Tramadol non-medical use in Four European countries: A comparative analysis

Adverse effects from counterfeit and mislabeled medicine containing tapentadol and carisoprodol

When self-administration with counterfeit or mislabeled medicine is suspected, comprehensive laboratory analysis should be preferred over immunoassay screening to avoid false negative results. Carisoprodol, which was formerly a popular muscle relaxant drug in many countries, has reappeared on illegal drug markets, and may cause an itching, purple-colored rash, even after a single dose.

High-Intensity Interval Training Ameliorates Tramadol-Induced Nephrotoxicity and Oxidative Stress in Experimental Rats

INTRODUCTION

Tramadol (TRA) is an opioid analgesic widely prescribed for moderate-to-severe pain; however, its abuse and chronic use have been associated with kidney damage. Considering the protective role of exercise training in reducing organ damage, this study aimed to assess the influence of high-intensity interval training (HIIT) on a male rat's kidney following chronic TRA administration.

METHODS

In this experimental study, 30 male Wistar rats were assigned to the following groups: control (CON; animals received normal saline five days a week in the first month and three days a week in the second month), exercise (EXE; animals conducted HIIT training according to exercise protocol five days a week for two months), TRA (animals received TRA 50 mg/kg (i.p.) as described for the CON group), EXE-TRA (animals received TRA and conducted exercise protocol), and EXE-SL (animals received normal saline and conducted exercise protocol). Then, serum IL-6 and IL-10 levels, tissue malondialdehyde (MDA), total antioxidant capacity (TAC), glutathione peroxidase (GPx), superoxide dismutase (SOD), and levels of albumin, urea, and creatinine (CR), along with pathological changes in the kidney, were measured. A p-value of <0.05 was considered significant using GraphPad Prism v.9 (GraphPad Software, La Jolla, California, USA).

RESULTS

The inflammatory cytokines IL-6 and IL-10 were significantly increased in the EXE and EXE-TRA groups compared to the TRA group. Chronic administration of TRA in the TRA group decreased antioxidant indicators TAC, GPx, and SOD in kidney tissue while increasing oxidative stress MDA compared to the CON group (p<0.05). In contrast, the EXE-TRA group showed higher levels of TAC, GPx, and SOD, while MDA decreased compared to the TRA group. Additionally, serum levels of urea and CR were increased in the TRA group compared to the CON group, whereas these levels were decreased in the EXE-TRA group compared to the TRA group. The inflammatory effect of HIIT training, due to severe hyperemia and mild inflammatory cell infiltration, was seen in all EXE groups. Pathological findings confirmed TRA-induced kidney damage through moderate hyaline cast presence and severe apoptosis in the TRA group. Other findings were in line with the above results.

CONCLUSION

These findings confirm the nephrotoxicity of chronic use of TRA through biochemical and oxidative markers and pathological outcomes. In addition, the result suggests that HIIT has the potential to mitigate the detrimental effects of TRA through reversing biochemical and oxidative markers, including TRA-induced apoptosis. Consequently, considering its restorative properties, HIIT could be explored as a prospective nephroprotective approach for long-term TRA treatment.

Prevalence and health consequences of nonmedical use of tramadol in Africa: A systematic scoping review

Tramadol is a widely prescribed painkiller around the world. As a synthetic opioid, it offers a valuable substitute for morphine and its derivatives in African countries. However, the adverse health effects of tramadol use resulting from illicit trafficking, like those caused by fentanyl and methadone in North America, have not been well-documented in Africa. This scoping review aims to shed light on the nature and scope of the nonmedical use (NMU) of tramadol in Africa and its associated health consequences. To carry out our scoping review, we used Arksey and O'Malley's (2005) five-step approach for exploratory analysis and followed Joanna Briggs Institute guidelines for scoping reviews to ensure systematic and replicable studies. We then searched six databases: Medline, Global Health (EBSCO), Scopus, Web of Science, the African Journals online database, and for grey literature via Google Scholar without any time restriction. The articles were imported into Covidence and reviewed by two independent researchers. Eighty-three studies on NMU of tramadol's prevalence or health consequences were selected from 532 titles/abstracts screened, including 60 cross-sectional and six qualitative studies from 10 African countries. Findings from the included studies highlighted five distinct groups significantly affected by the NMU of tramadol. These groups include: 1) young adults/active populations with varying degrees of prevalence ranging from 1.9% to 77.04%, 2) professionals, where drivers exhibit a relatively high prevalence of tramadol NMU, ranging from 7.2% to 35.1%, and commercial motorcyclists, with a prevalence of 76%, 3) patients, who have a high rate of tramadol NMUs, with prevalence rates ranging from 77.1% to 92%, 4) academics, with a considerable rate of tramadol misuse among substance-using undergraduates (74.2%) and substance-using high school students (83.3%), and 5) other individuals impacted in various ways. The health consequences are classified into four distinct types: intoxication, dependence syndrome, withdrawal syndrome and other symptoms. Despite providing a comprehensive global overview of the phenomenon described in the African literature, this systematic scoping review's main limitations stem from the relatively limited exploration of various consequences of the NMU of tramadol, notably those of a social and economic nature. Our review shows that tramadol misuse affects diverse populations in Africa. The prevalence of misuse varies within sub-populations, indicating the complexity of the issue. Professional and academic groups have different rates of misuse across regions. This highlights the need for targeted interventions to address unique challenges contributing to tramadol misuse. Future studies should focus on the social and economic costs of abuse on households to better understand the impact on well-being. Systematic review registration: Open Science Framework: https://osf.io/ykt25/.

Patterns of Opioid and Non-Opioid Analgesic Consumption in Patients with Post-COVID-19 Conditions

Pain is a major health issue for healthcare systems, and access to pain treatment is a fundamental human right. Pain is a common symptom experienced in the post-COVID phase by a significant percentage of patients. This study describes the prevalence and associated factors associated with the use of opioid and non-opioid analgesics in subjects with post-COVID-19 condition. Sociodemographic data, post-COVID symptoms, health profile, and opioid and non-opioid analgesic consumption were collected in 390 subjects with post-COVID-19 condition. We analyzed the independent effect of all variables on opioid/non-opioid analgesic consumption by using logistic multivariate regressions. The prevalence of opioid and non-opioid analgesic consumption was 24.1% and 82.3%, respectively. Tramadol (17.18%) and codeine (7.95%) were the most commonly used opioid analgesics, and Paracetamol (70%) and ibuprofen (45.4%) were the most commonly used non-opioid analgesics. Females were more likely to consume non-opioid analgesics (aOR2.20, 95%CI 1.15, 4.22) than males. Marital status of married/partner vs. single (aOR2.96; 95% CI 1.43, 6.12), monthly income < EUR 1000 VS. > EUR 2000 (aOR3.81; 95% CI 1.37, 10.61), number of post-COVID symptoms < 5 (aOR2.64, 95%CI 1.18, 5.87), and anxiolytics consumption (aOR 1.85, 95%CI 1.05, 3.25) were associated with a greater likelihood of opioid analgesic consumption. Age > 55 years (aOR3.30, 95%CI 1.34, 8.09) and anxiolytics consumption (aOR2.61, 95%CI 1.36, 4.98) were associated with a greater likelihood of non-opioid analgesic consumption. Opioid analgesic consumption was highly associated (aOR 3.41, 95%CI 1.27, 6.11) with non-opioid analgesic consumption. The prevalence of opioid analgesic and non-opioid analgesic consumption in individuals with post-COVID-19 condition was 24.1% and 82.3%. Females with post-COVID-19 condition showed higher non-opioid analgesic consumption than men. Predictors of opioid consumption were marital status, lower monthly income, number of post-COVID symptoms, and anxiolytic consumption. Older age and anxiolytic consumption were predictors of non-opioid consumption.

Global trends in the consumption of benzodiazepines and Z-drugs in 67 countries and regions from 2008 to 2018: a sales data analysis

STUDY OBJECTIVES

To investigate the trends in the consumption of benzodiazepines (BZDs) and Z-drugs at global, regional, and national levels from 2008 to 2018, across 67 countries and regions.

METHODS

This cross-sectional descriptive study investigated the consumption of BZDs and Z-drugs analyzed by global pharmaceutical sales data from the IQVIA-Multinational Integrated Data Analysis System database between 2008 and 2018. Consumption was measured in defined daily dose (DDD) per 1000 inhabitants per day (DDD/TID). The global, regional, and national trends were estimated using linear mixed models. Additional analyses were conducted by grouping countries by income level. The association between consumption and Gross Domestic Product (GDP) and the prevalence of different medical conditions was explored in univariable linear models.

RESULTS

BZD consumption decreased annually by -1.88% (95% CI: -2.27%, -1.48%), and Z-drugs increased by + 3.28% (+2.55%, +4.01%). In 2008, the top ten countries for BZD and Z-drug consumption were all European, ranging from 63.69 to 128.24 DDD/TID. Very low levels were found in Russia, Kuwait, United Arab Emirates, Saudi Arabia, French West Africa, and the Philippines, with DDD/TID < 1. The consumption in high-income countries was much higher than in middle-income countries. The results showed that increased consumption of BZDs and Z-drugs was statistically associated (p < 0.05) with higher GDP and increased prevalence of anxiety, self-harm, neurological disorders, chronic respiratory diseases, cardiovascular diseases, and cancers.

CONCLUSIONS

Distinct differences in consumption and trends of BZDs and Z-drugs were found across different countries and regions. Further exploration is needed to understand the association and safety of the use of BZDs and Z-drugs in patients with comorbidities.

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients

OBJECTIVE

To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals.

MATERIALS AND METHODS

A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated.

RESULTS

A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone.

DISCUSSION

Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Protocol for a scoping review study on the prevalence and public health consequences of non-medical use (NMU) of tramadol in Africa

BACKGROUND

Tramadol is one of the most prescribed painkillers in the world. It is a synthetic opioid that is an excellent alternative to morphine and its derivatives in African countries. It is an essential drug due to its low cost and constant availability. However, the health consequences of tramadol use due to illicit trafficking, like those caused by fentanyl and methadone in North America, are poorly documented. This scoping review aims to understand the nature and extent of the use and health consequences of the Non-Medical Use (NMU) of tramadol in Africa to guide future research.

METHODS

Due to the perceived lack of African literature on the subject, our search strategy is based on the simultaneous use of the keywords "tramadol" and Medical Subject Heading (MeSH), such as "Drug abuse," "illicit drugs," or "Prescription Drug Misuse," combined with the term "Africa" and Boolean operators (and, or not) to form our search equations. Two researchers will independently select studies from literature searched in several databases such as Medline, Embase, the Scopus database, Web of Science, the African Journals online database, and for grey literature Google Scholar without any time restriction. All research, in various formats, conducted in Africa, will be included in our study on the prevalence of use in different African population groups or on evidence of addiction, intoxication, seizures and mortality related to NMU of tramadol.

RESULTS

Through this study, we aim to map consumers and identify risk factors, health consequences, and prevalence of the NMU of tramadol in African countries.

DISCUSSION

We are conducting the first scoping review study to investigate the prevalence and consequences of NMU of tramadol in Africa. Upon completion, our findings will be published in a peer-reviewed journal and presented at relevant conferences and workshops. However, since health is not limited to the lack of disease, our study is likely incomplete without incorporating the studies of the social impact of NMU of tramadol.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework: https://osf.io/ykt25/.

Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update

INTRODUCTION

Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States.

AREAS COVERED

In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal.

EXPERT OPINION

To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.

Nationwide Population-Based Study About Patterns of Prescription Opioid Use and Misuse Among Young Adults in Spain

Objective: Prescription opioid misuse has become one of the most common ways drugs are consumed among young adults. The objective of our study was to describe the prevalence and factors associated with prescription opioid use and misuse among young adults living in Spain.

Methods: A nationwide, cross-sectional epidemiological study on the use and misuse of prescription opioids in Spanish Youngers. We used individualized secondary data provided by the Household Survey on Alcohol and Drugs in Spain 2017–2018.

Results: Prevalence of prescription opioid use among young adults was 4.89%. Misuse among this population reached prevalence values of 13.4%, with higher values observed among women . The variables associated with a greater probability of prescription opioid use and misuse were misuse of tranquilizers, sedatives, and sleeping pills, along with using cannabis and other illicit psychoactive drugs (aOR = 2.99; 95% CI: 1.10–8.15).

Conclusion: Prescription opioid use and misuse in Youngers has important implications for the Spanish public health system, because, even though not currently comparable to the situation in other countries, this drug use could be on the verge of creating similar problems.

Estimating the Prevalence of Recreational Opioid Use in Spain Using a Multiplier Method

Acknowledgement of the prevalence of recreational opioid use (PROU) is key to the planning and evaluation of care services. However, in Spain, the prevalence of PROU in recent years is unknown. The objective of this study was to estimate the PROU between 2005 and 2019 in the general populations of six Spanish cities. A benchmark-multiplier methodology was used to estimate the PROU population size. The benchmark used was overdose deaths from recreational opioid use in Spain’s six most populated cities. The multiplier was the overdose death rate in a cohort of heroin users. Linear regression was used to estimate the trend of the PROU estimate over the set period of years. In 2005, the PROU was 4.78 (95%CI 3.16–7.91) per 1000 people. The estimated trend decreased, with the two lowest values being 2.35 per 1000 in 2015 and 2.29 in 2018. In 2019 the PROU was 2.60 per 1000 (95%CI 1.72–4.31), 45% lower than in 2005. While the decline in the PROU continues, its deceleration over the last four years calls for increased vigilance, especially in light of the opioid crisis in North America that has occurred over the last few years.

Increase of high-risk tramadol use and harmful consequences in France from 2013-2018: evidence from the triangulation of addictovigilance data

Aims

The aim of this paper is to assess recent developments in non‐medical tramadol use, tramadol use disorder, illegal procurement and deaths.

Methods

This study used repeated cross‐sectional analysis of data collected nationwide from 2013 to 2018. Analysis was conducted through multisource monitoring of the French Addictovigilance Network of: (1) validated reports of high‐risk tramadol use, (2) record systems collecting information from toxicology experts investigating analgesic‐related deaths (DTA) and deaths related to substance abuse (DRAMES), and pharmacists for forged prescriptions (OSIAP), and (3) survey of drug users, with investigation of patterns of use while visiting addiction‐specialised institutions (OPPIDUM).

Results

Despite a plateauing level of tramadol exposure in the French population, the proportion of tramadol reports increased 1.7‐fold (187 cases in 2018, 3.2% (95% confidence interval [CI]: 2.74–3.63%), versus 1.9% (95% CI: 1.49–2.42% in 2013). Trends were similar in OSIAP: 11.9% of forged prescriptions in 2018 (95% CI: 10.56–13.45%); 1.7‐fold increase; in OPPIDUM: 0.76% (95% CI: 0.55–1.02); 2.2‐fold increase; and DRAMES: 3.2% of drug abuse‐related deaths in 2018 (95% CI: 1.89–5.16) versus 1.7% in 2013 (95% CI: 0.65–3.84). Tramadol was the primary opioid in analgesic‐related deaths in DTA (45% in 2018). Two profiles of high‐risk tramadol users were identified: (1) patients treated for pain or with tramadol persistence when pain disappeared (mainly women; mean age 44 years), and (2) individuals with non‐medical use for psychoactive effects (mainly men; mean age 36 years).

Conclusion

The triangulation of the data obtained through addictovigilance monitoring evidenced a recent increase in high‐risk tramadol use. These findings have a practical impact on the limitation of the maximal duration of tramadol prescriptions.

Surveying Over the Counter and Prescription Only Medication Misuse in Treatment Services During COVID-19

Background:

A greater understanding of Over the Counter (OTC) and Prescription Only Medication (POM) misuse amongst adults accessing substance misuse services (SMS) during COVID-19 is required to identify how SMS can better meet the needs of the people who require treatment.

Aim:

To use a questionnaire to explore OTC/POM misuse during COVID-19 in adults accessing community SMS in England.

Methods:

In 2020 to 2021 anonymous self-administered online/paper questionnaires which collated quantitative and qualitative data were completed. They were piloted for suitability and ethical approval was obtained. Thematic analysis was conducted for qualitative data and chi-square tests used to assess the relationship between quantitative variables.

Results:

Participants were Caucasian (94.6% British), majority male (58.9%), aged 18 to 61 years. Most were prescribed medication for problematic substance use, with a 92.5% self-reported adherence rate. The misuse of benzodiazepines (22.2%) codeine products (30.8%) and pregabalin (14.5%) predominated and 37.5% misused 2 or more medicines. Administration was usually oral and concomitant use of other substances was common: alcohol 44.6% (52% daily), tobacco/vaping 73.2% and illicit substances 58.9%. There were statistically significant associations identified, including between changes during COVID-19 to OTC/POM misuse and illicit use. Only 56 questionnaires were included in the analysis: we believe this low number was because of infection control measures, limited footfall in services, pressures on staff limiting their capacity to distribute the paper questionnaires and reliance upon telephone consultations limiting online distribution. Increasing OTC/POM misuse and obtaining illicit supplies were reported when access to usual supplies were restricted; however, changes to doses/dispensing arrangement liberalisation in response to COVID-19 were positively viewed.

Conclusion:

OTC/POM misuse, including polypharmacy and concomitant use of other substances occurred during COVID-19: SMS need to be vigilant for these issues and mitigate the associated risks for example with harm reduction interventions. Further qualitative research is required to explore the issues identified.