Page 23 - Delaware Medical Journal - September/October 2020
P. 23
EDITORIAL
may cause displacement of protein-bound phenytoin and warfarin, resulting in an increased biologic effect when they are a medical regimen containing warfarin, hemostasis is doubly impeded by both anticoagulation and antiplatelet effects. proscribed in the anticoagulated patient.
The bottom line to all this is that therapeutic options become quite limited in the patient with advancing age, i.e. the one with the needs intervention the most. So, what’s left? Opioids. Did I just hear the reader gasp? they are not. In the appropriate clinical
impact on quality of life. Which is why I was so maudlin when propoxyphene was
withdrawn. It worked and it was generally well-tolerated. Unlike many other opioids,
it did not seem to cause constipation or impaired cognition in the elderly. If it caused an increased risk of arrhythmia, it was not immediately apparent to me.
In this issue of the DMJ, Weiner et al present a cogent and timely article on the opioid tramadol. The authors correctly assert that the use of this agent has been increasing. For example, in 2013, there were over 44 million prescriptions written in the U.S. alone.4 The authors list some risks of the drug, including potential for abuse (“two to three cases per 100,000”), serotinergic syndrome (fewer than 1,000 cases reported to the FDA in 20 years), and seizures (approximately 2,000 cases over 20 years). While these adverse events merit caution on the part of the prescriber, they are not of such magnitude as to warrant pulling the medication from circulation.
I realize that we are in the midst of an opioid
crisis in our society. The crisis deserves
a thorough analysis of potential factors beyond the simplistic conclusion that doctors prescribe opioids carelessly. I have tried to make the case that even in situations that
do not include a terminal disease, opioids may be the best option. Take away tramadol and its cousins and my patients will, in their twilight years, have a very poor quality of life. They deserve better.
References:
1. https://www.cdc.gov/arthritis/basics/ osteoarthritis.htm
2. http://www.who.int/chp/topics/ rheumatic/en
3. Da Costa BR, Reichenbach S, Keller N, Nartey L, Wandel S, Juni P, et al. Effectiveness of non-steroidal anti- inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network metaanalysis. Lancet 2017;390:e21–33.
4. https://drugabuse.com/tramadol/ history-statistics
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Del Med J | September/October 2020 | Vol. 92 | No. 5 215
