Page 18 - Delaware Medical Journal - September/October 2020
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THE PAINFUL TRUTH:
Why Tramadol May Not Be the Ideal Analgesic
Ashley J. Weiner, PharmD; Mohamed E. Elmarakbi, PharmD; Katelyn McCormick, PharmD, BCPS
BACKGROUND
Prior to the advent of opioids, pharmacologic management of pain
Although responsible providers were utilizing multiple treatment modalities, pain was rarely well controlled. During the 1990s, the new opioid receptor agonists were brought to market
and appeared to revolutionize pain management, becoming the gold standard for adequate analgesia. It was not until years later that we, as a society, begin
to realize the detrimental impact of this class of medications, culminating with the current opioid epidemic.
In response to the opioid epidemic, there was a shift in the approach to managing pain by utilizing multimodal and non-opioid alternatives. In 1995, the U.S. Food and Drug Administration
(FDA) approved tramadol as a non- controlled analgesic that would provide
a multimodal mechanism of pain relief. This provided promise for the availability of an agent that would provide analgesia for moderate to severe pain while lacking the detrimental addictive properties of available short-acting opioids.1 However, in the United States, there were a multitude of reports surrounding patients abusing tramadol, with an estimated
two to three cases for every 100,000 patients.2 In 2010, it was reported that more than 16,000 emergency department visits were attributed to the misuse of tramadol. It was determined that 40% of adverse effects were due to withdrawal.2 Following these reports, in 2014, the U.S. Drug Enforcement Administration (DEA) mandated that tramadol be placed into schedule IV of the Controlled Substance Act to address concerns of abuse, misuse,
and diversion.2
Despite this setback, tramadol has gained popularity for use in the management of both acute and chronic pain in adults. While opioid prescribing rates decreased in 2016-2017, tramadol claimed its
place as the second-most commonly prescribed opioid, with an increase in utilization from 6.7% to 21.1% over a 10-year span.3 Its use may be of particular and neuropathic pain due to its dual mechanism of action. The World Health Organization (WHO) recognizes tramadol as a step-2 analgesic option for cancer pain that is moderate to moderately severe in nature.4 However, the evidence for chronic non-cancer pain has been modest, use in osteoarthritis and neuropathic pain. Tramadol is typically prescribed when
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Del Med J | September/October 2020 | Vol. 92 | No. 5
