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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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Thank you JesusBack in 2020 I had surgery on both my legs. the physician prescribed both Tramadol and Oxycodone. I took them as prescribed. After a month I refused to refill both and wiened myself off of both. Yes I still had pain, but, I also was in and out of rehab 3 times because I had surgery on one leg twice and it clearly helped! Now my problem is my back. Trying to deal with it without narcotics. I too pray and ask God for his help and I believe He is helping. My pain is not as severe as it was. Thank you Jesus!
Sorry, my computer hiccupped!
I have been on opioids for 15 years, I lessened the amount when the pain level warranted it. I went back up when needed. I have MRIs for each pain issue. c-4 to c-6 with bone spurs, torn rotator left side, need new knee right side and neuropathy both feet.
My take on the political aspect to the pain management issue is 2 fold. They reacted to the suffering of those loved ones who died from an overdose. I fully understand that, that is horrible but taking away my pain relief from me does nothing to bring their loved one to come back. The other one is more of a manufactured crisis, they added heroin, fentanyl, oxycontin, Percocet laced with fentanyl. They rolled all of those numbers together to increase the death toll. People were snorting it, shooting it up, taking them and drinking alcohol. Take them as prescribed and you should not have an issue, chronic pain is nothing I ever wanted and I don’t need a congress person telling me I can’t get them or putting pressure on my doctor. Hope all works out for you.
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6 ReactionsI'm so glad to read your responses and know that I'm not alone. I have written to the governor of my state about the difficulties I have encountered when trying to get prescriptions filled. I don't have a reply yet. I need to write to my representatives in Washington DC also (it's on my To Do list). In April, I had extensive surgery in my back and had to take pain medicine (morphine in the hospital, then tramadol and oxycodone at home for two weeks). Now I'm only taking Tramadol, only as needed, I'm going to physical therapy, and on Sundays I don't take anything - I just suffer all day - but I want to clear the medicine out of my body so it doesn't decrease its effectiveness. My pain doctor said that one day a week was enough of a break to avoid becoming dependent and having to increase the doses. Peggy
Amen! I totally agree with you. Tramadol has helped me successfully manage various pain episodes since 2004. The longest period I took it was 6 months. I stopped when I was ready with no issues. Each person is different and should be treated as an individual to resolve pain issues. One size does not fit all.
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1 ReactionI have PN and I have been taking Tramadol for five years. I take 50 mg 4x daily to help keep my pain at bay. My neurologist has no problem filling the prescription. I did recently receive a letter from my insurance expressing concern about possible addiction. That is the only thing I have ever heard in all these years. My primary doctor and my psychiatrist are not concerned.
I was thinking about this a lot yesterday and how 99% of physicians lump everyone into the category of "OMG! I can't prescribe painkillers! (or benzodiazapines, take your pick)"
I've never "craved" an opioid in my life, even when on very high doses for months. My body just does NOT react like that.
And I can take Xanax, Valium, etc and never want another pill.
Every person's physiology is different, but those of us who can responsibly be prescribed opioids and benzos are a little-known subgroup.
I've finally found doctors that trust me, but for every one there are are 100 that are afraid of the CDC prescribing quidelines (which have recently changed once again).
And sooo many people I meet will remark, "I just LOVE (fill in the blank w the addictive medication)!"
How can you "LOVE" any medication that should only be making them feel NORMAL?
Anyway, I don't get it, but then I don't have the "addictive" tendencies, so it's all a mystery to me.
Thanks for your response. Lin
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1 ReactionAfter a shoulder replacement I can't get Tramodol. I did but can only take one a day. They are so strict about giving any pain med, but Tramodol really helped me before my surgery. I don't know why I can't take 3 a day???
I agree with you. I'm working on getting my Complete Shoulder Replacement and can only take one Tramodol a day. I live with pain every day with fatigue and lightheaded.
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1 ReactionIt is terrible that real patients are being denied medicine that they need because parents of drug-addicted teenagers are blaming the medicine and the doctors instead of getting help for their child. They want our medicine to be banned from everyone so that their child can't get it. They don't want to be blamed for their child's addiction so they are yelling and pointing fingers elsewhere. We need to write to our legislators. "The squeaky wheel gets the grease" from politicians. Different states have different laws. In Delaware, I can't get health insurance because I filled prescriptions for gabapentin and tramadol less than a year ago. Some states suspend your driver's license if you fill a prescription for tramadol or anything stronger. If we don't yell louder than the frightened parents, laws will get worse for us. I have written to our governor, I need to write to each individual legislator. I commit to doing it this week. PS: In Canada and Mexico, people buy codeine over the counter in pharmacies. Peggy
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