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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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This article corroborates other research findings I have read: It says that: "Fewer than 10% of the 445,000 post-surgery patients sampled developed additional or persistent use of opioids". And, "Plans are tailored for each individual patient". This is why we need to get government out of health care. Currently, politicians are making laws about health care as though all people are alike. Some of us are having a hard time getting our medicine because of these laws directed at addicts, but they affect everyone.
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12 ReactionsAlthough I agree that these laws are being made wholesale, making it difficult, even for cancer patients to get the pain relief needed. I have unfortunately seen the flip side, of doctors who prescribe unlimited opioids to patients without really a regard for how it might end for them, even little old ladies hooked on pain meds. There has to be some reasonable research based, education for these doctors to create some balance. Not just laws that prevent even dying cancer patients from getting relief from pain.
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4 ReactionsI disagree with these laws completely. My healthcare should have nothing to do with what some Congress person believes I need. It shouldn’t even be decided by a doctor 3000 miles away from me. Whatever I am prescribed or not prescribed should be up to my healthcare providers and me. I have been on opioids for years. I never run out before I am supposed to nor have I asked for increases in my dosage other than once to get to a level that helped me. Now since my doctor retired I have to travel two hours to a pain clinic to get my prescriptions. I don’t understand the purpose of this because all they do is ask me what my pain level is, then take tests to make sure I am taking them. My new rheumatologist will not prescribe the meds for me because of all the scrutiny. I know some people will disagree with daily use of these drugs but they kept me working for years longer than I would have been without them
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16 ReactionsYou and I and folks like us are the collateral damage in the war on opioids. We are not the problem, we did not create the problem we did not further the problem. We found a way to live out the balance of Our Lives with pain was manageable and that means has been taken away from us. It is Extreme, but the only thing you can do really is get a pain pump which doesn't seem to cause the alarm that other ways of taking opioids to do. Playing the The Devil's Advocate I will remark that really really high doses of opioids did not take care of my pain as effectively as the extremely low doses that I got from the pain pump do and I did have some side effects of doubling my wits with the really high doses. Doses in the 230 to 250 mg of Oxycontin a day rage
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2 ReactionsAgree with you. Those who legitimately need opioids for pain management are being punished due to the illegal use of them. It IS for a patient and her doctor to decide. I alsof eel for the doctors who have been so subdued by Congress in prescribing these drugs.
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5 ReactionsI haven’t heard much about a pain pump. I think the only thing I really know is a friend’s doctor was trying to give her one but she was nervous that it wouldn’t work and then she wouldn’t be able to go back to her current prescriptions. My doctor never mentioned it. If you know can you tell me if this is an option from any doctor or is it a specialty from a pain management clinic?
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1 ReactionHi, i keep asking if anyone have Erythemamultiformamajor. my grandson is suffering it appears to be more like Steven Johnson Syndrone. I am trying to find out how to apply for GO FUND ME help to get to the Mayo Clinic in Rochester. I am 80 getting ready to have a Lung Cancer operation.
Anyone can create a Go Fund Me page. Just write up a compelling paragraph or two explaining why your grandson needs the help and go to the go fund me site. The site will walk you through the steps to get the page set up. I created one a few years ago for a friend who has since passed away from cancer. I think it works best if you know a lot of people to share your story. Good luck
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1 ReactionI have experienced the same thing - Politicians 'practicing medicine without a license' have enacted laws that prohibit real patients from getting the medicine we need. A pharmacist told me she would 'have to investigate me' before she gave me my medicine (gabapentin, it's anti-seizure medicine, not a drug that addicts want, and it was the same rx the pharmacy had been filling for me for a year). Doctors and nurses have interrogated me with lists of questions the government gave them. The government is threatening to take their license unless they cooperate. The government is also keeping records of every rx that every person fills. In some states they call it 'the data-sharing plan'. Humans stand pain for as long as we can then we look for something sharp to cut our veins with and end our misery. That's why armies are still using torture to get information - it works - pain breaks people. Politicians have not taken us into consideration. We need to speak up and write letters. Peggy
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10 ReactionsI agree with everyone. When l was first given tramdol l was told by doctors, nurses and other healthcare specialists it wasn't an opiod. And then l did my own research and when l saw some states saying it was l asked again even the pharmacist and again they said no. One day l was watching the doctors on TV and the doctor had just had surgery and he said they put him on tramadol and he talked about how he felt on it and he did his research. And found out lots of people in Virginia who were on it were committing suicide. So again l told my doctors about my finding. Now our state is saying it's an opiod. And they won't prescribe more than 20. We have the highest opiod addiction rate in the US. We rate number 1. And my doctors knew l wouldn't abuse it because l like to know my surroundings. But we even had doctors who over prescribed and they were incarcerated for maybe a day. And just last year this happened and the doctor is practicing at another hospital in the city. So how about that and they want to sue the pharmaceuticals. And no one forces a doctor to prescribe all those opioids. So yes people who really need it can't get it because not only drug dealers but also sometimes doctors. And they had an employee who was acting as a pharmacist and she was prescribing all kinds of opiods but not officially licensed as a pharmacist. So sometimes it greed also and that for law makers, states and so forth. We need more caring and compassionate people who care about others. And l saw that at the mayo clinic. And there are other wonderful hospitals we just have to get the bad out. And l like some of these different hospital because they have doctors from all over the world. And in different countries not all the sick they are taught to care for like they would for themselves. We need to get back to that wake up USA we are suppose to be the number one country in a lot of things but healthcare we are falling flat. Very good article.
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