Is Tramadol Actually Safer Than Other Opioids?

Patients who receive post-surgical tramadol have either similar or somewhat higher risk of prolonged use than patients who receive other common opioids, according to the results of a recent study.

“Tramadol is sort of having a moment in the medical community: it’s a drug that many clinicians have historically thought of as being pretty innocuous and not a 'real' opioid,” lead author Molly Jeffery, PhD, scientific director of emergency medicine research and research associate in the Department of Health Sciences Research at the Mayo Clinic in Rochester, Minnesota, told Consultant360.

“This is mirrored in how it is treated in the United States (and other countries), where prescribing rules are less restrictive than other opioids like hydrocodone and oxycodone. We think this is a myth—tramadol really is an opioid and has some of the same risks,” Dr Jeffery said.

For their study, Dr Jeffery and colleagues examined data from US commercial and Medicare Advantage insurance claims from opioid-naïve patients undergoing elective surgery from January 1, 2009, through June 30, 2018.

Prolonged opioid use was defined using 3 separate definitions:

• Additional opioid use: At least 1 opioid prescription fill within 90 to 180 days after surgery.
• Persistent opioid use: Any opioid use starting within the 180 days after surgery and lasting for 90 days or more.
• The CONSORT (CONsortium to Study Opioid Risks and Trends) definition: Opioid use starting within 180 days after surgery and lasting 90 days or more including either 10 or more opioid fills or 120 or more days’ supply of opioids.

Of the 444,764 patients included in the analysis, 357,884 filed discharge prescriptions for one or more opioids. Hydrocodone was the most commonly prescribed opioid (53.0%), followed by short-acting oxycodone (37.5%) and tramadol (4.0%).

Unadjusted risk of prolonged opioid use was 7.1% with “additional opioid use,” 1.0% with “persistent opioid use,” and 0.5% with use matching the CONSORT definition. Use of tramadol was associated with a 6% increase in risk of “additional opioid use” compared with other short-acting opioids, a 47% increase in adjusted risk of “persistent opioid use,” and a 41% increase in adjusted risk of use matching the CONSORT definition.

“We found that people who received tramadol were just as likely as people who received hydrocodone or oxycodone to continue using opioids past the point where their surgery pain would have been expected to be resolved. This does not tie to the idea that tramadol is less habit-forming than other opioids,” Dr Jeffery said.

“There are still major gaps in our knowledge of the ideal treatment for post-surgical pain. The existing guidelines are generally consensus reports, because there are not any large-scale, high-quality studies to tell us which drugs are best for which patients and in what quantity. We do know that many people have large amounts of opioids left over from their post-surgery prescriptions, which can be a problem. The Food and Drug Administration currently advises that most opioids (though not tramadol) be immediately taken to a takeback center or flushed if no takeback programs are available. Obviously, that is not ideal from a convenience or an environmental perspective, so figuring out the right dose and duration of medications after surgery is important. We also know that many people fill their opioid prescription but end up preferring to take over-the-counter medications to manage their pain. Again, figuring that out and getting it right is important both for patients and for the broader public health,” Dr Jeffery concluded.

—Michael Potts

Reference:
Thiels CA, Habermann EB, Jeffery MM, et al. Chronic use of tramadol after acute pain episode: cohort study [published online May 14, 2019]. BMJ. https://doi.org/10.1136/bmj.l1849.