Choosing the Right Painkiller: Curbing Tramadol Abuse in Patients
Jerry, a construction worker with no history of drug, alcohol or tobacco abuse, was in his 40s when he went to his doctor with chronic back pain. His doctor initially prescribed a course of hydrocodone to be taken alongside an analgesic. After two months, the doctor put Jerry on tramadol for better pain control. The tramadol worked, but Jerry was unable to stop taking the drug even after his pain resolved. His tramadol abuse became significant enough that he started experiencing anxiety, muscle cramps, and the feeling of insects crawling all over his body. He tried stopping on his own because his doctor said the drug wasn’t addictive, but it didn’t work. Months later, Jerry finally told his physician he was dependent on the drug, and the doctor immediately started tapering Jerry’s doses. Unfortunately, it was too late, and Jerry died from an accidental overdose.
Tramadol has long been thought of as a safe opioid with low potential for abuse or addiction. For the most part, it’s true that tramadol is a safe method of pain control, leading the Drug Enforcement Administration (DEA) to classify the drug as a Schedule IV controlled substance 1 An initial post-market surveillance confirmed that the rate of tramadol addiction was between one and two cases in 100,000 patients over an 18-month period of surveillance.2. Further, tramadol abuse was largely linked to a history of substance abuse.
Why, then, are addiction and rehab centers seeing a rapid increase of tramadol abuse patients? The answer is multifaceted.
Evolution of Tramadol Abuse
Tramadol is not just abused by patients who need increasingly higher doses to relieve pain. It’s also abused by recreational drug users. As a Scheduled IV drug, tramadol is easier to obtain than other illicit drugs, and it is often crushed and snorted for an immediate fix followed by a longer period of euphoria.3 The drug gives abusers an immediate high with a tapering sense of euphoria. There are much more addictive illicit drugs out there, but tramadol is easier to get and is often part of a more dangerous cocktail.
An investigation into how the FDA decided on tramadol’s classification showed that the agency considered the drug as an injection, rather than the more commonly prescribed oral drugs, and relied on tramadol abuse reports from Europe, which has a wildly different drug culture than America.4 In unpublished data, the FDA reportedly found that oral tramadol has opiate-like effects similar to oxycodone, a highly abused drug. Whether those opiate effects have an impact on abuse or addiction rates is not clear. Nevertheless, the investigation found that tramadol prescriptions and ER visits and fatalities related to tramadol abuse are increasing at alarming rates.
How Can Pharmacists Help Patients Avoid or Decrease Tramadol Abuse?
A closer look at tramadol use and drug cultures around the world can provide some lessons learned. Tramadol trafficking in North and West Africa, and well as in Asia, Saudi Arabia and Gaza, has also reached alarming levels. Tramadol is easily available in these countries, further suggesting that more rigorous control of the drug may lead to lower addiction and abuse. South and Central America are also seeing increased reports of tramadol abuse due to recreational drug use, again pointing to the need for better control of the drug. Meanwhile, studies in Germany have shown that a shift from immediate release tablets to extended- release formulations have decreased tramadol abuse.5
Pharmacists have several different routes they can take to help lower tramadol abuse, ranging from educating patients about the real risks of taking tramadol to offering other types of pain relief. Actions pharmacists can take to help lower the tramadol abuse problem include:
Offering parenteral delivery routes. Oral administration of tramadol comes with opiate-like effects that are not seen with other delivery methods. Injections may be a viable option; suppositories are only indicated for certain types of pain relief, but may also be an option. Oral tramadol use should be avoided in patients with a history of substance abuse and may benefit from other types of pain relief.
Cautioning patients against purchasing tramadol online or when abroad. Tramadol is available over-the-counter in much of North America and in some Asian countries, such as India.6 Although the lower international prices may seem attractive to patients, remind them that not only should they take tramadol under careful supervision, but that drugs purchased internationally may not be pure.
Telling patients that tramadol can lead to polydrug abuse. Although tramadol is usually given alongside other medications, tramadol abuse often occurs because patients knowingly or unknowingly take it alongside other substances, such as alcohol, cold medicine, or other painkillers.7
Helping addicted patients detox. A medically assisted detoxification program is the best and safest way to deal with tramadol abuse. Contact the local ER and the patient’s physician to start on detoxification right away.
Understanding what type of pain control is appropriate for each patient is an evolving science. As more research and evidence-based data become available, pharmacists must rethink what treatment plans they recommend for each patient. Luckily for compounding pharmacists, they already think that way.
Tramadol abuse is an increasingly serious problem in this country. Pharmaceutica North America is committed to providing you with updated research alongside safe and high-quality compounding materials so you can give your patients the care they deserve. Contact us today to learn more.
- “Rules – 2014,” July 2, 2014, http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0702.htm ↩
- “Tramadol Dependence in a Patient With No Previous Substance History,” December 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882815/ ↩
- “Snorting Tramadol,” 2016, http://luxury.rehabs.com/tramadol-addiction/snorting/ ↩
- “Drug tramadol escapes stricter regulation,” December 21, 2013, http://www.jsonline.com/watchdog/watchdogreports/drug-tramadol-escapes-stricter-regulation-b99158486z1-236900801.html ↩
- “Tramadol: Update Review Report,” June 16-20, 2014, http://www.who.int/medicines/areas/quality_safety/6_1_Update.pdf ↩
- “Hooked on Pharmaceuticals: Prescription Drug Abuse in the World,” August 10, 2015, https://www.drugwatch.com/2015/08/10/worldwide-prescription-drug-abuse/ ↩
- “Tramadol Addiction and Abuse,” 2016, https://www.addictioncenter.com/painkillers/tramadol/ ↩