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Dr. Cornelius Thiels and colleagues including Dr. W. Michael Hooten recently published an article, “Chronic use of tramadol after acute pain episode: cohort study” in the British Medical Journal. The key conclusion of this study is that the medication tramadol, which although an opioid medication is considered by the FDA to have less addictive potential than opioids such as oxycodone or hydrocodone, had just as much potential for prolonged use after surgery as other opioids. These findings highlight an important opportunity for patients and their doctors to have thoughtful and informed discussions about acute pain management in the post-operative period.
As a fellow in the Pain Division at Mayo Clinic, I have many conversations with patients regarding management of acute and chronic pain. In the hospital, I often am working with patients and their surgical teams to help manage pain after surgery. In the clinic, I often see patients to develop plans to manage chronic pain including pain that persists weeks and months after surgery. Opioids are almost always a part of this discussion, and our conversations are very individualized according to the patient. Some patients going into surgery have been using opioid medications for many years; some are opioid naïve or have only taken opioids sporadically and for short periods in the past. Some of my patients have a history of addiction and require a pain management strategy that minimizes the use of opioids or avoids them altogether. It is very important that every plan designed for effective post-surgical pain management takes into consideration the history, values and goals of each patient and is tailored to the needs of each individual patient. The culture of Mayo Clinic and within our division is to prioritize the needs of each patient, and this is always the focus of each pain management recommendation.
Most of my patients share the goal to avoid starting or increasing long-term opioid medication use after surgery, as we discuss long-term consequences including the potential for addiction, tolerance, and worsening chronic pain. Strategies for managing post-operative pain include maximizing our use of non-opioid medications and strategies while using the minimal effective dose of opioid medication for the shortest period of time. This is less than or equal to 3 days for most patients, and for nearly all patients and surgeries at most a period of 7 days. If I happen to have the opportunity to meet with a patient before surgery to discuss their upcoming surgery, I find it very helpful to discuss the patient’s hopes and expectations regarding their pain management plan. Many patients understandably have some fear or anxiety regarding post-operative pain, especially if they have had negative experiences in the past or if this is their first surgery. Most patients do very well with post-operative pain management, but our division of pain management specialists is available to help if there are any questions or concerns.
Dr. Thiels’ article will impact my practice and conversations with patients by having good evidence around which to have a conversation about opioid medicines. Many patients do hold the belief, as do non-pain medicine specialist physicians, that tramadol is a completely safe alternative to more traditional opioids such as oxycodone or hydrocodone. We know from research and the experiences of our patients that this is not true, and the use of tramadol carries similar risks in terms of addiction, dependence, tolerance and prolonged use as traditional opioids. One of my most important jobs is to make sure that my patients have a good understanding of the risks and benefits of various management plans, including medications. Our communities and our nation continues to cope with the so-called opioid crisis, and while a better understanding of the profound risks of the use of opioid medications in chronic pain is long overdue, there is a lot of misinformation out there as well. The more evidence-based information that we have available to us to discuss with our patients, the better, and I am grateful to Dr. Thiels and his colleagues including the Pain Division’s own Dr. Hooten to having investigated the important question of the risks of prolonged use of opioids after surgery. Interestingly, fewer than 10% of the nearly 445,000 patients in this nationwide sample developed additional or persistent opioid use after surgery, as defined by filling of opioid prescriptions 90 days or more following surgery. This does align with our clinical experience of most patients not developing problematic use of opioid medicines after surgery. Whenever possible we identify patients at increased risk prior to surgery and design our plan accordingly. It is important to understand that tramadol carries similar risks as oxycodone or hydrocodone in this regard, and we should make sure to counsel our patients appropriately.
Helpful Links:
- Watch a video with Dr. Thiels describing the study
- Learn more about Dr. Michael Hooten
- Read more about the study via Mayo Clinic News Network
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I too take Tramadol not knowing that it is an Opiod. I am so fed up with all the medicines that doctors have put us on without telling us the bad effects it will have on us.
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2 ReactionsI like Tramadol. I take 1/2 of 1 tablet when the over-the-counter pain killers have not worked and I'm at my limit with tolerating pain. I can take it during the day, it doesn't make me sleepy or 'ditsy', just dulls the pain so I can carry on with my life. I can't take it at night, it would keep me awake. If I have pain at night that otc meds won't mitigate and I can't sleep because of pain, I take 1/2 of 1 codeine tablet. I'm careful with both of them. 30 Tramadol will last me a year or more, 30 codeine will last me 1 1/2 years or more. Peggy
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3 ReactionsI agree 100% about our health care being decided by Congress. What do they actually know about it? They just see the statistics of people that abuse opioids but nothing about people with debilitating pain that take their medication as prescribed. It's not right. So far I don't have a problem getting my prescriptions but that's probably because my diagnosis is terminal otherwise I'd be going thru the same as you for my RA.
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6 ReactionsUnfortunately, having your situation described by the doctors as palliative care seems to be the only solution to long-term pain management drugs. You can get that description without being terminal. They just need to specify that you will never get better and will need treatment until you die. That being said, my doctor still comes under pressure from regulators and management. I am lucky to have a pain pump. Truth. I had unlimited access to oral meds before the pump. Real pain experts know that the patient who makes their own decisions about dose size will use less than the patient worried about where the next dose will come from. Large doses of oral meds will become ineffective over time and even if they don't make you high, they do alter your affect and slow your mental functioning. I know from personal experience.
The opiate problem was not caused by doctors treating real patients. Some of those patients screw up and get high and get hooked. The real villans were the producers who taught the unscrupulous doctors how to addict some patients, and distributors who made drugs available to pill mills. The vast majority of overdose deaths are the result of illegal drugs poorly titrated. It is just to hard to do it right. Tiny amounts of fentanyl can and do kill. Our government needs to find out where these drugs are coming from and stop the importers. The usual suspects would include the Ukraine, Mexico and India. They are the sources for the ephedrine which is turned into meth and is smuggled in my Mexican and other South American countries and our government knows this. Never forget that our government made it illegal for our Drug Enforcement Agency to investigate the opiate producers. Don't take my word for it. Research it. The Washington Post wrote about it in 2017. Passed by both houses of Congress and signed by the President. Drug lobbyists at work.
I came across a renegade pharmacist on this chat board. The guy would fill legitimate scripts for the same price as anyone else. He would sell you anything you asked for, for about 10 times the legal price. It was a real eye opener and was removed from the website quickly. We must continue to tell the real story about the opioid crisis and keep telling it over and over. Love and blessings.
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3 ReactionsI have chronic back pain. I did use low dose half of Hydrocodone, for about a year, but I found that eventually the pain was much the same when I took it and if I didn’t. That signaled to me the time had come to increase the dose. I did not want this so I stopped altogether. Nothing helps . I have exercised all my life and even during the last few years when I have been in considerable pain. With the arrival of COVID I had to stop.
I will go back to exercise, although it is very hard after not working out for several months. I am 90 and consider exercise has allowed me a much longer time to continue walking. I truly wish that I could have help with the pain. But I will not take opioids or any strong meds on a daily basis. Even Tylenol.
Sincerely.
Isla Stefanovich.
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5 ReactionsThanks for your insight into chronic pain. I also have chronic low back pain and am awaiting a trial of Medtronic spinal cord stimulation. Neither tramadol nor hydrocodone with acetaminophen control the pain well. What kind of exercise do you do? I am an 83 y/o woman. I wonder if medicinal marijuana is effective?
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3 ReactionsSome people can get addicted easily while others do not. A blanket statement about addiction of a patient is not good practice.
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3 ReactionsThis article is primarily about post surgical pain and opioid use, and hardly anything about Tramadol! Retitle it!
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2 ReactionsI Can't agree with you anymore !!
Substance abuse of opioids or non opioids will always continue no matter what Congress or world leaders say or do. If you want to get high and abuse or profit from it you will find the products and a way to do what you intend to do!!!
What is concerning and SAD, it's hurting the folks that actually need this medication/drug to live a normal life or as normal as possible. Everyday, common folks that live with chronic pain, are the true victims of this opioid crisis. Dr 's are afraid to prescribe for the fear of litigation and loosing everything they worked for.
I need pain relief each day and shouldn't be told what I need or do from a government entity.
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6 ReactionsYour exactly right
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5 Reactions