dispensing levels either decelerated their increase or plateaued; “strong opioid” dispensing levels, in comparison, increased strongly until 2011 and decelerated or decreased for the remaining period. Tramadol was consistently dispensed at lower levels than “strong opioids.” Conclusions Tramadol and “strong opioids” showed similar (bifurcated) use trends, with initial increases and subsequent inflections, yet reductions in dispensing occurred earlier for tramadol than for “strong opioids” (the latter occurring following with recent interventions). Distinct from experiences with differential opioid control regimes elsewhere, there is no evidence that tramadol figured as a “substitution” drug for increasingly restricted “strong opioids” in Canada.

Association of Tramadol Use With Risk of Hip Fracture

“…Tramadol, a commonly used weak opioid for the treatment of pain, has been considered an analgesic alternative, since its perceived risk of serious cardiovascular and gastrointestinal adverse effects was lower than that of nonsteroidal anti‐inflammatory drugs (NSAIDs), and its risk of addiction and respiratory depression was lower than that of traditional opioids . As a result, tramadol use has been increasing rapidly worldwide over the past decades .…”

“…Tramadol, a commonly used weak opioid for the treatment of pain, has been considered an analgesic alternative, since its perceived risk of serious cardiovascular and gastrointestinal adverse effects was lower than that of nonsteroidal anti‐inflammatory drugs (NSAIDs), and its risk of addiction and respiratory depression was lower than that of traditional opioids . As a result, tramadol use has been increasing rapidly worldwide over the past decades . For example, data from Truven Health Analytics MarketScan in the United States showed that prescriptions of tramadol increased by 22.8% between 2012 and 2015, and tramadol dispensing rates increased in each of the provinces in Canada, with the highest in Nova Scotia increasing from 0.50/defined daily doses (DDD) in 2007 to 2.64/DDD in 2016 …”

“…As a result, tramadol use has been increasing rapidly worldwide over the past decades . For example, data from Truven Health Analytics MarketScan in the United States showed that prescriptions of tramadol increased by 22.8% between 2012 and 2015, and tramadol dispensing rates increased in each of the provinces in Canada, with the highest in Nova Scotia increasing from 0.50/defined daily doses (DDD) in 2007 to 2.64/DDD in 2016 …”

Duplicated tramadol use in chronic low back pain: A nationwide cross‐sectional study

“…Additionally, tramadol is not classified as a scheduled drug in Korea, unlike opioids, ; thus, tramadol is widely used instead of opioids. In a similar case, a recent study in Canada showed that tramadol (unscheduled under Canada's narcotics law) use is considerable (although it is not considered a substitute for strong opioids) as an alternative intervention for reducing opioid use . In Korea, duplicate use of tramadol has been confirmed under a nationwide drug utilization review system; however, duplicate use is possible by entering a specific reason for duplication in the system because it is not mandatory to change the prescription to avoid duplicate use .…”

“…In a similar case, a recent study in Canada showed that tramadol (unscheduled under Canada's narcotics law) use is considerable (although it is not considered a F I G U R E 2 Age-and sex-standardized prevalence of tramadol use at least once a year, and age-standardized prevalence of using tramadol twice or more a year in 2014-2016 substitute for strong opioids) as an alternative intervention for reducing opioid use. 29 In Korea, duplicate use of tramadol has been confirmed under a nationwide drug utilization review system; however, duplicate use is possible by entering a specific reason for duplication in the system because it is not mandatory to change the prescription to avoid duplicate use. 30 The reasoning for this behaviour has been postulated as a lack of understanding of opioid prescriptions for non-cancer pain by healthcare providers.…”