Rochester, MN—Tramadol, a centrally acting synthetic weak mu-opioid receptor agonist, is phenotypically distinct from conventional short-acting opioids. In fact, the painkiller’s lower affinity for the mu-opioid receptor has given it a reputation for having a more favorable side-effect profile, including reduced rates of constipation, respiratory depression, overdose, and addiction.

That’s why U.S. Government agencies continue to classify tramadol at a lower level than other opioids such as morphine and oxycodone, both schedule II. But that doesn’t mean the drug is without risks, according to a study published in The BMJ.

Mayo Clinic researchers report that surgical patients receiving tramadol have a somewhat higher risk of prolonged use than those receiving other common opioids.

“This data will force us to reevaluate our postsurgical prescribing guidelines,” suggested lead author Cornelius Thiels, DO, a general surgery resident in Mayo Clinic School of Graduate Medical Education. “And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids.”

In an observational study of administrative claims data using Optum Labs Data Warehouse commercial and Medicare Advantage claims from January 1, 2009, to June 30, 2018, the study team focused on opioid-naive patients undergoing elective surgery.

Defined as the primary outcome measure was risk of persistent opioid use after discharge for patients treated with tramadol alone compared with other short-acting opioids. The study employed three commonly used definitions of prolonged opioid use:
• Additional opioid use (defined as at least one opioid fill 90-180 days after surgery);
• Persistent opioid use (any span of opioid use starting in the 180 days after surgery and lasting 90 days or more); and
• CONSORT definition (an opioid-use episode starting in the 180 days after surgery that spans ≥ 90 days and includes either ≥ 10 opioid fills or ≥ 120 days’ supply of opioids).

Of more the than 444,000 patients identified, about 358,000 filled a discharge prescription for one or more opioids associated with one of 20 included operations. Among postsurgery opioids, the most commonly prescribed were hydrocodone (53.0% of those filling a single opioid), followed by short-acting oxycodone (37.5%), and tramadol (4.0%).

The unadjusted risk of prolonged opioid use after surgery was calculated at 7.1% with additional opioid use, 1.0% with persistent opioid use, and 0.5% meeting the CONSORT definition.

Researchers determined that receiving tramadol alone was associated with a 6% increase in the risk of additional opioid use relative to people receiving other short-acting opioids (incidence rate ratio 95%; CI, 1.00-1.13; risk difference 0.5 percentage points; P = .049), a 47% increase in the adjusted risk of persistent opioid use (1.25-1.69; 0.5 percentage points; P < .001), and a 41% increase in the adjusted risk of a CONSORT chronic opioid use episode (1.08-1.75; 0.2 percentage points; P = .013).

“People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids,” study authors concluded. “Federal governing bodies should consider reclassifying tramadol, and providers should use as much caution when prescribing tramadol in the setting of acute pain as for other short acting opioids.”

“We found that people who got tramadol were just as likely as people who got hydrocodone or oxycodone to continue using opioids past the point where their surgery pain would have been expected to be resolved,” added senior author Molly Jeffery, PhD, the scientific director of research for the Mayo Clinic Division of Emergency Medicine. “This doesn’t tie to the idea that tramadol is less habit forming than other opioids.”

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