A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States

The Effectiveness of Tramadol in Pain Relief in Chronic Diseases: A Review Based on Clinical Trials

Tramadol is a synthetic opioid with a central effect from the aminocyclohexanol group, which has two main mechanisms of action, including as a weak agonist of opioid receptors and as a norepinephrine and serotonin reuptake inhibitor. The present study presents a review based on clinical trials designed in 2023. In July 2023, six international databases, including Medline/PubMed, ProQuest, Scopus, EMBASE, Google Scholar, and ISI (Web of Science), were searched and 58 articles were included in the study. The results of most studies showed that tramadol can be used as an analgesic drug, although in some studies it was shown that tramadol is not therapeutically superior in reducing pain compared to other treatments. Also, complications related to this treatment have been reported in some studies. Physicians should consider these factors to prevent drug toxicity, poor pain relief, use disorder in patients, and unpredictable complications. It should be noted that there is not enough evidence to support the long-term effectiveness of tramadol, but this argument also extends to nonopioid and other types of opioid analgesics, and the lack of long-term trials is due to regulatory and ethical issues. Although opioids can cause addiction when used for a long time, tramadol has a reasonable safety profile. According to the patient's condition and the clinical judgment of the medical professional, tramadol can be prescribed for patients, but the consequences of its use must be considered and a personalized treatment algorithm should be selected if the benefits outweigh the risks of the drug.

Prevalence and factors associated with tramadol use among university students in Ghana: a cross-sectional survey

BACKGROUND

There are progressively alarming rates of non-medical use, addiction and possible dependence on tramadol in low-middle-income countries. Tramadol is known to heighten negative consequences on social interactions, physical and cognitive abilities among adolescents, students and youth, particularly those with polysubstance use. However, literature on the use of tramadol in low-middle-income countries, especially among undergraduate university students in Ghana remains inadequate. Thus, this study sought to determine the prevalence and factors associated with tramadol use among undergraduate students in Ghana.

METHODS

An institutional-based cross-sectional study and a quota sampling technique were employed to gather data from January to March 2023 on 600 undergraduate students from the University for Development Studies, Tamale, Ghana and analyzed with SPSS (version 26.0). Multiple logistic regression model was used to identify factors associated with the use of tramadol (p-value ≤ 0.05).

RESULTS

The lifetime prevalence of tramadol use was 17.8%. Among those who used tramadol in their lifetime, 14.95% used tramadol alone whereas 85.05% used at least one substance alongside tramadol. The study recorded more females (67.8%) than males. Students aged 20-24 years (20.5%), those single/never married (18.7%), those renting/living alone (19.7%) and first year students (17.4%) accounted for the majority of groups at high risk of lifetime tramadol use. To improve academic performance was the primary reason for initiating tramadol use. Male sex (adjusted odds ratio [AOR] 2.673; 95% confidence interval [CI] 1.590-4.493; p < 0.0001) and those with lifetime cannabis use (AOR 2.137; 95%CI 1.267-3.604; p = 0.004) were significantly associated with lifetime tramadol use.

CONCLUSIONS

This study revealed that lifetime tramadol use was high. Male sex and those with lifetime cannabis use were significantly related with lifetime tramadol use. The use of tramadol has become a public health threat and is important to limit its incidence and continuous use through extensive school and community health campaigns and strengthening of governmental policies against tramadol and other substance use since they increase the propensity of unwarranted cognitive, physical and social outcomes.

Tramadol poisoning and its management and complications: a scoping review

Tramadol (TR) is an opioid agonist (μ-opioid receptors) that also affects the noradrenergic and serotonergic systems. TR is a synthetic analgesic substance with opioid agonist properties that has been approved for pain management by affecting the central nervous system.

Objective

The primary objective of this scoping review was to determine the poisoning consequences of TR and its associated symptom management techniques, as well as its effect on opioid and non-opioid receptors, metabolism, and complications on various organ systems.

Discussion

Typically, acute overdose of TR is not considered life threatening, and most fatalities are attributed to polysubstance overdose. TR can cause drowsiness, headaches, seizures, respiratory depression, low heart rate, coma, and even death. Additionally, the prolonged use of TR can lead to addiction, with withdrawal resulting in both common and atypical symptoms.

Conclusions

Therefore, it is recommended that patients with TR poisoning receive close monitoring of their cardiovascular system, along with a comprehensive management plan for their levels of consciousness and respiratory function.

The role of lateral habenula NMDA receptors in tramadol-induced conditioning

The role of the lateral habenula (LHb) as a hub for receiving and relaying signals from the limbic system to serotonergic, dopaminergic, and norepinephrinergic regions in the brainstem makes this area a critical region in the control of reward and addiction. Behavioral evidence reveals the vital role of the LHb in negative symptoms during withdrawal. In this investigation, we study the role of the LHb N-Methyl D-Aspartate receptor (NMDAR) in the modulation of tramadol reward. Male adult Wistar rats were used in this study. The effect of intra-LHb micro-injection of NMDAR agonist (NMDA, 0.1, 0.5, 2 µg/rat) and antagonist (D-AP5, 0.1, 0.5, 1 µg/rat) was evaluated in conditioned place preference (CPP) paradigm. The obtained results showed that intra-LHb administration of NMDA induced place aversion dose-dependently, while blockade of NMDAR in the LHb using D-AP5 micro-injection led to an increased preference score in the CPP task. Co-administration of NMDA (0.5 µg/rat) with tramadol (4 mg/kg) reduced preference score, while co-administration of D-AP5 (0.5 µg/rat) with a non-effective dose of tramadol (1 mg/kg) potentiate the rewarding effect of tramadol. LHb receives inputs from the limbic system and projects to the monoaminergic nuclei in the brainstem. It has been declared that NMDAR is expressed in LHb, and as obtained data revealed, these receptors could modulate the rewarding effect of tramadol. Therefore, NMDA receptors in the LHb might be a new target for modulating tramadol abuse.

Reinforcing effect of tramadol in the rat

Tramadol is one of the most commonly prescribed analgesic opioids in various pharmacopeias. Tramadol has been linked to abuse in recent clinical investigations. However, the behavioral effects and neural substrates of the drug have not been well characterized in preclinical studies. As a result, the present study investigated the effects of tramadol on behavioral sensitizations in rats. Its impacts on cellular and molecular alterations in the brain were also investigated. In conditioned place preference (CPP) paradigm, tramadol induced behavioral as well as motor sensitizations. These effects were dramatically reduced by intraperitoneal administration of naltrexone, an opioid receptor antagonist. Tramadol caused changes in several molecular markers (pERK1/2, Δ-FosB, PKCγ, PKMζ GAD67) in the anterior cingulate cortex, which could indicate an increase in excitation within this structure. Tramadol is demonstrated in the present study to be a reinforcing drug in rats, as it increased both behavioral and motor sensitizations. Tramadol's effects are most likely due to the high levels of excitation it causes in the brain, which is mostly caused by the activation of opioid receptors.

Tramadol and Tapentadol Induce Conditioned Place Preference with a Differential Impact on Rewarding Memory and Incubation of Craving

Tramadol and tapentadol, synthetic opioids commonly prescribed for moderate-to-severe pain, have a unique pharmacology that optimizes their analgesia and safety. However, they are not devoid of risks, presenting addictive, abuse, and dependence potential. While tramadol-reinforcing properties have been documented by various studies with human and animal models, including conditioned place preference (CPP) assays, no similar studies have been performed with tapentadol. In the present study, we performed CPP assays by intraperitoneally administering Wistar rats with a tramadol/tapentadol therapeutic dose. Animal permanence and the number of entries in the CPP compartments were recorded in the preconditioning phase and then 1 (T1), 7 (T7), and 14 (T14) days after conditioning. Both opioids induced a change in place preference (T1), suggesting that they have short-term reinforcing properties. However, only tramadol was associated with place preference retention (T7 and T14), with an increase in the number of entries in the opioid-paired compartment (T1 and T7), showing that it causes rewarding memory and incubation of craving. The results indicate that at therapeutic doses: (1) both drugs cause short-term rewarding effects and (2) as opposed to tramadol, tapentadol does not cause CPP retention, despite its higher central nervous system activity and stricter scheduling.

Tramadol in seized drugs containing non-pharmaceutical fentanyl: Crime lab data from Ohio, USA

Introduction

Non-pharmaceutical fentanyl and related drugs (NPF) have contributed to increases in drug-related overdose mortality in the U.S. More data are needed to track the shifting composition of fentanyl-containing drug mixtures. The key aims of the study are to characterize the crime lab data from Montgomery County, Ohio on the increased cases of seized drugs containing mixtures of NPF and tramadol.

Methods

Crime lab data on seized drugs in Montgomery County, Ohio (2015 - 2020) were analyzed to extract information on cases that tested positive for NPF and tramadol. Descriptive statistics are provided to characterize NPF/tramadol mixtures in terms of the quantity, weight, form of the drug seized (powder, tablet, capsule, residue), and the types of fentanyl analogs and other drugs identified.

Results

In December 2017, the first case of NPF/tramadol mixture was identified in the amount of 0.2 g. Sub-sequently, cases containing NPF/tramadol increased significantly to 149 cases in 2018, 102 in 2019, and 134 in 2020. The total yearly amounts of seized NPF/tramadol mixtures increased to 373.27 g in 2018, 2,601.82 g in 2019, and 13,487.62 g in 2020. The majority (72.6%) of the cases were in powder form. There were 15 other drugs identified along with fentanyl with tramadol mixtures, including heroin (38.8%), 5.7% cocaine (5.7%), and methamphetamine (4.9%).

Conclusions

The addition of tramadol to NPF may be viewed as a harm mitigation strategy but contributes to the overall unpredictability of the illicit drug supply. According to Ohio legal statutes, identification of schedule IV drugs such as tramadol with fentanyl (schedule II) may provide a reduction in drug-related charges from a felony to a misdemeanor. More research is needed to characterize potential sources of tramadol in NPF-containing drugs.

Effects of imidazoline agents in a rat conditioned place preference model of addiction

Agmatine (AG), idazoxan (IDZ), and efaroxan (EFR) are imidazoline receptor ligands with beneficial effects in central nervous system disorders. The present study aimed to evaluate the interaction between AG, IDZ, and EFR with an opiate, tramadol (TR), in a conditioned place preference (CPP) paradigm. In the experiment, we used five groups with 8 adult male Wistar rats each. During the condition session, on days 2, 4, 6, and 8, the rats received the drugs (saline, or TR, or IDZ and TR, or EFR and TR, or AG and TR) and were placed in their least preferred compartment. On days 1, 3, 5, and 7, the rats received saline in the preferred compartment. In the preconditioning, the preferred compartment was determined. In the postconditioning, the preference for one of the compartments was reevaluated. TR increased the time spent in the non-preferred compartment. AG decreased time spent in the TR-paired compartment. EFR, more than IDZ, reduced the time spent in the TR-paired compartment, but without statistical significance. AG reversed the TR-induced CPP, while EFR and IDZ only decreased the time spent in the TR-paired compartment, without statistical significance.

Bupropion Use Disorder by Chewing

INTRODUCTION

Bupropion is a widely used antidepressant that plays an essential role in treating mental disorders. Due to its structural similarities with psychostimulants, bupropion is suggested to have addictive potential. Several case reports have been published addressing its misuse in recent years, mainly through nasal insufflation and intravenous administration. Most of the reported cases cited a history of substance use disorder.

METHODS

Written informed consent was obtained from the patient to write this case report.

CASE PRESENTATION

We present a case with alcohol use disorder and attention deficit hyperactivity disorder, who developed a substance use disorder to bupropion while chewing it in doses up to 2250 mg, in an attempt to get "high" with no history of seizures.

DISCUSSION

Our case suggests that bupropion can also be misused by chewing even at high doses and that it can lead to a substance use disorder. Its use in various indications in treating mental disorders and its over-the-counter accessibility, along with a lower risk of stigmatization, could increase the prevalence of bupropion misuse. It is essential to know the medical consequences of bupropion misuse as there is increasing data on its addictive potential. More information is needed to clarify the impact of the route of administration on drug metabolism and adverse effects.

Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature

BACKGROUND

Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management.

OBJECTIVE

To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients.

METHODS

A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020.

RESULTS

Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist.

CONCLUSION

Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.

A Patient-Controlled Intravenous Analgesia With Tramadol Ameliorates Postpartum Depression in High-Risk Woman After Cesarean Section: A Randomized Controlled Trial

Background: Postpartum depression (PPD) is a severe psychiatric disorder. Its risk is associated with the cesarean section (CS). Currently, there are few early intervention strategies for these women with PPD who underwent CS.

Methods: This was a parallel-group randomized controlled trial of singleton pregnant women who underwent elective CS in a tertiary referral hospital in China from October, 2017 to September, 2019. After operation, patients received randomly tramadol patient-controlled intravenous analgesia (PCIA; 4 mg/ml; TRA group), hydromorphone PCIA (0.04 mg/ml; HYD group), or ropivacaine patient-controlled epidural analgesia (PCEA; 1.5 mg/ml; ROP group) for 48 h in a 1:1:1 ratio. Total blinding during hospitalization was not feasible due to differences between the PCEA and PCIA treatments. All investigators who performed the follow-up were blinded to the group assignment.

Outcomes: A total of 1,230 patients were enrolled for eligibility. Intention-to-treat analysis showed reduced incidence of PPD in the TRA group (n = 27 [6.6%]) than that in the HYD (10.2%, OR 1.62, 95% CI 0.98~2.68; p = 0.059) and ROP groups (10.5%, OR 1.66, 95% CI 1.01~2.75; p = 0.046) at 4 weeks post-operation, however, the difference was not statistically significant (Bonferroni corrected p = 0.118, p = 0.098, respectively). Subgroup analysis in high-risk women (preoperative Edinburgh Postpartum Depression Scale [EPDS] ≥10) showed a significantly lower incidence of PPD in the TRA group (16.5%) than in the HYD (32.6%) and ROP groups (30.9%) (Bonferroni corrected p = 0.022 and p = 0.038, respectively). The per-protocol analysis yielded similar results. Reported adverse events (AEs) were mostly mild. None of the women or infant discontinued treatment due to AEs.

Conclusions: Tramadol PCIA after CS in high-risk women can help to reduce the risk of PPD at 4 weeks after elective CS.

Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03309163?term=ETPPD&draw=2&rank=1; ClinicalTrials.gov (NCT03309163).

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

BACKGROUND

Understanding prescription medication misuse is challenging due to lack of consistent measures of misuse behaviors and prevalence between countries. Tramadol is an atypical opioid with a dual mechanism, and has low drug liking compared to conventional opioids. We evaluate tramadol misuse compared to conventional opioids utilizing a harmonized validated national survey across four countries: Germany, Italy, Spain, and the United Kingdom (UK).

METHODS

Data from the Survey of Non-Medical Use of Prescription Drugs (NMURx) Program online cross-sectional general population national surveys are analyzed from 2018 from four countries, with 45,000 total responses. Misuse and abuse of tramadol, codeine, morphine, and oxycodone are compared, and national prevalence estimates calculated via calibration weighting. Rates are calculated per population and per drug availability. Supplemental data are included from patients entering treatment centres and poison centre exposures.

RESULTS

In 2018, distribution, misuse, and abuse of four prescription opioids show similar patterns across four countries. In all countries, codeine is misused by the largest number of adults (estimated 861,181 in Italy to 4,676,680 in Spain in past 12 months). When adjusted for availability, tramadol is misused uncommonly with lowest or second lowest rates in all countries. Most abuse occurs by the oral route for all opioids, including tramadol with only 7.27 (Germany) to 54.92 (UK) cases per 100,000 units sold.

CONCLUSIONS

In four countries, tramadol misuse and abuse are infrequent both in absolute number of cases and in comparison to conventional opioids. Even with availability of intravenous tramadol formulations, misuse by injection is rare.

An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK

AIM

To identify and describe the nature of online discussion relating to prescription opioids within the UK.

METHODS

We performed analysis of posts originating in the UK related to buprenorphine, hydrocodone, oxycodone and tramadol using Social Studio, a web-monitoring platform. The study included posts published between January 2014 and December 2016. The data were cleaned to produce a final dataset consisting only of substantive mentions, which were then categorised by defined themes.

RESULTS

The final dataset included a total of 17 361 substantive mentions (2936 buprenorphine, 2894 hydrocodone, 3826 oxycodone and 7705 tramadol). The most common theme for all 4 drugs was sharing experience or opinion comprising over 90% of mentions for each drug, while discussion related to polysubstance use was present in >1/4 of mentions across drug substances. Mentions related to diversion were more common for hydrocodone and oxycodone (8.1% [6.3-10.1 95% confidence interval] and 7.8% [6.5-9.2], respectively) than buprenorphine or tramadol (4.1 and 3.9% [3.5-4.3], respectively).

CONCLUSION

This investigation shows that there is substantial online discussion relating to a variety of nonmedical use (NMU) behaviours of prescription opioids within the UK, including for hydrocodone, which is not medically available. Web monitoring provides useful data and merits future investigation; this could include expansion to other categories of drugs and a more in-depth analysis of motivations behind NMU, both of which could add timely evidence regarding the current situation in the UK and help inform public health interventions for NMU of prescription drugs.

The role of cannabinoid 1 receptor in the nucleus accumbens on tramadol induced conditioning and reinstatement

AIMS

Previous investigations demonstrated that tramadol, as a painkiller, similar to morphine induces tolerance and dependence. Furthermore, the cannabinoid receptor 1 (CB1R) located in the nucleus accumbens (NAc) plays a critical role in morphine-induced conditioning. Therefore, the main objective of this study was to evaluate the role of NAc CB1R in tramadol induced conditioning and reinstatement.

MAIN METHODS

In the present experiment, the effect of NAc CB1 receptors on tramadol induced conditioning was tested by microinjecting of arachidonylcyclopropylamide (ACPA, CB1R agonist) and AM 251 (CB1R inverse agonist) in the NAc during tramadol-induced conditioning in the adult male Wistar rats. In addition, the role of NAc CB1R in the reinstatement was also evaluated by injecting ACPA and AM 251 after a 10-days extinction period.

KEY FINDINGS

The obtained data revealed that the administration of tramadol (1,2, and 4 mg/kg, ip) dose-dependently produced conditioned place preference (CPP). Moreover, intra-NAc administration of ACPA (0.25, 0.5, and 1 μg/rat) dose-dependently induced conditioning, while the administration of AM-251 (30, 60, and 120 ng/rat) induced a significant aversion. In addition, the administration of a non-effective dose of AM251 during tramadol conditioning inhibited conditioning induced by tramadol. On the other hand, the administration of ACPA after extinction induced a significant reinstatement. Notably, the locomotor activity did not change among groups.

SIGNIFICANCE

Previous studies have shown that tramadol-induced CPP occurs through μ-opioid receptors. The data obtained in the current study indicated that CB1R located in the NAc is involved in mediating conditioning induced by tramadol. Besides, CB1R also plays a vital role in the reinstatement of tramadol-conditioned animals. It might be due to the effect of opioids on enhancing the level of CB1R.

Efficacy and Safety of Intravenous Tramadol versus Intravenous Paracetamol for Relief of Acute Pain of Primary Dysmenorrhea: A Randomized Controlled Trial

INTRODUCTION

Many pharmaceutical, surgical, and complementary medical interventions are used for primary dysmenorrhea treatment. However, no consensus has been reached about the most effective intervention.

OBJECTIVE

To compare the efficacy and safety of IV tramadol versus IV paracetamol in relieving acute pain of primary dysmenorrhea.

METHODS

This randomized controlled trial was conducted in a tertiary referral hospital and included 100 patients between 18 and 35 years old diagnosed with primary dysmenorrhea. Patients received either 1-g paracetamol or 100-mg tramadol in 100-mL normal saline as an IV infusion over 10 min. Pain intensity was measured by using a visual analog scale at 15, 30, 60 min, and 2 h. We recorded drug side effects and requirements for rescue analgesics.

RESULTS

Pain scores were significantly lower in the tramadol group compared with the paracetamol group at 15, 30, 60 min, and 2 h (p < 0.001). Fewer patients in the tramadol group needed rescue analgesics compared with the paracetamol group (p = 0.04). No significant differences were reported in side effects between both groups.

CONCLUSIONS

IV tramadol is superior to IV paracetamol in relieving acute pain of primary dysmenorrhea with a comparable side effect profile.

Tramadol abuse among workers in an industrial city in mid-Nile Delta region, Egypt

Tramadol abuse is an increasingly alarming phenomenon among Egyptian Community especially among workers and drivers. Study profile and factors affecting tramadol abuse among industrial workers in Mid-Nile Delta Region. A cross sectional study among minibus drivers, construction and textile industries workers. From each target group 300 males were chosen randomly. The total sample size was 900 persons. Interview questionnaire was used for data collection. Diagnosis of tramadol abuse was according DSM-5 Criteria. Intake of tramadol was high among construction workers (92.3%) followed by bus drivers (53.0%) and lastly textile workers (25.3%). The main source of tramadol was friends (45.4%) followed by drug dealers (16.6%). The main reason of abuse was to improve mood (54.3%) followed by relief of pain and help to continue work (37.3%). Tramadol is prevalent among industrial workers due to different reasons related to the work load and stressful events. Ever intake of tramadol was high among construction workers followed by bus drivers and lastly textile workers. Drug testing for workers in workplace is a must to ensure community safety.

Acute toxicity related to misuse (nonmedical use) of tramadol: Experience of the European Drug Emergencies Network Plus

Following the development of the tramadol crisis currently affecting countries in the Middle East, and Africa, there has been increasing international interest in the regulation of tramadol. This study investigates the misuse of tramadol in patients presenting to emergency departments across Europe. Data from 32 emergency departments in 21 countries were extracted from the Euro-DEN Plus database for the 4-year period from 1 January 2014 to 31 December 2017. Of the reported 24,957 emergency department presentations, tramadol misuse was reported in 105 (0.4% presentations). Tramadol misuse was most common in Bratislava (Slovakia; n = 11, 7.5% of all presentations to this centre), Riga (Latvia; n = 4, 4.9%) and Munich (Germany; n = 17, 2.9%). On arrival, 14 (13.3%) of presentations were in coma/Glasgow coma score ≤ 8 and 9 of these had a respiratory rate <12 breaths/min. These presentations potentially pose a significant burden on emergency departments with a large proportion requiring admission to hospital for ongoing care.

The Anesthesiologist's Armamentarium: From Recreation to Medication and Back

For millennia, mankind has sought a means of altering consciousness, often aided by naturally occurring elements. Psychotropic substances have been an integral part of spiritual, medicinal, and recreational aspects of life. The origin of anesthesiology stems directly from the use of recreational drugs; early inhaled anesthetics were first used as a means of entertainment. Hence, it is no surprise that many medications in the anesthesiologist's armamentarium are diverted for recreational use. In the 172 years following the first successful public demonstration of ether anesthesia, many drugs with abuse potential have been introduced to the practice of anesthesia. Although anesthesiologists are aware of the abuse potential of these drugs, how these drugs are obtained and used for recreational purposes is worthy of discussion. There are articles describing the historical and recreational use of specific drug classes. However, to the best of our knowledge, this is the first comprehensive review focusing on the breadth of drugs used by anesthesiologists.

Facilitators to the continuous abuse of tramadol among the youth: A qualitative study in Northern Ghana

STUDY AIM

Considering the alarming rate at which young people abuse tramadol, as evidenced by the numerous media reports on the subject, this qualitative study was conducted to explore the facilitators to the abuse of tramadol by young people.

DESIGN AND METHODS

A qualitative exploratory descriptive design was employed in conducting the study. A total of 18 participants were purposively sampled. Data for the study were collected through two focused group discussions and three in-depth-interviews. Thematic analysis was used to analyse the data.

RESULTS

The findings of the study revealed four main themes. These themes were initiating factors of abuse; desirable physical effects; desirable psychological effects; and undesirable effects. It was revealed that many young people initially get into tramadol abuse because of peer pressure, curiosity or post-traumatic addiction. However, they often continue the practice for various physical and psychological gratifications including euphoria, attentiveness, high energy levels, pain relief and improved sexual performance. The study also revealed some unpleasant side effects of tramadol abuse such as severe vomiting, loss of appetite, seizures, emotional aloofness and irritability. Many of the participants in this study also expressed willingness to quit tramadol abuse because of social discrimination and the enormous side effects that come with the abuse of the drug.

Revisiting Tramadol: A Multi-Modal Agent for Pain Management

Tramadol-an atypical opioid analgesic-has a unique pharmacokinetic and pharmacodynamic profile, with opioidergic, noradrenergic, and serotonergic actions. Tramadol has long been used as a well-tolerated alternative to other drugs in moderate pain because of its opioidergic and monoaminergic activities. However, cumulative evidence has been gathered over the last few years that supports other likely mechanisms and uses of tramadol in pain management. Tramadol has modulatory effects on several mediators involved in pain signaling, such as voltage-gated sodium ion channels, transient receptor potential V1 channels, glutamate receptors, α₂-adrenoceptors, adenosine receptors, and mechanisms involving substance P, calcitonin gene-related peptide, prostaglandin E₂, and proinflammatory cytokines. Tramadol also modifies the crosstalk between neuronal and non-neuronal cells in peripheral and central sites. Through these molecular effects, tramadol could modulate peripheral and central neuronal hyperexcitability. Given the broad spectrum of molecular targets, tramadol as a unimodal analgesic relieves a broad range of pain types, such as postoperative, low back, and neuropathic pain and that associated with labor, osteoarthritis, fibromyalgia, and cancer. Moreover, tramadol has anxiolytic, antidepressant, and anti-shivering activities that could improve pain management outcomes. The aim of this review was to address these issues in the context of maladaptive physiological and psychological processes that are associated with different pain types.

Tramadol induces changes in Δ-FosB, µ-opioid receptor, and p-CREB level in the nucleus accumbens and prefrontal cortex of male Wistar rat

BACKGROUND

Besides the analgesic effect of tramadol, prolonged exposure to tramadol can induce adaptive changes thereby leading to dependence and tolerance. Tramadol induces its effect via µ-opioid receptor (MOR). However, tramadol has other targets such as serotonin and epinephrine transporters.

OBJECTIVE

CREB and ΔFosB are transcriptional factors, which are involved in the behavioral abnormalities underlying drug abuse. In this study, the effects of acute and chronic tramadol treatments on MOR, ΔFosB, and CREB levels were studied.

METHODS

For this purpose, 36 male Wistar rats were used. The animals were divided into two main groups. A total of 18 animals received tramadol (0, 5, and 10 mg/kg) acutely and 18 animals received the same doses for the following 14 days. One hour after the last injection, the NAC and PFC were dissected and kept at -80°C in liquid nitrogen. Using western blotting technique, the levels of MOR, ΔFosB, and p-CREB were evaluated.

RESULTS

In the NAC, acute tramadol exposure increases the levels of MOR and p-CREB. Moreover, chronic tramadol administration in this region results in elevated levels of MOR, ΔFosB and p-CREB compared with saline-treated rats. The levels of MOR and p-CREB in the PFC increased in both acute and chronic tramadol exposure. Also, ΔFosB levels increased only following chronic tramadol administration. The results revealed that adaptive changes occurred during drug exposure.

CONCLUSION

We concluded that both CREB and ΔFosB played a role in tramadol dependence. Additionally, increased MOR levels during tramadol treatments might be due to receptor desensitization.

Tramadol dispensing patterns and trends in Canada, 2007-2016

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.

Effect of tramadol addiction alone and its co-abuse with cannabis on urinary excretion of Copper, Zinc, and Calcium among Egyptian addicts

BACKGROUND

The use of illicit drugs has become a worldwide health problem. Substances with the potential to be abused may have direct or indirect effects on physiologic mechanisms that lead to organ system dysfunction and diseases.

OBJECTIVE

The present study aims to investigate the structural and reabsorption integrity of the nephron among Egyptian addicts of tramadol alone and coabused with cannabis.

METHODS

Sixty-five males were included in the study, they were classified into control group (G1=19), tramadol addicts group (G2=18), and tramadol coabused with cannabis addicts group (G3=28). Parameters investigated for structural integrity were urinary levels ofleucineaminopeptidase and N-acetyl-β-D-glucosaminidase, and urinary parameters for reabsorption integrity were levels of copper and zinc as well as calcium, also urinary creatinine was measured. In addition, urinary levels of tramadol and tetrahydrocannabinol were estimated.

RESULTS

Among the two addicted groups, all measured parameters were not significantly different in comparison with the control group except for urinary calcium excretion which was found to be significantly increased among the two addicted groups.

CONCLUSION

Both tramadol addiction alone or coabused with cannabis causes increased urinary excretion of calcium, indicating reabsorption dysfunction of calcium without affecting structural integrity along the nephron.

Contemporary management of ejaculatory dysfunction

Although erectile dysfunction is the most common disorder of male sexual health, ejaculatory dysfunction is the most common form of sexual dysfunction experienced by men. Ejaculatory dysfunction covers a broad range of disorders that we have divided into four main categories: premature ejaculation, delayed ejaculation (DE)/anorgasmia, unsatisfactory sensation of ejaculation (including painful ejaculation and ejaculatory anhedonia), and absent ejaculate (including retrograde ejaculation and aspermia). We also cover several special scenarios including hematospermia, spinal cord injury and fertility with anejaculation. In this paper, we will review the anatomy and pathophysiology of normal ejaculation to establish the baseline knowledge of how this pathway can go awry. We will then briefly review the critical diagnostic criteria, pertinent steps in evaluation, risk factors, and causes (if known) for each of the ejaculatory disorders. Finally, the bulk of the paper will discuss current management strategies of each disorder.

Using drug courts for drug postmarketing surveillance

Purpose

– One of the greatest challenges for drug regulation is valid, comprehensive surveillance of drugs after they reach the pharmaceutical market. The purpose of this paper is to propose a new method of individual and aggregate-level postmarket surveillance using data previously (and continuously) collected by drug courts, which are in operation in nearly every geographic corner of the USA.

Design/methodology/approach

– To determine the feasibility of such an undertaking, data were obtained from an urban, southern county drug court. Intake data included all participants from September 2012 to November 2013. The final sample included 532 drug court participants.

Findings

– Intake data were found to include various demographic variables, measures of drug use, and various sociological/criminological variables such as familial and social support, church attendance, and other pertinent variables for studying drug use and crime trends generally.

Practical implications

– By using intake data from drug courts in a manner similar to Uniform Crime Report or National Incident-Based Reporting System, this could add greatly to the understanding of crime and drug use.

Social implications

– The authors purport that a data management system of drug court intake data could provide a cost-efficient and generalizable representation of drug use of those within the criminal justice system.

Originality/value

– Many efforts have been employed in an attempt to better ascertain where high rates of drug use occur. By using drug courts as more than just a system of treatment, postmarketing surveillance could be improved.

Detection and quantification of the opioid tramadol in urine using surface enhanced Raman scattering

There is an on going requirement for the detection and quantification of illicit substances. This is in particular the case for law enforcement where portable screening methods are needed and there has been recent interest in breath tests for a range of narcotics. In this study we first developed surface enhanced Raman scattering (SERS) for the detection of tramadol in water and establish robust and reproducible methods based on silver hydroxylamine colloid. We used 0.5 M NaCl as the aggregating agent, with the pH ∼ 7.0 and SERS data were collected immediately (i.e., the analyte association and colloid aggregation times were zero). The limit of detection was rather high and calculated to be 5 × 10(-4) M which would not be practical in the field. Undeterred we continued with spiking tramadol in artificial urine and found that no aggregating agent or modification of pH was necessary. Indeed aggregation occurred spontaneously due to the complexity of the medium which is rich in multiple salts, which are commonly used for SERS. We estimated the limit of detection in artificial urine to be 2.5 × 10(-6) M which is equivalent to 657.5 ng mL(-1) and very close to the levels typically found in individuals who use tramadol for pain relief. We believe this opens up opportunities for testing SERS in real world samples and this will be an area of future study.

A randomized, double-blind, placebo-controlled, crossover trial of "on-demand" tramadol for treatment of premature ejaculation

Objectives:

The objective of this study is to assess the dose-related effects of tramadol on a group of patients with premature ejaculation (PE).

Subjects and Methods:

During the period of months between June 2010 and July 2012, 180 PE patients presented to outpatient clinic of our hospital. Patients were randomized in a 1:1:1 fashion to receive different sequences of the three medications: placebo, 50 mg of tramadol and 100 mg of tramadol. Every patient received 10 doses of each medication for 2 months. Intra-vaginal ejaculatory latency time (IELT) was recorded in seconds initially and for each arm. Successful treatment of PE is defined if IELT exceeded 120 s. Side-effects of medications were reported.

Results:

Of patients enrolled, 125 (69.4%) continued the study. Patients’ age range was 20-55 years with PE complaint of 1 to 10 years duration. Mean IELT was 72 at presentation, 82 for placebo, 150 for tramadol 50 mg, and 272 for tramadol 100 mg (P < 0.001 for all comparisons). PE was successfully treated in only 2.4% of patients with placebo, in contrast to 53.6% and 85.6% with 50 and 100 mg tramadol, respectively (P < 0.001 for all comparisons). On multivariate logistic regression analysis, baseline IELT was the only predictor of successful treatment of PE with both tramadol 50 mg (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.03-1.07, P < 0.001) and tramadol 100 mg (OR: 1.07, 95% CI: 1.04-1.11, P < 0.001). Postmicturition dribble annoyed 12.8% of those who received 50 mg tramadol and 33.6% of those who received 100 mg tramadol (P < 0.001). Weak scanty ejaculation was the main complaint in 7.2% versus 21.6% of those using 50 and 100 mg tramadol, respectively (P = 0.002). Two patients discontinued tramadol 100 mg due to side-effects.

Conclusion:

Tramadol hydrochloride exhibits a significant dose-related efficacy and side-effects over placebo for treatment of PE.

Nalbuphine could decrease the rewarding effect induced by tramadol in mice while enhancing its antinociceptive activity

Nalbuphine, a kappa-opioid agonist and mu-opioid partial agonist, has been used as an analgesic or an adjuvant with morphine to attenuate the development of morphine dependence and rewarding effect. In this study, we investigated the effect of nalbuphine on tramadol rewarding effect and antinociception. Using the conditioned place preference (CPP) paradigm in mice, we demonstrated that co-administration of nalbuphine (7mg/kg, s.c.) with tramadol (70mg/kg, s.c.) during conditioning completely blocked the CPP induced by tramadol. Co-administration of nalbuphine blocked the increase in dopamine level in the nucleus accumbens induced by tramadol. These actions were accompanied by an increase rather than attenuation of the antinociceptive effect of tramadol. These results suggest that nalbuphine could have a great potential as a pharmacotherapy for tramadol abuse.

Using Web searches to track interest in synthetic cannabinoids (a/k/a 'herbal incense')

INTRODUCTION AND AIMS

This article reports a content analysis of Internet websites related to an emerging designer drug, synthetic cannabinoids. The number of synthetic cannabinoids searchers in the USA has steadily increased from November 2008 to November 2011.

DESIGN AND METHODS

To determine the information available on the Internet in relation to synthetic cannabinoids, sites were identified using the Google search engine and the search term 'herbal incense'. The first 100 consecutive sites were visited and classified by two coders. The websites were evaluated for type of content (retail, information, news, other). US unique monthly visitor data were examined for the top 10 retail sites, and these sites were coded for the quality of information available regarding the legality of synthetic cannabinoids sale and use.

RESULTS

The Google search yielded 2,730,000 sites for 'herbal incense' (for comparison of search terms: 'synthetic marijuana', 1,170,000; 'K2 Spice', 247,000; and 'synthetic weed', 122,000). Moreover, in the Google search, 87% of the sites were retail sites, 5% news, 4% informational and 4% non-synthetic cannabinoid sites.

DISCUSSION AND CONCLUSIONS

Many tools found within Google free services hold promise in providing a technique to identify emerging drug markets. We recommend continued surveillance of the Internet using the online tools presented in this brief report by both drug researchers and policy-makers to identify the emerging trends in synthetic drugs' availability and interest.

A European community pharmacy-based survey to investigate patterns of prescription fraud through identification of falsified prescriptions

AIM

To identify prescription drugs involved in falsified prescriptions in community pharmacies in 6 European countries.

METHODS

A cross-sectional survey among 2,105 community pharmacies in Belgium, France, Italy, the Netherlands, Spain and Sweden was carried out to collect all suspect prescription forms. For each reported drug, the number of reported falsified prescriptions per thousand inhabitants was estimated. A falsification ratio was calculated by dividing the number of reports by the number of defined daily doses per 1,000 inhabitants per day for this drug, computed from national sale or reimbursement data.

RESULTS

On 862 prescription forms, benzodiazepines (zolpidem, bromazepam, alprazolam), buprenorphine (as an opioid maintenance drug) and tramadol were the most frequently reported. Depending on their level of use in each country, methylphenidate, morphine and flunitrazepam presented the highest falsification ratios, particularly in Spain, Belgium and France.

CONCLUSIONS

Stimulants, opioids and some benzodiazepines were the most frequently reported drugs in this survey on falsified prescriptions, but differences between countries were observed.

A case of tramadol dependence and successful treatment with buprenorphine/naloxone

Tramadol, a synthetic, centrally acting analgesic with weak mu-opioid agonist activity, is often prescribed as an alternative to opioids due to its negligible abuse potential. Although the potential for the abuse of tramadol appeared low when the medication first became available, findings have demonstrated increased rates of abuse with extended time on the market. This case report details the addiction to tramadol of a 39-year-old female serving in the United States Army. At the height of her addiction, she was consuming an average of 1400mg tramadol daily. Eventually the patient entered into residential inpatient treatment for 28 days at our facility. During this time she was successfully titrated to buprenorphine 8mg/naloxone 2mg daily while maintaining abstinence. Patient care transitioned to the outpatient treatment center during which she maintained sobriety with the continued use of buprenorphine/naloxone. This case adds to previous reports of the increasing abuse of tramadol and the need for quality evidence on successful treatments for this escalating concern.

Efficacy of extended-release tramadol for treatment of prescription opioid withdrawal: a two-phase randomized controlled trial

BACKGROUND

Tramadol is an atypical analgesic with monoamine and modest mu opioid agonist activity. The purpose of this study was to evaluate: (1) the efficacy of extended-release (ER) tramadol in treating prescription opioid withdrawal and (2) whether cessation of ER tramadol produces opioid withdrawal.

METHODS

Prescription opioid users with current opioid dependence and observed withdrawal participated in this inpatient, two-phase double blind, randomized placebo-controlled trial. In Phase 1 (days 1-7), participants were randomly assigned to matched oral placebo or ER tramadol (200 or 600 mg daily). In Phase 2 (days 8-13), all participants underwent double blind crossover to placebo. Breakthrough withdrawal medications were available for all subjects. Enrollment continued until 12 completers/group was achieved.

RESULTS

Use of breakthrough withdrawal medication differed significantly (p<0.05) among groups in both phases; the 200mg group received the least amount in Phase 1, and the 600 mg group received the most in both phases. In Phase 1, tramadol 200mg produced significantly lower peak ratings than placebo on ratings of insomnia, lacrimation, muscular tension, and sneezing. Only tramadol 600 mg produced miosis in Phase 1. In Phase 2, tramadol 600 mg produced higher peak ratings of rhinorrhea, irritable, depressed, heavy/sluggish, and hot/cold flashes than placebo. There were no serious adverse events and no signal of abuse liability for tramadol.

CONCLUSIONS

ER tramadol 200mg modestly attenuated opioid withdrawal. Mild opioid withdrawal occurred after cessation of treatment with 600 mg tramadol. These data support the continued investigation of tramadol as a treatment for opioid withdrawal.

Serotonin syndrome: is it a reason to avoid the use of tramadol with antidepressants?

BACKGROUND

There is a warning associated with all serotonergic antidepressants and its concomitant use with tramadol due to the concern for a drug-drug interaction resulting in serotonin syndrome (SS). The prescribing of antidepressants with tramadol may be unnecessarily restricted due to fear of causing this syndrome.

OBJECTIVES

There are 3 objectives of this review. To (1) review case reports of SS associated with the combination of tramadol and antidepressant drugs in recommended doses, (2) describe the mechanisms of the drug interaction, and (3) identify the potential risk factors for SS.

METHODS

Case reports of SS associated with tramadol and antidepressants were identified via Cochrane Library, PubMed, and Ovid (through October 2012) using search terms SS, tramadol, antidepressants, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram, venlafaxine, desvenlafaxine, duloxetine, mirtazapine, milnacipran, trazodone, vilazodone, and bupropion. Cases involving monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants were excluded.

RESULTS

Nine articles were identified describing 10 cases of suspected SS associated with therapeutic doses of tramadol combined with an antidepressant. Mechanisms of the drug-drug interactions involve pharmacodynamic, pharmacokinetic, and possible pharmacogenetic factors.

CONCLUSIONS

Review of the available case reports of tramadol combined with antidepressant drugs in therapeutic doses indicates caution in regard to the potential for SS but does not constitute a contraindication to their use. Tramadol is only contraindicated in combination with MAOIs but not other antidepressants in common use today. These case reports do suggest several factors associated with a greater risk of SS, including increased age, higher dosages, and use of concomitant potent cytochrome P450 2D6 inhibitors. Tramadol can be safely combined with antidepressants; however, monitoring and counseling patients are prudent when starting a new serotonergic agent or when doses are increased.

The investigation of tramadol dependence with no history of substance abuse: a cross-sectional survey of spontaneously reported cases in Guangzhou City, China

The study was to survey and assess the drug dependence and abuse potential of tramadol with no history of substance abuse. Subjects of tramadol dependence with no prior history of substance abuse were surveyed by interview. Physical dependence of tramadol was assessed using 10 items opiate withdrawal scale (OWS), and psychological dependence was assessed by Addiction Research Center Inventory-Chinese Version (ARCI-CV). Twenty-three male subjects (the median age was 23.4 ± 4.1 years) referred to the addiction unit in Medical Hospital of Guangzhou with tramadol abuse problems were included in this cross-sectional study. The control group included 87 heroin addicts, 60 methamphetamine (MA) abusers, and 50 healthy men. The scores of OWS of tramadol were 0.83-2.30; the mean scores of identifying euphoric effects-MBG, sedative effects-PCAG, and psychotomimetic effects-LSD of ARCI were 8.96 ± 3.08, 6.52 ± 3.25, and 6.65 ± 2.50, respectively, F = 4.927, P < 0.001. Scores of MBG scale in tramadol did not differ from those in heroin and MA groups (P > 0.05) but were higher than those in healthy men (P < 0.05). Tramadol with no history of substance abuse has a clear risk of producing high abuse potential under the long-term infrequent abuse and the high doses.

PREDOSE: a semantic web platform for drug abuse epidemiology using social media

OBJECTIVES

The role of social media in biomedical knowledge mining, including clinical, medical and healthcare informatics, prescription drug abuse epidemiology and drug pharmacology, has become increasingly significant in recent years. Social media offers opportunities for people to share opinions and experiences freely in online communities, which may contribute information beyond the knowledge of domain professionals. This paper describes the development of a novel semantic web platform called PREDOSE (PREscription Drug abuse Online Surveillance and Epidemiology), which is designed to facilitate the epidemiologic study of prescription (and related) drug abuse practices using social media. PREDOSE uses web forum posts and domain knowledge, modeled in a manually created Drug Abuse Ontology (DAO--pronounced dow), to facilitate the extraction of semantic information from User Generated Content (UGC), through combination of lexical, pattern-based and semantics-based techniques. In a previous study, PREDOSE was used to obtain the datasets from which new knowledge in drug abuse research was derived. Here, we report on various platform enhancements, including an updated DAO, new components for relationship and triple extraction, and tools for content analysis, trend detection and emerging patterns exploration, which enhance the capabilities of the PREDOSE platform. Given these enhancements, PREDOSE is now more equipped to impact drug abuse research by alleviating traditional labor-intensive content analysis tasks.

METHODS

Using custom web crawlers that scrape UGC from publicly available web forums, PREDOSE first automates the collection of web-based social media content for subsequent semantic annotation. The annotation scheme is modeled in the DAO, and includes domain specific knowledge such as prescription (and related) drugs, methods of preparation, side effects, and routes of administration. The DAO is also used to help recognize three types of data, namely: (1) entities, (2) relationships and (3) triples. PREDOSE then uses a combination of lexical and semantic-based techniques to extract entities and relationships from the scraped content, and a top-down approach for triple extraction that uses patterns expressed in the DAO. In addition, PREDOSE uses publicly available lexicons to identify initial sentiment expressions in text, and then a probabilistic optimization algorithm (from related research) to extract the final sentiment expressions. Together, these techniques enable the capture of fine-grained semantic information, which facilitate search, trend analysis and overall content analysis using social media on prescription drug abuse. Moreover, extracted data are also made available to domain experts for the creation of training and test sets for use in evaluation and refinements in information extraction techniques.

RESULTS

A recent evaluation of the information extraction techniques applied in the PREDOSE platform indicates 85% precision and 72% recall in entity identification, on a manually created gold standard dataset. In another study, PREDOSE achieved 36% precision in relationship identification and 33% precision in triple extraction, through manual evaluation by domain experts. Given the complexity of the relationship and triple extraction tasks and the abstruse nature of social media texts, we interpret these as favorable initial results. Extracted semantic information is currently in use in an online discovery support system, by prescription drug abuse researchers at the Center for Interventions, Treatment and Addictions Research (CITAR) at Wright State University.

CONCLUSION

A comprehensive platform for entity, relationship, triple and sentiment extraction from such abstruse texts has never been developed for drug abuse research. PREDOSE has already demonstrated the importance of mining social media by providing data from which new findings in drug abuse research were uncovered. Given the recent platform enhancements, including the refined DAO, components for relationship and triple extraction, and tools for content, trend and emerging pattern analysis, it is expected that PREDOSE will play a significant role in advancing drug abuse epidemiology in future.

A patient with Tramadol dependence and predictable provoked epileptic seizures

Tramadol is an atypical, centrally acting synthetic analgesic with propensity for provoked seizures as well as abuse potential. The index case of Tramadol dependence discussed in this case report developed multiple epileptic seizures with high doses of Tramadol, used as a sexual enhancer by him, and later he learned to prevent the seizures by self-medicating with Alprazolam. The authors further emphasize on the regulation of Tramadol prescription.

"I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide

AIMS

Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users.

METHODS

A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use.

RESULTS

There has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010-2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as "poor man's" methadone. Typical doses ranged 70-100mg per day, much higher than an indicated daily dose of 16mg.

CONCLUSIONS

This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a "leading edge" data source in identifying emerging drug use practices.

Abuse liability and reinforcing efficacy of oral tramadol in humans

BACKGROUND

Tramadol, a monoaminergic reuptake inhibitor, is hepatically metabolized to an opioid agonist (M1). This atypical analgesic is generally considered to have limited abuse liability. Recent reports of its abuse have increased in the U.S., leading to more stringent regulation in some states, but not nationally. The purpose of this study was to examine the relative abuse liability and reinforcing efficacy of tramadol in comparison to a high (oxycodone) and low efficacy (codeine) opioid agonist.

METHODS

Nine healthy, non-dependent prescription opioid abusers (6 male and 3 female) participated in this within-subject, randomized, double blind, placebo-controlled study. Participants completed 14 paired sessions (7 sample and 7 self-administration). During each sample session, an oral dose of tramadol (200 and 400 mg), oxycodone (20 and 40 mg), codeine (100 and 200 mg) or placebo was administered, and a full array of abuse liability measures was collected. During self-administration sessions, volunteers were given the opportunity to work (via progressive ratio) for the sample dose or money.

RESULTS

All active doses were self-administered; placebo engendered no responding. The high doses of tramadol and oxycodone were readily self-administered (70%, 59% of available drug, respectively); lower doses and both codeine doses maintained intermediate levels of drug taking. All three drugs dose-dependently increased measures indicative of abuse liability, relative to placebo; however, the magnitude and time course of these and other pharmacodynamic effects varied qualitatively across drugs.

CONCLUSIONS

This study demonstrates that, like other mu opioids, higher doses of tramadol function as reinforcers in opioid abusers, providing new empirical data for regulatory evaluation.