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Langford R, Viscusi ER, Morte A, Cebrecos J, Sust M, Giménez-Arnau JM, de Leon-Casasola O. Efficacy of Co-Crystal of Tramadol-Celecoxib (CTC) in Patients with Acute Moderate-to-Severe Pain: A Pooled Analysis of Data from Two Phase 3 Randomized Clinical Trials. Drugs R D 2024:10.1007/s40268-024-00469-3. [PMID: 38874739 DOI: 10.1007/s40268-024-00469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES New acute pain medications are needed that provide effective analgesia while minimizing side effects and opioid exposure. Clinical trials of co-crystal of tramadol-celecoxib (CTC) have demonstrated an improved benefit/risk profile versus tramadol or celecoxib alone. We pooled data from two phase 3 clinical trials to evaluate the efficacy of CTC 200 mg twice daily (BID) in acute moderate-to-severe pain. METHODS Efficacy data were pooled from STARDOM1 [acute pain following oral surgery (NCT02982161)] and ESTEVE-SUSA-301 [acute pain following bunionectomy (NCT03108482)]. The primary efficacy outcome was sum of pain intensity difference from 0 to 48 h (SPID0-48). RESULTS A total of 344 patients received CTC 200 mg BID, 342 received tramadol 50 or 100 mg four times a day, 181 received celecoxib 100 mg BID, and 172 received placebo. The least-squares mean difference in SPID0-48 was -21.8 (p = 0.002) for CTC versus tramadol and -72.8 (p < 0.001) for CTC versus placebo. A similar pattern of SPID0-48 was observed with CTC versus comparator whether patients had moderate or severe pain at baseline. Reduction in pain intensity was faster and reached mild intensity earlier with CTC versus comparators. Patients were significantly (p ≤ 0.005) less likely to receive rescue medication within 4 or 48 h with CTC compared with tramadol or placebo. CONCLUSIONS This pooled analysis reinforces the efficacy profile of CTC versus tramadol and, given that CTC permits lower daily tramadol dosing and thereby reduces unnecessary opioid use, this highlights its improved benefit/risk profile and its potential for the management of moderate-to-severe pain.
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Affiliation(s)
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | - Oscar de Leon-Casasola
- Department of Anesthesiology, University of Buffalo/Roswell Park Cancer Institute, Buffalo, NY, USA
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Hakami AY, Alghamdi BS, Alshehri FS. Exploring the potential use of melatonin as a modulator of tramadol-induced rewarding effects in rats. Front Pharmacol 2024; 15:1373746. [PMID: 38738177 PMCID: PMC11082292 DOI: 10.3389/fphar.2024.1373746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/08/2024] [Indexed: 05/14/2024] Open
Abstract
Background Melatonin is responsible for regulating the sleep-wake cycle and circadian rhythms in mammals. Tramadol, a synthetic opioid analgesic, is used to manage moderate to severe pain but has a high potential for abuse and dependence. Studies have shown that melatonin could be a potential modulator to reduce tramadol addiction. Methods Male Wistar rats were used to investigate the effect of melatonin on tramadol-induced place preference. The rats were divided into four groups: control, tramadol, tramadol + melatonin (single dose), and tramadol + melatonin (repeated doses). Tramadol was administered intraperitoneally at 40 mg/kg, while melatonin was administered at 50 mg/kg for both the single dose and repeated-dose groups. The study consisted of two phases: habituation and acquisition. Results Tramadol administration produced conditioned place preference (CPP) in rats, indicating rewarding effects. However, melatonin administration blocked tramadol-induced CPP. Surprisingly, repeated doses of melatonin were ineffective and did not reduce the expression of CPP compared to that of the single dose administration. Conclusion The study suggests that melatonin may be a potential therapeutic option for treating tramadol addiction. The results indicate that melatonin attenuates the expression of tramadol-induced CPP, supporting its uses as an adjunct therapy for managing tramadol addiction. However, further studies are needed to investigate its effectiveness in humans.
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Affiliation(s)
- Alqassem Y. Hakami
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Badrah S. Alghamdi
- Department of Physiology, Neuroscience Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Neuroscience and Geroscience Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fahad S. Alshehri
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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Chaturvedi A, Afroz O, Sarkar S. A case of use of tramadol and alprazolam for mood altering effects: Intertwined hedonic and distress alleviating use. Indian J Psychiatry 2024; 66:406-407. [PMID: 38778848 PMCID: PMC11107933 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_968_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
- Ayushi Chaturvedi
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Omar Afroz
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Siddharth Sarkar
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India E-mail:
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McDonald R, Eide D, Skurtveit S, Clausen T. Pills and the damage done: the opioid epidemic as man-made crisis. Front Public Health 2024; 11:1241404. [PMID: 38283292 PMCID: PMC10820717 DOI: 10.3389/fpubh.2023.1241404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024] Open
Abstract
The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where - because of human intent, error, negligence, or the failure of manmade systems - the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.
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Affiliation(s)
- Rebecca McDonald
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Desiree Eide
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Bedar M, Dejam D, Caprini RM, Huang KX, Cronin BJ, Khetpal S, Morgan KBJ, Lee JC. An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay. J Plast Reconstr Aesthet Surg 2023; 85:393-400. [PMID: 37572387 DOI: 10.1016/j.bjps.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/18/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery. METHODS A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes. RESULTS Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery. CONCLUSIONS The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.
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Affiliation(s)
- Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Dillon Dejam
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Rachel M Caprini
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Brendan J Cronin
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Katarina B J Morgan
- T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States; UCLA Gender Health Program, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States.
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Gholami M, Hayes AW, Jamaati H, Sureda A, Motaghinejad M. Role of apoptosis and autophagy in mediating tramadol-induced neurodegeneration in the rat hippocampus. Mol Biol Rep 2023; 50:7393-7404. [PMID: 37453963 DOI: 10.1007/s11033-023-08641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Tramadol (TRA) is an analgesic prescribed for treating mild to moderate pains, the abuse of which has increased in recent years. Chronic tramadol consumption produces neurotoxicity, although the mechanisms are unclear. The present study investigated the involvement of apoptosis and autophagy signaling pathways and the mitochondrial system in TRA-induced neurotoxicity. MATERIALS AND METHODS Sixty adult male Wistar rats were divided into five groups that received standard saline or TRA in doses of 25, 50, 75, 100, or 150 mg/kg intraperitoneally for 21 days. On the 22nd day, the Open Field Test (OFT) was conducted. Jun N-Terminal Kinase (JNK), B-cell lymphoma-2 (Bcl-2), Beclin1, and Bcl-2-like protein 4 (Bax) proteins and tumor necrosis factor α (TNF-α) and interleukin 1β (IL-1β) were measured in rat hippocampal tissue. RESULTS TRA at doses 75, 100, and 150 mg/kg caused locomotor dysfunction in rats and increased total and phosphorylated forms of JNK and Beclin-1, Bax, and Caspase-3. TRA at the three higher doses also increased the phosphorylated (inactive) form of Bcl-2 level while decreasing the unphosphorylated (active) form of Bcl-2. Similarly, the protein levels of TNF-α and IL-1β were increased dose-dependently. The mitochondrial respiratory chain enzymes were reduced at the three higher doses of TRA. CONCLUSION TRA activated apoptosis and autophagy via modulation of TNF-α or IL-1β/JNK/Bcl-2/Beclin1 and Bcl-2/Bax signaling pathways and dysfunction of mitochondrial respiratory chain enzymes.
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Affiliation(s)
- Mina Gholami
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Wallace Hayes
- University of South Florida College of Public Health, Tampa, FL, USA
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA
| | - Hamidreza Jamaati
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Antoni Sureda
- Research Group in Community Nutrition and Oxidative Stress (NUCOX), University of Balearic Islands and, Health Research Institute of Balearic Islands (IdISBa), Palma de Mallorca, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Majid Motaghinejad
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Gish A, Richeval C, Wiart JF, Hennart B, Hakim F, Demarly C, Balgairies A, Hédouin V, Allorge D, Gaulier JM. Interpretation of hair and nails findings in an infant death case related to maternal addiction to tramadol. Drug Test Anal 2023; 15:1022-1026. [PMID: 37105763 DOI: 10.1002/dta.3485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Abstract
An 11-month-old boy was found dead. Autopsy findings (cyanosis and polyvisceral congestion) and blood tramadol (TR) concentration of 6240 μg/L were consistent with an acute TR intoxication. In this poisoning situation, owing to the mother's statements (TR addiction leading to daily TR-orange juice mixture preparation accidentally used for the baby bottle preparation by the mother's partner), and the question of possible previous TR administrations to the infant, hair and/or nails (infant, mother, partner, 6-year-old sister) analysis was performed. Hair (2-cm-long hair segments from proximal [S1] to distal [S3]) and nails concentrations (pg/mg; nd: not detected) were as follows: Infant (hair: TR 1420 [S1], 1622 [S2], 2736 [S3]; O-DMT 16-38; N-DMT 34-100 [TR in significant quantities in the hair decontamination bath]-toenails: TR 584; O-DMT 8; N-DMT 15), mother (hair: TR 2340 [S1], 2150 [S2], 2500 [S3]; O-DMT 704-1170; N-DMT 827-1360), mother's partner (fingernails: TR 72; O-DMT nd; N-DMT nd) and sister (hair: TR 261 [S1], 524 [S2]; O-DMT 15 [S1], 16 [S2]; N-DMT 20 [S1], 38 [S2]). Metabolite ratio (infant and sister hair) was comparable to those observed in hair of pharmaceutical industry employees manufacturing tramadol. TR in washing baths, low observed nail concentrations (infant and partner) confirm (i) TR-related mother's addiction and (ii) external contamination issues (TR in sweat of the child at the time of death and in living environment) to explain the infant's keratinized samples results. This case report illustrates the interest of analyzing keratinized matrices of the whole family in such a situation.
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Affiliation(s)
- Alexandr Gish
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
- Univ. Lille, URL 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
| | - Camille Richeval
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
- Univ. Lille, URL 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
| | | | | | - Florian Hakim
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
- Univ. Lille, URL 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
| | | | | | | | - Delphine Allorge
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
- Univ. Lille, URL 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
| | - Jean-Michel Gaulier
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
- Univ. Lille, URL 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
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Schepman P, Rice JB, Beck CG, White A, Robinson RL, Thakkar S, Fernan C, Emir B, Silverman S. Prescription opioid utilization patterns, and associated outcomes, among privately insured patients prescribed opioids to manage pain associated with osteoarthritis. Curr Med Res Opin 2023; 39:1147-1156. [PMID: 37435803 DOI: 10.1080/03007995.2023.2234727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To describe utilization patterns, negative clinical outcomes and economic burden of patients diagnosed with osteoarthritis (OA) of the hip and/or knee who received a prescription for tramadol or non-tramadol opioids vs. non-opioid drugs. METHODS Optum Healthcare Solutions, Inc. commercial claims data were used (1/2012--3/2017). Adults with ≥2 diagnoses of OA of the hip and/or knee, and ≥30 days supply of pain medications were identified during the three-year period from the date of first prescription (index date) after the first OA diagnosis. Drug utilization statistics in the follow-up period were summarized by initial treatment (i.e. tramadol, non-tramadol opioids, non-opioid drugs). Opioid initiators were matched to those initiated on non-opioid treatments using a propensity score model accounting for baseline characteristics. Matched pairs analysis compared outcomes for these cohorts. RESULTS Of 62,715 total patients, 15,270 (24.3%) initiated treatment with opioids, including 3,513 (5.6%) on tramadol and 11,757 (18.7%) on non-tramadol opioids. Opioid initiators had more comorbidities, higher baseline healthcare costs, and were more likely to have OA of the hip. Among non-opioid initiators, 27.5% switched to tramadol and 63% switched to non-tramadol opioids. Among tramadol initiators, 71% switched to non-tramadol opioids. Patients initiated on opioids had 20.4% (p < .01) higher all-cause healthcare costs and higher percentages experiencing multiple negative clinical outcomes (all p < .01) compared to matched controls. CONCLUSIONS Most patients with OA of the hip and/or knee either initiate on or switch to opioids for long-term management of OA-related pain despite known risks. This highlights the need for new treatments that delay or prevent use of opioids.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Stuart Silverman
- David Geffen School of Medicine of University of California, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Lam T, Xia T, Biggs N, Treloar M, Cheng O, Kabu K, Stevens JA, Evans JD, da Gama ME, Lubman DI, Nielsen S. Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone. Anaesthesia 2023; 78:420-431. [PMID: 36535726 DOI: 10.1111/anae.15933] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.
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Affiliation(s)
- T Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - T Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - N Biggs
- NostraData, Kew, VIC, Australia
| | | | - O Cheng
- IQVIA, St Leonards, NSW, Australia
| | - K Kabu
- IQVIA, St Leonards, NSW, Australia
| | - J A Stevens
- St Vincent's Clinical School, UNSW Medicine, Darlinghurst, NSW, Australia
| | - J D Evans
- Slade Pharmacy, Mount Waverley, VIC, Australia
| | | | - D I Lubman
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
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10
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Moses-Hampton MK, Povieng B, Ghorayeb JH, Zhang Y, Wu H. Chronic low back pain comorbidity count and its impact on exacerbating opioid and non-opioid prescribing behavior. Pain Pract 2023; 23:252-263. [PMID: 36447402 DOI: 10.1111/papr.13185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/28/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022]
Abstract
RESEARCH OBJECTIVES The objective of the study was to determine the characteristics of chronic low back pain (CLBP) comorbidity and its impact on opioid and non-opioid treatments among Chicagoland patients with CLBP. DESIGN A retrospective cross-sectional study comparing differences in comorbidity and treatment patterns among Chicagoland patients with CLBP against a matched control arm without chronic low back pain (NCLBP). SETTING Academic hospital system outpatient services. PARTICIPANTS Using the International Classification of Diseases, 10th Revision codes (ICD 10) 9589 patients were identified with CLBP with a median age of 57 years old and 62.32% female distribution. The NCLBP group comprised 9589 age-, sex-, race-, and region-matched patients. RESULTS An increased prevalence across all 17 studied comorbidities was found in CLBP patients as compared to NCLBP patients. CLBP patients carried an average of 3.5 comorbidities compared with 2.4 comorbidities in NCLBP patients. Rheumatoid arthritis (RA), joint arthritis, and obesity had the strongest relationship with CLBP. Additionally, we found that the most prescribed treatment for CLBP were opioids, which ranked above NSAIDs and physical therapy. 56% of CLBP patients were prescribed opioids as compared to 36% of NCLBP patients (Odds Ratio = 2.28, 95% CI: 2.16-2.42). Tramadol was the agent with the strongest relationship to CLBP. CLBP patients were more likely to use two or more opioids concomitantly. The number of total treatments was positively associated with the number of comorbidities in both CLBP and NCLBP patients (Cochran-Armitage trend test p < 0.0001). CONCLUSIONS Chronic low back pain patients showed a higher number of comorbidities than their NCLBP counterparts. Comorbidity count trended positively with higher treatment burden with opioids being the most prescribed treatment, often with poly-opioid use, over conservative modalities such as NSAIDs and physical therapy.
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Affiliation(s)
- Malcolm K Moses-Hampton
- Department of Physical Medicine and Rehabilitation, Rush University Medical Center, Chicago, Illinois, USA
| | - Boss Povieng
- Department of Physical Medicine and Rehabilitation, Rush University Medical Center, Chicago, Illinois, USA
| | - Joe H Ghorayeb
- University of Medicine and Health Sciences, New York, New York, USA
| | - Yanyu Zhang
- Rush University Medical Center Bioinformatics and Biostatistics Core, Chicago, Illinois, USA
| | - Hong Wu
- Department of Physical Medicine and Rehabilitation, Rush University Medical Center, Rush University Medical College, Chicago, Illinois, USA
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11
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Omara-Reda H, Ouachikh O, Hamdi D, Lashin M, Hafidi A. Reinforcing effect of tramadol in the rat. Neurosci Lett 2023; 796:137053. [PMID: 36621588 DOI: 10.1016/j.neulet.2023.137053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Hend Omara-Reda
- Université Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, TGI, 63000 Clermont-Ferrand, France
| | - Omar Ouachikh
- Université Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, TGI, 63000 Clermont-Ferrand, France
| | - Dhouha Hamdi
- Université Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, TGI, 63000 Clermont-Ferrand, France
| | - Mohamed Lashin
- Université Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, TGI, 63000 Clermont-Ferrand, France
| | - Aziz Hafidi
- Université Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, TGI, 63000 Clermont-Ferrand, France.
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12
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Viscusi ER, de Leon‐Casasola O, Cebrecos J, Jacobs A, Morte A, Ortiz E, Sust M, Vaqué A, Gottlieb I, Daniels S, Gimbel JS, Muse D, Winkle P, Kuss M, Videla S, Gascón N, Plata‐Salamán C. Celecoxib-tramadol co-crystal in patients with moderate-to-severe pain following bunionectomy with osteotomy: A phase 3, randomized, double-blind, factorial, active- and placebo-controlled trial. Pain Pract 2023; 23:8-22. [PMID: 35686380 PMCID: PMC10084286 DOI: 10.1111/papr.13136] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Celecoxib-tramadol co-crystal (CTC) is a first-in-class analgesic co-crystal of celecoxib and racemic tramadol with an improved pharmacologic profile, conferred by the co-crystal structure, compared with its active constituents administered alone/concomitantly. AIM We evaluated CTC in moderate-to-severe acute postoperative pain. MATERIALS AND METHODS This randomized, double-blind, factorial, active- and placebo-controlled phase 3 trial (NCT03108482) was conducted at 6 US clinical research centers. Adults with moderate-to-severe acute pain following bunionectomy with osteotomy were randomized to oral CTC (200 mg [112 mg celecoxib/88 mg rac-tramadol hydrochloride] every 12 h), tramadol (50 mg every 6 h), celecoxib (100 mg every 12 h), or placebo for 48 h. Patients, investigators, and personnel were blinded to assignment. The primary endpoint was the 0-48 h sum of pain intensity differences (SPID0-48) in all randomized patients. Pain intensity was assessed on a 0-10 numerical rating scale (NRS). Safety was analyzed in patients who received study medication. Funded by ESTEVE Pharmaceuticals. RESULTS In 2017 (March to November), 1323 patients were screened and 637 randomized to CTC (n = 184), tramadol (n = 183), celecoxib (n = 181), or placebo (n = 89). Mean baseline NRS was 6.7 in all active groups. CTC had a significantly greater effect on SPID0-48 (least-squares mean: -139.1 [95% confidence interval: -151.8, -126.5]) than tramadol (-109.1 [-121.7, -96.4]; p < 0.001), celecoxib (-103.7 [-116.4, -91.0]; p < 0.001), or placebo (-74.6 [-92.5, -56.6]; p < 0.001). Total treatment-emergent adverse events (TEAEs) were 358 for CTC and 394 for tramadol. Drug-related TEAEs occurred in 37.7% patients in the CTC group, compared with 48.6% in the tramadol group. There were no serious TEAEs/deaths. CONCLUSION CTC provided greater analgesia than comparable daily doses of tramadol and celecoxib, with similar tolerability to tramadol. CTC is approved in the United States.
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Affiliation(s)
- Eugene R. Viscusi
- Department of AnesthesiologySidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Oscar de Leon‐Casasola
- Department of AnesthesiologyUniversity of Buffalo/Roswell Park Cancer InstituteBuffaloNew YorkUSA
| | | | | | | | | | | | - Anna Vaqué
- ESTEVE Pharmaceuticals S.ABarcelonaSpain
| | - Ira Gottlieb
- Chesapeake Research Group LLCPasadenaMarylandUSA
| | | | | | - Derek Muse
- JBR Clinical ResearchSalt Lake CityUtahUSA
| | | | - Michael E. Kuss
- Premier ResearchDurhamNorth CarolinaUSA
- Present address:
Michael Kuss ConsultingAustinTexasUSA
| | - Sebastián Videla
- ESTEVE Pharmaceuticals S.ABarcelonaSpain
- Present address:
Clinical Research Support UnitClinical Pharmacology DepartmentBellvitge University HospitalL’Hospitalet deLlobregat and Pharmacology UnitDepartment of Pathology and Experimental TherapeuticsFaculty of Medicine and Health SciencesIDIBELL, University of Barcelona, L’Hospitalet de LlobregatBarcelonaSpain
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13
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Alshehri FS. Tapentadol: A Review of Experimental Pharmacology Studies, Clinical Trials, and Recent Findings. Drug Des Devel Ther 2023; 17:851-861. [PMID: 36974332 PMCID: PMC10039632 DOI: 10.2147/dddt.s402362] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Tapentadol is an analgesic compound that acts centrally to attenuate pain. Previous studies have shown that tapentadol has dual mechanisms of action as a mu-opioid receptor agonist and noradrenaline re-uptake inhibition. Therefore, tapentadol provides a great advantage over classic opioids in pain management from nociceptive to neuropathic. Cumulative evidence from in vitro data suggests that tapentadol effect of norepinephrine re-uptake could be a new target that overcomes other classic opioids in chronic neuropathic pain. Compared to tramadol and other opioids, tapentadol is associated with fewer adverse effects than tramadol. Tapentadol is a new alternative to treat acute, chronic, and neuropathic pain. Thus, this review article was focused on understanding the studies that led to the development of tapentadol as a novel analgesic drug and its advantages over conventional opioids. Thus, tapentadol is a good alternative with fewer adverse effects and is available for human use.
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Affiliation(s)
- Fahad S Alshehri
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
- Correspondence: Fahad S Alshehri, Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al‑ Qura University, Makkah, 24382, Saudi Arabia, Email
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14
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Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naïve Medicaid patients. PLOS DIGITAL HEALTH 2022; 1:e0000075. [PMID: 36203857 PMCID: PMC9534483 DOI: 10.1371/journal.pdig.0000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naïve Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naïve patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.
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15
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Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AH. Prevention and Management Strategies for Diabetic Neuropathy. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081185. [PMID: 36013364 PMCID: PMC9410148 DOI: 10.3390/life12081185] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/17/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022]
Abstract
Diabetic neuropathy (DN) is a common complication of diabetes that is becoming an increasing concern as the prevalence of diabetes rapidly rises. There are several types of DN, but the most prevalent and studied type is distal symmetrical polyneuropathy, which is the focus of this review and is simply referred to as DN. It can lead to a wide range of sensorimotor and psychosocial symptoms and is a major risk factor for diabetic foot ulceration and Charcot neuropathic osteoarthropathy, which are associated with high rates of lower limb amputation and mortality. The prevention and management of DN are thus critical, and clinical guidelines recommend several strategies for these based on the best available evidence. This article aims to provide a narrative review of DN prevention and management strategies by discussing these guidelines and the evidence that supports them. First, the epidemiology and diverse clinical manifestations of DN are summarized. Then, prevention strategies such as glycemic control, lifestyle modifications and footcare are discussed, as well as the importance of early diagnosis. Finally, neuropathic pain management strategies and promising novel therapies under investigation such as neuromodulation devices and nutraceuticals are reviewed.
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Affiliation(s)
- Sasha Smith
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Pasha Normahani
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Tristan Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - David Hohenschurz-Schmidt
- Pain Research Group, Department of Surgery and Cancer, Imperial College London, London SW10 9NH, UK;
| | - Nick Oliver
- Section of Metabolic Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W2 1PG, UK;
- Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Alun Huw Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- Correspondence:
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16
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Hosseindoost S, Akbarabadi A, Sadat-Shirazi MS, Mousavi SM, Khalifeh S, Mokri A, Hadjighassem M, Zarrindast MR. Effect of tramadol on apoptosis and synaptogenesis in hippocampal neurons: The possible role of µ-opioid receptor. Drug Dev Res 2022; 83:1425-1433. [PMID: 35808942 DOI: 10.1002/ddr.21973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/23/2022] [Accepted: 04/22/2022] [Indexed: 11/07/2022]
Abstract
Tramadol is a synthetic opioid with centrally acting analgesic activity that alleviates moderate to severe pain and treats withdrawal symptoms of the other opioids. Like other opioid drugs, tramadol abuse has adverse effects on central nervous system components. Chronic administration of tramadol induces maladaptive plasticity in brain structures responsible for cognitive function, such as the hippocampus. However, the mechanisms by which tramadol induces these alternations are not entirely understood. Here, we examine the effect of tramadol on apoptosis and synaptogenesis of hippocampal neuronal in vitro. First, the primary culture of hippocampal neurons from neonatal rats was established, and the purity of the neuronal cells was verified by immunofluorescent staining. To evaluate the effect of tramadol on neuronal cell viability MTT assay was carried out. The western blot analysis technique was performed for the assessment of apoptosis and synaptogenesis markers. Results show that chronic exposure to tramadol reduces cell viability of neuronal cells and naloxone reverses this effect. Also, the level of caspase-3 significantly increased in tramadol-exposed hippocampal neurons. Moreover, tramadol downregulates protein levels of synaptophysin and stathmin as synaptogenesis markers. Interestingly, the effects of tramadol were abrogated by naloxone treatment. These findings suggest that tramadol can induce neurotoxicity in hippocampal neuronal cells, and this effect was partly mediated through opioid receptors.
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Affiliation(s)
- Saereh Hosseindoost
- Pain Research Center, Neuroscience Institute, Tehran University of Medical Science, Tehran, Iran
| | - Ardeshir Akbarabadi
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Seyed M Mousavi
- Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Solmaz Khalifeh
- Cognitive and Neuroscience Research Center (CNRC), Tehran Medical Sciences, Amir-Almomenin Hospital, Islamic Azad University, Tehran, Iran
| | - Azarakhsh Mokri
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoudreza Hadjighassem
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Zarrindast
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran.,Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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17
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Nobile B, Bonnin M, Olié E, Courtet P. Multiple suicide attempts associated with addiction to tramadol. Ann Gen Psychiatry 2022; 21:24. [PMID: 35778765 PMCID: PMC9247960 DOI: 10.1186/s12991-022-00401-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/22/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The opioid tramadol is used as analgesic drug, and more recently was also proposed for the management of major depressive disorder. However, growing evidence suggests a link between opioid system dysfunction and suicidal behaviors, raising the question of tramadol use in view of the high addictive and suicidal risk. Here, we present the case of a young adult woman with multiple suicide attempts related to tramadol addiction. CASE PRESENTATION A 25-year-old woman was admitted for suicide attempt by phlebotomy in the Department of Psychiatric Emergency and Acute Care, Montpellier (France), in March 2020. The suicide attempt occurred 3 days after an abrupt tramadol withdrawal. In 2018, due to spinal disc herniation, she had a first prescription of tramadol to which she became addicted. The patient described an effect on psychological pain and suicidal ideation. However, she had to increase tramadol dose to obtain the desired effects, and for several months her intake was 2 000 mg per day. When she could not obtain tramadol any longer, suicidal ideation and psychological pain increased, leading to the suicide attempt. At the time of a worldwide opioid crisis that contributes to increasing suicidal behaviors, this case raises questions about tramadol prescription (often considered to be less addictive and with lower abuse potential) to individuals at risk of suicide.
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Affiliation(s)
- Bénédicte Nobile
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France. .,IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France. .,FondaMental Foundation, Montpellier, France.
| | - Marine Bonnin
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France.,IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France.,FondaMental Foundation, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France.,IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France.,FondaMental Foundation, Montpellier, France
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18
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Mullins PM, Mazer-Amirshahi M, Pourmand A, Perrone J, Nelson LS, Pines JM. Tramadol Use in United States Emergency Departments 2007-2018. J Emerg Med 2022; 62:668-674. [PMID: 35370038 DOI: 10.1016/j.jemermed.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 01/04/2022] [Accepted: 01/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids. OBJECTIVE Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates. RESULTS Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018. CONCLUSIONS Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.
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Affiliation(s)
- Peter M Mullins
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia
| | - Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jeanmarie Perrone
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jesse M Pines
- US Acute Care Solutions, Canton, Ohio; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
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19
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Lam T, Biggs N, Xia T, Evans J, Stevens J, da Gama M, Lubman DI, Nielsen S. Comparing opioid types in the persistence of opioid use following surgical admission: a study protocol for a retrospective observational linkage study comparing tapentadol and oxycodone in Australia. BMJ Open 2022; 12:e060151. [PMID: 35418442 PMCID: PMC9014068 DOI: 10.1136/bmjopen-2021-060151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Each year, an estimated two million Australians commence opioids, with 50 000 developing longer-term (persistent) opioid use. An estimated 3%-10% of opioid-naïve patients prescribed opioids following surgery develop persistent opioid use. This study will compare rates of persistent opioid use between two commonly used postoperative opioids, oxycodone and tapentadol, to understand if initial postoperative opioid type is important in determining longer-term outcomes. METHODS AND ANALYSIS A retrospective data linkage study that analyses administrative data from hospital and community pharmacies. Data will be obtained from at least four pharmacies that service large hospitals with comparable supplies of oxycodone and tapentadol. The study will include at least 6000 patients who have been dispensed a supply of oxycodone or tapentadol to take home following their discharge from a surgical ward. The primary outcome measure will be persistent opioid use at 3 months postdischarge for opioid naïve people who receive either immediate release tapentadol or immediate release oxycodone. Hierarchical logistic regression models will be used to predict persistent opioid use, controlling for covariates including comorbidities. ETHICS AND DISSEMINATION Ethics approval has been obtained through the Monash University Human Research Ethics Committee (29977). We will present project findings in a peer-reviewed journal article, in accordance with the REporting of studies Conducted using Observational Routinely-collected health Data statement.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
| | | | - Ting Xia
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
| | - John Evans
- Slade Pharmacy, Mount Waverley, Victoria, Australia
| | - Jennifer Stevens
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | | | - Dan I Lubman
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
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20
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Roussin A, Soeiro T, Fouque C, Jouanjus E, Frauger E, Fouilhé N, Mallaret M, Micallef J, Lapeyre-Mestre M. Increase of high-risk tramadol use and harmful consequences in France from 2013-2018: evidence from the triangulation of addictovigilance data. Br J Clin Pharmacol 2022; 88:3789-3802. [PMID: 35318713 PMCID: PMC9545570 DOI: 10.1111/bcp.15323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 03/03/2022] [Accepted: 03/13/2022] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Anne Roussin
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,Pharmacologie en Population Cohortes et Biobanques, Centre d'Investigation Clinique 1436, Université de Toulouse, France
| | - Thomas Soeiro
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France
| | - Charlotte Fouque
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France
| | - Emilie Jouanjus
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,CERPOP, Université de Toulouse, INSERM, France
| | - Elisabeth Frauger
- Aix-Marseille Université, Assistance publique-Hôpitaux de Marseille, Inserm, Inst Neurosci System, UMR 1106, Service de pharmacologie clinique et Pharmacovigilance, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
| | - Nathalie Fouilhé
- Département de Pharmacologie Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire Grenoble Alpes, France
| | - Michel Mallaret
- Département de Pharmacologie Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire Grenoble Alpes, France
| | - Joëlle Micallef
- Aix-Marseille Université, Assistance publique-Hôpitaux de Marseille, Inserm, Inst Neurosci System, UMR 1106, Service de pharmacologie clinique et Pharmacovigilance, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
| | - Maryse Lapeyre-Mestre
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,Pharmacologie en Population Cohortes et Biobanques, Centre d'Investigation Clinique 1436, Université de Toulouse, France
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21
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Silverman S, Rice JB, White AG, Beck CG, Robinson RL, Fernan C, Schepman P. Clinical and economic burden of prescribing tramadol and other opioids for patients with osteoarthritis in a commercially insured population in the United States. Pain 2022; 163:75-82. [PMID: 34924552 PMCID: PMC8675056 DOI: 10.1097/j.pain.0000000000002300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/15/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT In 2019, the American College of Rheumatology conditionally recommended tramadol and conditionally recommended against nontramadol opioids for patients with hip and knee osteoarthritis. Although tramadol is known to be less prone to opioid use disorders, little is known about the differing magnitude of negative clinical outcomes, health care resource utilization, and costs of tramadol relative to nontramadol opioids. Administrative claims records for commercially insured patients with osteoarthritis who were prescribed opioids were used to compare clinical and cost outcomes during a 3-year follow-up period by conducting a pre-post analysis and a matched case-cohort analysis. Data for 14,491 patients were analyzed: 4048 (28%) were initiated on tramadol, and 10,443 (72%) were initiated on nontramadol opioids. After matching, 4048 patients per cohort were analyzed. In each empirical analysis, tramadol patients did develop opioid use disorders; however, opioid use disorder rates were 3.5-fold higher in the nontramadol cohort (1.2% vs 4.2%). In addition, rates of other opioid-related clinical outcomes (falls, fractures, nausea, fatigue, and constipation) were also directionally lower among the tramadol cohort, although quantitatively similar (<5% difference) to the nontramadol cohort. Finally, in both analyses, the nontramadol cohort incurred higher levels of inpatient and emergency department visits and all-cause costs during the 3-year follow-up period. However, tramadol patients incur a higher incremental change (+$24,013) in costs relative to their pretreatment baseline compared with nontramadol (+$18,191). These real-world findings demonstrated lower risks with tramadol relative to other opioids, albeit risks and increased health care costs were present with tramadol, highlighting the need for further strategies to improve outcomes.
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Affiliation(s)
- Stuart Silverman
- Department of Medicine/Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Medicine/Rheumatology, David Geffen School of Medicine of University of California Los Angeles, Los Angeles, CA, United States
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22
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Heins SE, Buttorff C, Armstrong C, Pacula RL. Claims-based measures of prescription opioid utilization: A practical guide for researchers. Drug Alcohol Depend 2021; 228:109087. [PMID: 34598101 PMCID: PMC8595838 DOI: 10.1016/j.drugalcdep.2021.109087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/14/2021] [Accepted: 08/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the increased attention to the opioid epidemic and the role of inappropriate prescribing, there has been a marked increase in the number of studies using claims data to study opioid use and policies designed to curb misuse. Our objective is to review the medical literature for recent studies that use claims data to construct opioid use measures and to develop a guide for researchers using these measures. METHODS We searched for articles relating to opioid use measured in health insurance claims data using a defined set of search terms for the years 2014-2020. Original research articles based in the United States that used claims-based measures of opioid utilization were included and information on the study population and measures of any opioid use, quantity of opioid use, new opioid use, chronic opioid use, multiple providers, and overlapping prescriptions was abstracted. RESULTS A total of 164 articles met inclusion criteria. Any opioid use was the most commonly included measure, defined by 85 studies. This was followed by quantity of opioids (68 studies), chronic opioid use (53 studies), overlapping prescriptions (28 studies), and multiple providers (8 studies). Each measure contained multiple, distinct definitions with considerable variation in how each was operationalized. CONCLUSIONS Claims-based opioid utilization measures are commonly used in research, but definitions vary significantly from study to study. Researchers should carefully consider which opioid utilization measures and definitions are most appropriate for their study and recognize how different definitions may influence study results.
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Affiliation(s)
| | | | | | - Rosalie Liccardo Pacula
- RAND Corporation, Santa Monica, CA, USA,Schaeffer Center for Health Policy & Economics, University of Southern California
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23
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Gistelinck L, Heylens G, Schelfout S, Lemmens G. Oral and buccal abuse of transdermal opioids : an underdetected but potentially lethal practice. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objectives : Transdermal opioid patches (TOPs) are effective and well tolerated in patients with moderate to severe chronic pain syndromes. Their specific pharmacological properties, however, make them prone to abuse. The objective of this article is to describe the practice of oral and buccal abuse of TOPs and to discuss its clinical implications.
Methods : We present the case of a patient admitted to the intensive care unit after oral abuse of transdermal opioid patches. Additionally, a narrative literature review on the topic is conducted, referring to Pubmed and Embase.
Results : Oral or buccal TOP abuse is the most frequent method of TOP abuse, followed by intravenous injection, inhaling, and applying multiple patches. The main reasons for TOP abuse include drug addiction, suicidal behavior and self-medication. Oral ingestion is potentially lethal because of the high doses of fentanyl that are found in a single patch. Buccal abuse results in fast elevations of fentanyl serum concentrations, caused by transmucosal absorption of fentanyl, thus bypassing hepatic metabolism. During emergency management, naloxone should be administered in a continuous infusion, given the high risk of recurrence of symptoms. Evidence suggests that transdermal buprenorphine is safer in terms of abuse potential. This is explained by its ceiling effect for respiratory depression and its lower peak effects in supratherapeutic doses. Risk factors for abuse include history of substance use disorder, prior opioid overdose and mental illness. Patients with suspected opioid abuse should be referred to pain clinics, mental health specialists or drug addiction facilities.
Conclusion : Oral or buccal abuse is the most reported non-dermal form of TOP abuse. When ingested or chewed, TOPs pose considerable health risks. It is critical to screen patients with chronic opioid therapy regularly for opioid use disorder. When confronted with patients at risk of abuse, close monitoring and referral to specialist care is advised.
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24
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Murphy PZ, Thomas J, McClelland TP. Pain Management of Budd Chiari Syndrome in the Primary Care Setting: A Case Study. Innov Pharm 2021; 12. [PMID: 34345504 PMCID: PMC8326689 DOI: 10.24926/iip.v12i2.3906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Budd Chiari Syndrome (BCS) is a very rare disease affecting approximately 1 in 100,000 people in the general population. It is caused by an obstruction of the hepatic veins leading to blood backing up in the liver. Treatment options to improve hepatic blood flow and relieve ascites are well documented. However, there are no established guidelines or treatment preferences for pain associated with BCS while patients are awaiting other treatment options. Case: A 22-year-old African American female was diagnosed with Budd Chiari Syndrome. The initial attempt at a transjugular intrahepatic portosystemic shunt (TIPS) procedure failed. While awaiting a second attempt at the procedure, the patient presented to her primary care provider complaining of abdominal and right upper quadrant pain. Treatment guidelines were searched for acute pain management options; however, no BCS pain management guidelines exist. Discussion: Individuals with BCS often present with abdominal pain, however, no guidelines outlining analgesic options in BCS exists. Acetaminophen, NSAIDs, and opioids are commonly used prescription medications for moderate to severe pain. Acetaminophen use was not considered due to acute liver injury and portal venous thrombosis. Anticoagulation with apixaban prevented concurrent use with NSAIDs. Opioid medications combined with acetaminophen were excluded to minimize exacerbating the liver injury. Tramadol 25 mg was chosen due to its lower abuse profile than other opioid analgesics, and was initiated for pain management. Conclusion: The patient reported adequate pain control with tramadol, tolerated the medication with no complications, and underwent a successful TIPS procedure one month later. Abdominal pain is a common symptom of BCS and needs to be effectively managed. Guidelines on treating pain associated with BCS in the outpatient setting would improve quality of life for patients and provide guidance to primary care providers requiring direction on how to address pain associated with Budd Chiari Syndrome safely and adequately.
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25
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Mullins PM, Merriman JG, Jaffe TA, Mazer-Amirshahi M, Weiner SG. Trends in the Evaluation and Management of Back Pain in Emergency Departments, United States, 2007-2016. PAIN MEDICINE 2021; 22:67-74. [PMID: 33338224 DOI: 10.1093/pm/pnaa385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Back pain is one of the most common pain syndromes in the United States, but there has been limited recent description of the role of emergency departments (EDs) in caring for patients with back pain. We investigated trends in the evaluation and management of back pain in U.S. EDs from 2007 to 2016. METHODS We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative annual survey of ED visits, which includes data on patient-, hospital-, and visit-level characteristics. We evaluated trends among adult ED visits for back pain, including demographics, resource utilization, and disposition. Trends were assessed through the use of survey-weighted analyses. RESULTS Visit rates as a proportion of overall ED visits were stable from 2007 to 2016 (9.1% [95% confidence interval (CI): 8.5-9.6] vs. 9.3% [95% CI: 8.6-10.0]; P = 0.44). Admission rates declined from 6.4% (95% CI: 5.1-8.0) to 5.0% (95% CI: 3.5-6.9; P < 0.001). Imaging utilization increased from 51.7% (95% CI: 49.3-54.1) to 57.6% (95% CI: 53.3-61.7; P = 0.023), with an increase of 58.3% in computed tomography. Overall opioid utilization declined from 53.5% (95% CI: 49.4-57.5) to 46.5% (95% CI: 43.2-49.8; P < 0.001). Tramadol use increased over the study period (4.1% [95% CI: 3.0-5.8] vs. 8.4% [95% CI: 6.6-10.7]; P < 0.001). CONCLUSIONS Opioid utilization during ED visits for back pain decreased from 2007 to 2016, whereas tramadol use more than doubled. Care intensity increased significantly despite declining admission rates. Further research into optimal strategies for back pain management in the ED is needed.
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Affiliation(s)
- Peter M Mullins
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - John Gates Merriman
- Department of Anesthesiology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Todd A Jaffe
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center; Georgetown University School of Medicine, Washington, DC, USA
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
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26
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Minkowitz H, Salazar H, Leiman D, Solanki D, Lu L, Reines S, Ryan M, Harnett M, Singla N. Intravenous Tramadol is Effective in the Management of Postoperative Pain Following Abdominoplasty: A Three-Arm Randomized Placebo- and Active-Controlled Trial. Drugs R D 2021; 20:225-236. [PMID: 32409981 PMCID: PMC7419412 DOI: 10.1007/s40268-020-00309-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Oral tramadol, an atypical opioid approved in the United States (US) since 1995 and a Schedule IV controlled substance, has less abuse liability compared to Schedule II conventional opioids. Intravenous (IV) tramadol is not available in the US, but has the potential to fill a gap between non-opioid medications and conventional opioids for treatment of acute pain. This study evaluates IV tramadol in the management of postoperative pain compared to placebo and standard-of-care active control. METHODS A phase 3, multicenter, double-blind, three-arm, randomized, placebo- and active-controlled, multiple-dose, parallel-group study was conducted to evaluate the efficacy and safety of 50 mg IV tramadol versus placebo and 4 mg IV morphine over 48 h in patients with postoperative pain following abdominoplasty surgery. RESULTS IV tramadol was statistically superior (p < 0.05) to placebo and comparable to IV morphine for the primary and all key secondary efficacy outcomes and demonstrated numerically lower rates for the incidence of most common treatment-emergent adverse events (TEAEs) compared to morphine. No unexpected findings were observed for TEAEs, laboratory tests, vital signs, or electrocardiograms (ECGs). Over 90% of patients completed the study. CONCLUSION The study demonstrated that IV tramadol 50 mg is highly effective in the management of postoperative pain following abdominoplasty. The consistency of effects between tramadol and morphine (as compared to placebo) for primary and key secondary endpoints validates the efficacy of tramadol observed. The study also provided direct evidence of improved tolerability of IV tramadol over a standard-of-care conventional Schedule II opioid. IV tramadol may become a useful option in patients where exposure to conventional opioids is not desired.
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Affiliation(s)
| | - Hernan Salazar
- Clinical Investigation, Endeavor Clinical Trials, HD, San Antonio, TX, USA
| | - David Leiman
- Clinical Investigation, HD Research, LLC, Bellaire, TX, USA
| | | | - Lucy Lu
- Clinical Research, Avenue Therapeutics, 1140 Avenue of the Americas, 9th Floor, New York, NY, 10036, USA.
| | - Scott Reines
- Clinical Research, Avenue Therapeutics, 1140 Avenue of the Americas, 9th Floor, New York, NY, 10036, USA
| | - Michael Ryan
- Clinical Research, Avenue Therapeutics, 1140 Avenue of the Americas, 9th Floor, New York, NY, 10036, USA
| | - Mark Harnett
- Clinical Research, Avenue Therapeutics, 1140 Avenue of the Americas, 9th Floor, New York, NY, 10036, USA
| | - Neil Singla
- Clinical Investigation, Lotus Clinical Research, LLC, Pasadena, CA, USA
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27
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Connors NJ, Mazer-Amirshahi M, Motov S, Kim HK. Relative addictive potential of opioid analgesic agents. Pain Manag 2020; 11:201-215. [PMID: 33300384 DOI: 10.2217/pmt-2020-0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Opioid overdoses and deaths continue to be a problem in the USA with a significant portion related to prescribed opioid analgesic agents. The role of pharmacogentic factors in opioid addiction is an active area of research. While all opioid analgesic agents have some addictive potential, it is clear that there are some with greater addictive potential. Oxycodone is the most widely abused opioid analgesic and it appears to predispose to chronic use with high likability by users. Fentanyl and hydromorphone are both very lipophilic allowing rapid penetration into the CNS, but are not rated as highly as other agents. Providers should consider the risk of addiction with the opioids they prescribe and give those with a lower addictive potential.
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Affiliation(s)
- Nicholas J Connors
- HCA Healthcare, Trident Medical Center, Charleston, SC 29406, USA.,Palmetto Poison Center, Columbia, SC 29201, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, USA
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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28
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Bumpus JA. Low-Dose Tramadol as an Off-Label Antidepressant: A Data Mining Analysis from the Patients' Perspective. ACS Pharmacol Transl Sci 2020; 3:1293-1303. [PMID: 33344902 PMCID: PMC7737323 DOI: 10.1021/acsptsci.0c00132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Indexed: 01/09/2023]
Abstract
Objectives: The purpose of this analysis was to assess, from the patients' perspective, the effectiveness and relative safety of tramadol as an off-label antidepressant and to determine if patients' views and experiences are consistent with the biomedical literature. Method: A data mining approach was used to analyze databases available at drugs.com. Results: Tramadol was reported to be an effective or very effective antidepressant by 94.6% of patients (123/130) who provided ratings submitted to User Reviews for Tramadol to Treat Depression (https://www.drugs.com/comments/tramadol/for-depression.html). When compared to 34 other antidepressants in the database titled Drugs Used to treat Depression (https://www.drugs.com/condition/depression.html), for which there were ≥100 individual reviews for each drug, tramadol was rated as being the most effective (effectiveness rating = 9.1/10). Phenelzine (effectiveness rating = 8.7/10) was the only other antidepressant having ≥100 individual reviews coupled with a very high (8.0-10.0) effectiveness rating. Eleven patients reported significant symptoms of withdrawal upon cessation of tramadol, and five patients reported loss or reduction of libido as a side effect. Most (57/72, 79.2%) patients who reported a dose consumed experienced relief from depression at low therapeutic doses (25-150 mg/day). Fourteen patients reported taking this antidepressant for 5-10 years, and four patients reported taking tramadol for 10 or more years. Results demonstrated that most patients' comments and beliefs are consistent with the biomedical literature. Conclusions: Patients' reviews coupled with a survey of the biomedical literature indicate that at low therapeutic doses in the absence of interactions with other drugs, adult patients found tramadol to be a generally safe, effective, and fast-acting medication for relief from depression.
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Affiliation(s)
- John A. Bumpus
- Department of Chemistry and Biochemistry, University of Northern Iowa, Cedar Falls, Iowa 50614, United States
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29
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Green JL, Dailey-Govoni T, Butler SF. Real-World Data on Nonmedical Use of Tramadol from Patients Evaluated for Substance Abuse Treatment in the NAVIPPRO Addiction Severity Index-Multimedia Version (ASI-MV ®) Network. Drug Saf 2020; 44:235-244. [PMID: 33175336 PMCID: PMC7847458 DOI: 10.1007/s40264-020-01012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Drug safety studies regarding comparative risk of different opioid compounds are important as providers and regulatory agencies in the United States continue to balance pain management with an ongoing opioid epidemic. OBJECTIVE The aim of this study was to evaluate nonmedical use (NMU) and diversion of tramadol and comparator opioids using real-world data from the Addiction Severity Index-Multimedia Version (ASI-MV®). METHODS A cross-sectional study design was used to evaluate past 30-day tramadol and comparator opioid NMU among adults assessed for substance abuse treatment using the ASI-MV from 2010 to 2018. Population and drug utilization-adjusted rates were studied, as well as patient characteristics, route of administration, and diversion. RESULTS Past 30-day NMU of one or more prescription opioid was reported in 125,048 (22.6%) of ASI-MV assessments (2010-2018); 46.5% reported oxycodone, 43.2% hydrocodone, 8.1% morphine, and 7.2% tramadol. Male respondents ranged from 43.2% in the tramadol group to 51.8% in the oxycodone group. Majority (~ 76%) were Caucasian in all groups, with 86.9% Caucasian in the morphine group. Prevalence of past 30-day tramadol NMU was significantly lower than that of morphine, oxycodone, and hydrocodone for both population and utilization-adjusted rates. Rate of snorting of tramadol was 4-7 times lower than comparator opioids and injection was 14-34 times lower than morphine and oxycodone. Tramadol was most likely to be obtained via the patient's own prescription while the comparator opioids were more often obtained via dealers or family/friends. CONCLUSION Tramadol had a significantly lower rate of NMU than comparator opioids and was less likely to be diverted or used via higher-risk non-oral routes. These findings support previous evaluations by WHO and the United States Drug Enforcement Agency that concluded that tramadol has a low potential for abuse.
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Affiliation(s)
- Jody L Green
- Inflexxion, A Division of Integrated Behavioral Health, Irvine, CA, USA.
| | | | - Stephen F Butler
- Inflexxion, A Division of Integrated Behavioral Health, Irvine, CA, USA
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30
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Hockenhull J, Black JC, Bletz A, Margolin Z, Olson R, Wood DM, Dart RC, Dargan PI. An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK. Br J Clin Pharmacol 2020; 87:1637-1646. [PMID: 33464643 DOI: 10.1111/bcp.14603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 08/21/2020] [Accepted: 09/30/2020] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joshua C Black
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Alex Bletz
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Zachary Margolin
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Rick Olson
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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31
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The Potential Role of Dual Mechanistic Opioids in Combating Opioid Misuse. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00414-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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32
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Knezevic NN, Jovanovic F, Candido KD, Knezevic I. Oral pharmacotherapeutics for the management of peripheral neuropathic pain conditions - a review of clinical trials. Expert Opin Pharmacother 2020; 21:2231-2248. [PMID: 32772737 DOI: 10.1080/14656566.2020.1801635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Epidemiological studies have shown that 6.9-10% of people suffer from neuropathic pain, a complex painful condition which is often undertreated. Data regarding the effectiveness of treatment options for patients with neuropathic pain is inconsistent, and there is no single treatment option that shows cost-effectiveness across studies. AREAS COVERED In this narrative review, the authors present the results of different prospective, randomized controlled trials, systematic reviews and meta-analyses assessing the effects of different oral medications in the management of various peripheral neuropathic pain conditions. The authors discuss the effectiveness of commonly used oral medications such as voltage-gated calcium channels antagonists, voltage-gated sodium channel antagonists, serotonin-norepinephrine reuptake inhibitors, NMDA antagonists, and medications with other mechanisms of action. EXPERT OPINION Most of the presented medications were more effective than placebo; however, when compared to each other, none of them were significantly superior. The heterogeneity of the studies looking into different oral neuropathic conditions has been the major issue that prevents us from making stronger recommendations. There are multiple reasons including high placebo responsiveness, improperly treated underlying comorbidities (particularly anxiety and depression), and inter-patient variability. Different sensory phenotypes should also be taken into consideration when designing future clinical trials for neuropathic pain.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Ivana Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
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33
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Reines SA, Goldmann B, Harnett M, Lu L. Misuse of Tramadol in the United States: An Analysis of the National Survey of Drug Use and Health 2002-2017. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2020; 14:1178221820930006. [PMID: 32547049 PMCID: PMC7271275 DOI: 10.1177/1178221820930006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/01/2020] [Indexed: 11/17/2022]
Abstract
Objective: To analyze the rates of misuse - that is, use in any way not directed by a
doctor - of products containing oral tramadol, a Schedule IV opioid, from
the National Survey of Drug Use and Health (NSDUH), as compared to
comparator Schedule II opioids (morphine, oxycodone, and hydrocodone) and
alprazolam, a commonly prescribed Schedule IV controlled substance in the
U.S. Methods: The NSDUH is a congressionally mandated household survey that collects
information on tobacco, alcohol, and drug use, mental health and other
health-related issues in the US. A cross-sectional surveillance study design
was used to examine lifetime and past year misuse of oral tramadol and
comparators of interest among NSHUH respondents aged 12 years or older.
Based on when particular data were available, the past-year misuse analysis
includes NSDUH data from 2015 to 2017, and the lifetime misuse analysis
includes NSDUH data from 2002 to 2014. Results: In 2015 to 2017, past-year misuse of oral tramadol was approximately 4% of
the total number of prescriptions, versus 7% to 8% for all of the
comparators when adjusted for drug availability. In 2002 to 2014, lifetime
misuse of oral tramadol remained at 1.5% or less over the 13-year period,
and was lower than reported for hydrocodone (6%) and oxycodone (4%),
respectively. Comparison of oral tramadol and alprazolam showed misuse of
tramadol was also much lower than alprazolam. Too few reports of tramadol
misuse by injection (n = 7) were reported, versus 570, 1096, and 32 reports
of injection of morphine, oxycodone, and hydrocodone, respectively, during
the 16-year analysis period to allow for any population-based estimation.
Only morphine has an intravenous formulation available and tramadol was not
available as an intravenous formulation in the U.S. during that time
period. Conclusions: This analysis shows a low prevalence of oral tramadol misuse, relative to
other commonly prescribed opioids, in a nationally representative sample of
noninstitutionalized US residents. Estimates of reported oral tramadol
misuse have remained relatively stable over time and are substantially lower
than those reported for comparators when adjusted for prescription volume.
Reports of oral tramadol misuse are also much less than alprazolam, another
Schedule IV drug.
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Affiliation(s)
| | | | | | - Lucy Lu
- Avenue Therapeutics, New York, NY, USA
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Minkowitz H, Leiman D, Lu L, Reines S, Ryan M, Harnett M, Singla N. IV Tramadol - A New Treatment Option for Management of Post-Operative Pain in the US: An Open-Label, Single-Arm, Safety Trial Including Various Types of Surgery. J Pain Res 2020; 13:1155-1162. [PMID: 32547178 PMCID: PMC7250287 DOI: 10.2147/jpr.s251175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/28/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose There is a need to reduce exposure to Schedule II opioids in the United States (US) due to the ongoing opioid epidemic. Schedule II opioids have higher potential for abuse and misuse than Schedule IV opioids. This Phase 3, multicenter, single-arm, open-label, multiple-dose US trial evaluated the safety and tolerability of intravenous tramadol 50 mg, a Schedule IV opioid, in the management of postoperative pain in a real-world setting, where intravenous tramadol is not yet approved for use. Patients and Methods Patients undergoing a range of soft-tissue and orthopedic surgeries were enrolled. Intravenous tramadol 50 mg was given at hours 0, 2, 4, and every 4 h thereafter through up to 7 days of treatment. Non-opioid medications per treating physicians' discretion were allowed if additional pain relief was needed. Endpoints included treatment-emergent adverse events (TEAEs), laboratories, vital signs, electrocardiograms (ECGs), and patient global assessment (PGA) of effectiveness. Results A total of 251 patients were enrolled, with 4% discontinuing due to TEAE; no patient discontinued due to a lack of efficacy. Patients averaged 13 doses, resulting in average 48 h of exposure. Intravenous tramadol was well tolerated, with TEAEs consistent with known tramadol pharmacology. No unexpected findings were observed, with 95% of patients reporting study medication was good, very good, or excellent for controlling pain. Conclusion Outcomes from this real world use study demonstrated intravenous tramadol 50 mg was safe and well tolerated in the management of postoperative pain where intravenous conventional opioids are often used. Intravenous tramadol alone or coadministered with non-opioid medication (when needed) as a multimodal combination analgesia approach resulted in high patient satisfaction with their pain relief. In light of the US opioid epidemic, reducing the exposure to conventional opioids in these patients via use of IV tramadol may be possible.
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Affiliation(s)
| | - David Leiman
- Clinical Research, HD Research, Bellaire, TX, USA
| | - Lucy Lu
- Clinical Operations, Avenue Therapeutics, New York, NY, USA
| | - Scott Reines
- Clinical Operations, Avenue Therapeutics, New York, NY, USA
| | - Michael Ryan
- Clinical Operations, Avenue Therapeutics, New York, NY, USA
| | - Mark Harnett
- Clinical Operations, Avenue Therapeutics, New York, NY, USA
| | - Neil Singla
- Clinical Research, Lotus Clinical Research, Pasadena, CA, USA
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