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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 for the replies at this point.
I appreciate your reading my comment, and furthermore I am not impressed at all with the new Netflix series called Pain or Painkiller. It is well done but the patient is literally left out of the picture who truly needs pain meds. It focuses and quite rightly so, on big pharma, lesser conscientious and almost stupid doctors and pharmacists who did not have enough conversation with their patient or client in anticipation of critical and excruciatingly felt pain. There ARE TWO SIDES TO EVERY STORY…..
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3 ReactionsI watched the program too. It made the point that big Pharma is out to make money often without regard to the people. I think things are slowly changing in big part because of big law suits and some legislation. We need more and better input to the laws so that the law protects us but doesn't become an overlord.
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1 ReactionThis publication from the fed s seems to settle the issue,
https://pubmed.ncbi.nlm.nih.gov/15811163/. But as we age and breakdown more our pains can increase and you need to be cautious with over use of Tramadol. You may reach a point that stronger meds are a better option for your degree of pain. This is when you get your pain doctor involved.
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3 ReactionsIt’s a shame that congress decides. Let’s test each one, bet they are on something. Bu the way they act, think they are in many different ones. One had to look at the individual, the pain level, any other intervention used and did not work. I hate them, but it gets me through the day, barely. I only take 7 mg a day! One bottle lasts 2 months.
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2 ReactionsAnd "pain" doctors warn you about overuse of medication that is keeping us alive, and then say they can't prescribe anything else...and "Oh, have you tried exercise and meditation?"
It’s worked for and I hope for many others who followed that advice. I walk 2 miles a day (I’ve always been a walker), do a home exercise program 2 x day, go to PT when I need a tune-up. I use buprenorphine patch for pain and cannabis for breakthrough pain instead of Percocet. At 71 for me I feel I’m doing pretty good. Just discharged from outpatient PT today and went to the gym. Yes I ache but found that exercise is a great pain reliever. As a retired nurse I understand why and what the docs must do when prescribing narcotics to patients. Everybody has hoops they must jump through in this age of substance abuse. I hope you’re able to find peace with your health.
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2 ReactionsPharma, etc. appears to be in the business of treatments and not cures.
You sparked comment to this one! Exercise and meditation. Don’t they sound great? Especially when you have a neurological condition that makes your processing of things all skewed from an illness like mine- Lyme disease - which is famous for hitting the nuero system. And oh my- exercise when your joints are so swollen that you can barely walk. It’s absurd that we continually listen to this well meaning, but medically “static filled” nonsense all the time. It’s serious and I have yet to come across a proposal to start a grounds-up patient and group conscious group to tackle this problem. And that which takes care of the patient in small increments to BUILD UP to the almighty exercise and meditation - which by the way, many well people cannot embrace.
Good for you. I hope many who reply are not sitting on their “pity pots” and actively working at becoming as active and healthy as described above.
I for one am trying every day and okay make believe that I will be well and healthy like I once was. But my tick borne disease decides when I will be well and when it emerges in crafty fashion into the bloodstream and causes havoc and back to bed for the next cocktail of abx to get me going again.
The above mentioned comments are good incentives to follow. Not all of us are so lucky. We hope we will be but it’s - as my father would say—a crap shoot. Pardon my descriptive language.
Correct - but after years of this being the norm and standard situation, I’ve been watching and reading and slowly seeing this massive untouchable government control morph into another control by who’s who in the pharma industry….and the meds will not be available. They will promise relief at a significant lower price by offering a new and “functional” routine for us. I hope these columns are being scrutinized by a narrator or whomever offers these unbiased discussions. There will be a reduction of price to the consumer as promised, but it will still not have bettered the much needed collaboration between doctor, patient and industry. Our internist won’t be afraid to prescribe; the insurance industry will draw a sigh of relief and the patient will more than likely deal with ongoing pain.
We should all have the sense and strong dialogue to show control with our doctor with controlled and strictly monitored help and not be automatically labeled the abuser. Pain is pain and it produces an unproductive person much like the junkie or a user who leeches on society. What have we accomplished here except still being under the thumb of big government?
What about researching means to work internally with our injured or sick bodies and investigate alternative treatment to help improve to lessen the pain?