Trends in Tramadol

Chronic low back pain comorbidity count and its impact on exacerbating opioid and non-opioid prescribing behavior

RESEARCH OBJECTIVES

The objective of the study was to determine the characteristics of chronic low back pain (CLBP) comorbidity and its impact on opioid and non-opioid treatments among Chicagoland patients with CLBP.

DESIGN

A retrospective cross-sectional study comparing differences in comorbidity and treatment patterns among Chicagoland patients with CLBP against a matched control arm without chronic low back pain (NCLBP).

SETTING

Academic hospital system outpatient services.

PARTICIPANTS

Using the International Classification of Diseases, 10th Revision codes (ICD 10) 9589 patients were identified with CLBP with a median age of 57 years old and 62.32% female distribution. The NCLBP group comprised 9589 age-, sex-, race-, and region-matched patients.

RESULTS

An increased prevalence across all 17 studied comorbidities was found in CLBP patients as compared to NCLBP patients. CLBP patients carried an average of 3.5 comorbidities compared with 2.4 comorbidities in NCLBP patients. Rheumatoid arthritis (RA), joint arthritis, and obesity had the strongest relationship with CLBP. Additionally, we found that the most prescribed treatment for CLBP were opioids, which ranked above NSAIDs and physical therapy. 56% of CLBP patients were prescribed opioids as compared to 36% of NCLBP patients (Odds Ratio = 2.28, 95% CI: 2.16-2.42). Tramadol was the agent with the strongest relationship to CLBP. CLBP patients were more likely to use two or more opioids concomitantly. The number of total treatments was positively associated with the number of comorbidities in both CLBP and NCLBP patients (Cochran-Armitage trend test p < 0.0001).

CONCLUSIONS

Chronic low back pain patients showed a higher number of comorbidities than their NCLBP counterparts. Comorbidity count trended positively with higher treatment burden with opioids being the most prescribed treatment, often with poly-opioid use, over conservative modalities such as NSAIDs and physical therapy.

A comparative study of postmortem distribution and postmortem diffusion of tramadol in rabbits

In recent years, the cases of tramadol intoxication have become more frequent in many countries. However, most of the previous studies have been based on cases of tramadol intoxication, and the detailed information on the differences between postmortem distribution and diffusion of tramadol remains unclear. To investigate this issue systematically, we established a postmortem distribution model and two postmortem diffusion models. Then, gas chromatography-mass spectrometry (GC/MS) was used to measure the concentrations of tramadol in various biological specimens of fluids and tissues. In postmortem distribution, the results showed an uneven distribution of tramadol in various biological specimens, and the concentrations of tramadol in urine were significantly higher than those in other fluids. In postmortem diffusion, the results showed a dosage-dependent increase of tramadol concentration in most specimens; at all time points from 0.25 to 6 h after postmortem administration, the concentrations of tramadol in fluids were not significantly different from those in tissues, and the concentrations of tramadol in urine were lower than those in both tissues and other fluids in most time points. We recommend a quantitative examination of the specimens of both fluids and tissues to provide more evidence for the forensic identification, and the realization that there is a correlation between the concentrations of fluids and tissues is important for determining antemortem and postmortem administration of tramadol. This information can serve as ancillary data in inferring the contribution of a drug to death in cases of suspected tramadol poisoning.

Tramadol regulates the activation of human platelets via Rac but not Rho/Rho-kinase

Tramadol is a useful analgesic which acts as a serotonin and noradrenaline reuptake inhibitor in addition to μ-opioid receptor agonist. Cytoplasmic serotonin modulates the small GTPase activity through serotonylation, which is closely related to the human platelet activation. We recently reported that the combination of subthreshold collagen and CXCL12 synergistically activates human platelets. We herein investigated the effect and the mechanism of tramadol on the synergistic effect. Tramadol attenuated the synergistically stimulated platelet aggregation (300 μM of tramadol, 64.3% decrease, p<0.05). Not morphine or reboxetine, but duloxetine, fluvoxamine and sertraline attenuated the synergistic effect of the combination on the platelet aggregation (30 μM of fluvoxamine, 67.3% decrease, p<0.05; 30 μM of sertraline, 67.8% decrease, p<0.05). The geranylgeranyltransferase inhibitor GGTI-286 attenuated the aggregation of synergistically stimulated platelet (50 μM of GGTI-286, 80.8% decrease, p<0.05), in which GTP-binding Rac was increased. The Rac1-GEF interaction inhibitor NSC23766 suppressed the platelet activation and the phosphorylation of p38 MAPK and HSP27 induced by the combination of collagen and CXCL12. Tramadol and fluvoxamine almost completely attenuated the levels of GTP-binding Rac and the phosphorylation of both p38 MAPK and HSP27 stimulated by the combination. Suppression of the platelet aggregation after the duloxetine administration was observed in 2 of 5 patients in pain clinic. These results suggest that tramadol negatively regulates the combination of subthreshold collagen and CXCL12-induced platelet activation via Rac upstream of p38 MAPK.

Tramadol and Cycling: Is It the End of a "Painful" Relationship? An Insight From 60,802 Doping-Control Samples From 2012 to 2020

PURPOSE

To assess the prevalence of tramadol use among athletes from 2012 to 2020.

METHODS

All urine samples were collected from national and international in-competition doping-control tests that took place in Italy between 2012 and 2020. The analysis of the samples was performed by gas chromatography coupled with mass spectrometry with electronic ionization and acquisition in selected ion monitoring. The cutoff tramadol concentration was >50 ng/mL.

RESULTS

Of the 60,802 in-competition urine samples we analyzed, 1.2% (n = 759) showed tramadol intake, with 84.2% (n = 637) of these coming from cyclists and 15.8% (n = 122) from other sports. In cycling, a strong and significant negative correlation was found (r = -.738; P = .003), showing a decrease of tramadol use compared with the other sports.

CONCLUSIONS

The decrease in tramadol prevalence in cycling in the last years may be due to (1) the deterrent action of antidoping regulations and (2) the fact that tramadol may not have any actual ergogenic effect on performance.

"What a man can do, a woman can do better": women farmers, livelihood and drug abuse in Adamawa State, northeastern Nigeria

Drug and substance abuse among female population is on the rise but yet to be given adequate scholarly attention. This study examines how women farmers in Adamawa State are engaging in drug and substance abuse to enhance their farming livelihood practices and the implications of their action for health and social cohesion around their communities. Using data collected from interviews and observations, the study discovered that rising female-breadwinning in the study area put a lot of pressure on women to engage in farming as owners, hired or eclectic farmers. To be able to withstand the stress of farming, some engage in the use of psychotropic stimulant substances to enhance their performance. The study also discovered that the most abused substances are cannabis and tramadol due to affordability and availability. On the other hand however, the study found out that increasing indulgence of women in substance abuse is already impacting on spousal relationship between the women indulging in substance abuse and their husbands. The study recommended that government of Adamawa State should enforce in full, the Adamawa State Unclassified (Local Substances) Abuse Law 2015 by establishing a rehabilitation center for correction and reformation of addicts in the state. Furthermore, it is also recommended that all stakeholders should give empowerment of women in the state serious attention.

Acute Pain Management Pearls: A Focused Review for the Hospital Clinician

Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.

Molecular Docking and Dynamic Simulation Revealed the Potential Inhibitory Activity of Opioid Compounds Targeting the Main Protease of SARS-CoV-2

Opioids are a class of chemicals, naturally occurring in the opium poppy plant, and act on the brain to cause a range of impacts, notably analgesic and anti-inflammatory actions. Moreover, an overview was taken in consideration for SARS-CoV-2 incidence and complications, as well as the medicinal uses of opioids were discussed being a safe analgesic and anti-inflammatory drug in a specific dose. Also, our article focused on utilization of opioids in the medication of SARS-CoV-2. Therefore, the major objective of this study was to investigate the antiviral effect of opioids throughout an in silico study by molecular docking study to fifteen opioid compounds against SARS-CoV-2 main protease (PDB ID 6LU7, M^pro). The docking results revealed that opioid complexes potentially inhibit the M^pro active site and exhibiting binding energy (-11.0 kcal/mol), which is comparably higher than the ligand. Furthermore, ADMET prediction indicated that all the tested compounds have good oral absorption and bioavailability and can transport via biological membranes. Finally, M^pro-pholcodine complex was subjected to five MD (RMSD, RMSF, SASA, Rg, and hydrogen bonding) and two MM-PBSA, and conformational change studies, for 100 ns, confirmed the stability of pholcodine, as a representative example, inside the active site of M^pro.

Pre-emptive analgesia efficacy of piroxicam versus tramadol in oral surgery

Background

This double-blind randomized controlled trial (RCT) was conducted to evaluate the pre-emptive analgesia and anti-inflammatory efficacy of piroxicam compared with tramadol in patients undergoing oral surgery.

Methods

Seventy-eight patients who required extraction of impacted mandibular third molars were randomized into three treatment groups of 26 patients each: group I received 100 mg of tramadol, group II received 20 mg of piroxicam, and group III received a placebo. Drugs were administered intramuscularly 30 min prior to the extraction procedure.

Results

Pain intensity, time to first analgesic administration, total analgesic consumption, facial edema, and trismus were the outcomes of interest. The group receiving 20 mg of piroxicam showed significantly lower pain intensity, increased time to first analgesic, and reduced edema from preoperative to postoperative day seven than those in the tramadol and placebo groups.

Conclusion

The findings of this study showed that piroxicam had significant pain relief efficacy after third molar surgery compared with that in tramadol.

Tramadol misuse in treatment-seeking adolescents and young adults with problematic substance use - Prediction of treatment retention

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Misuse of tramadol is increasingly highlighted as a problem in adolescents and adults.

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In treatment for substance use in the young, tramadol use increased the risk of treatment drop-out.

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Tramadol misuse, hitherto little examined, requires further clinical research.

Non-medical prescription use of opioids (NMPUO) is a public health concern worldwide. Recently, tramadol misuse is increasing, but the systematic research of misuse of this specific opioid is limited. This study set out to assess the relationship between tramadol use and completion of treatment for substance use among adolescents and adults ≤ 25 years in an outpatient clinical setting. A retrospective cohort study of treatment outcome, expressed as “completion” or “non-completion” of treatment, was conducted in treatment-seeking adolescents with problematic substance use (n = 335). Data was extracted from Ung-DOK interviews, a semi-structured assessment instrument designed for adolescents with substance abuse. The study included all treatment-seeking patients at an out-patient facility in 2014–2017. A total of 26% (n = 88) were tramadol users (life-time prevalence). Twenty percent (n = 66) of all treatments were non-completed. Tramadol users were significantly more likely than non-users to drop out of treatment (35% vs 15%, p < 0.001). In multivariate logistic regression, tramadol use and age 18 and above were factors significantly associated with non-completion. Tramadol use was statistically significantly associated with non-completion of treatment. Further research addressing treatment needs and treatment completion among tramadol users is needed.

Glutamatergic systems in neuropathic pain and emerging non-opioid therapies

Neuropathic pain, a disease of the somatosensory nervous system, afflicts many individuals and adequate management with current pharmacotherapies remains elusive. The glutamatergic system of neurons, receptors and transporters are intimately involved in pain but, to date, there have been few drugs developed that therapeutically modulate this system. Glutamate transporters, or excitatory amino acid transporters (EAATs), remove excess glutamate around pain transmitting neurons to decrease nociception suggesting that the modulation of glutamate transporters may represent a novel approach to the treatment of pain. This review highlights and summarizes (1) the physiology of the glutamatergic system in neuropathic pain, (2) the preclinical evidence for dysregulation of glutamate transport in animal pain models, and (3) emerging novel therapies that modulate glutamate transporters. Successful drug discovery requires continuous focus on basic and translational methods to fully elucidate the etiologies of this disease to enable the development of targeted therapies. Increasing the efficacy of astrocytic EAATs may serve as a new way to successfully treat those suffering from this devastating disease.

Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update

INTRODUCTION

Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States.

AREAS COVERED

In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal.

EXPERT OPINION

To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.

Comparative Histological Study on the Effect of Tramadol Abuse on the Testis of Juvenile and Adult Male Albino Mice

As a synthetic analog of codeine, tramadol is often prescribed to treat mild to moderate pains. This study was designed to estimate and compare the histological effect of tramadol on testes of both juvenile and adult male albino mice. A total number of 40 healthy male albino mice were classified into two main groups as follows: group I (juvenile group, includes 20 mice aged three weeks) subdivided equally into group Ia (control group received isotonic saline) and group Ib (tramadol-treated group received 40 mg/kg/d tramadol orally for 30 days); group II (adult group, includes 20 mice aged two months) subdivided equally into group IIa (control group received isotonic saline) and group IIb (tramadol-treated group). Juvenile and adult tramadol-treated groups showed numerous testicular changes, including blood vessels congestion, widening of intercellular spaces, vacuolization in interstitial tissues, luminal germ cells exfoliation, and increased expression of caspase-3 that indicated cellular apoptosis. In the ultrastructural examination, spermatogenic cells degenerated with the frequent appearance of apoptotic cells. Sertoli cells showed vacuolations, large lipid droplets, and disrupted intercellular cell junctions. These observed testicular changes were markedly observed in the juvenile group. Testicular abnormalities and apoptotic changes can be caused by tramadol administration. These abnormalities are more common in juvenile mice.

Role of daytime variation in pharmaceutical effects of sufentanil, dezocine, and tramadol: A matched observational study

The role of daytime variation in the comprehensive pharmaceutical effects of commonly used opioid analgesics in clinical setting remains unclear. This study aimed to explore the differences in daytime variation among elective surgery patients who were scheduled to receive preemptive analgesia with equivalent doses of sufentanil, dezocine, and tramadol in the morning and afternoon. The analgesic effect was assessed by changes in the pressure pain threshold before and after intravenous administration of sufentanil, dezocine, and tramadol. Respiratory effects were evaluated using pulse oximetry, electrical impedance tomography, and arterial blood gas analysis. Other side effects, including nausea, sedation, and dizziness, were also recorded, and blood concentration was measured. The results showed that the analgesic effects of sufentanil, dezocine, and tramadol were significantly better in the morning than in afternoon. In the afternoon, sufentanil had a stronger sedative effect, whereas dezocine had a stronger inhibitory respiratory effect. The incidence of nausea was higher in the morning with tramadol. Additionally, significant differences in different side effects were observed among three opioids. Our results suggest that the clinical use of these three opioids necessitates the formulation of individualized treatment plans, accounting for different administration times, to achieve maximum analgesic effect with minimal side effects.

Addiction and human male fertility: A systematic review and a critical appraisal

BACKGROUND

Addiction is a global problem that has many negative consequences on human health as well as the quality of life.

OBJECTIVES

This review aimed to assess the effect of addiction on human male fertility.

METHODS

A systematic review was conducted on various electronic sites.

RESULTS

The initial literature search identified a total of 5239 articles in all searched databases. After removing duplicates and application of inclusion/exclusion criteria, 177 were potential articles, 112 were omitted because no direct relevance was encountered. Finally, 65 studies were retained for review. They were classified according to the type of addiction into; opioids and cannabinoids (18 articles), alcohol (7 articles), cocaine (2 articles), Androgenic Anabolic steroids (AAS, 15 articles), tobacco (10 articles) and caffeine (13 articles). Most of these recruited articles demonstrated a negative impact of the addressed substance on male fertility with variable levels of evidence.

CONCLUSIONS

It was concluded that addiction harms human male fertility that should be put into consideration. More future studies are needed after a proper methodological and statistical approach, including logistic regression analysis, to predict the effect of a specific substance on human male fertility.

Opioid sales and opioid-related poisonings in Switzerland: A descriptive population-based time-series analysis

Background

To examine time trends and characteristics of calls related to opioid poisonings reported to the National Poison Centre and opioid sales in Switzerland.

Methods

We used population-level data from the Swiss National Poisons Information Centre on reported opioid-related poisonings and data provided by the Swiss Pharmacists’ Association (pharmaSuisse) based on IQVIA data to identify sold opioid packages. The rate of opioid-related poisoning calls and dispensed opioid packages per 100,000 Swiss inhabitants between 2000 and 2019 were plotted by year and annual trends were assessed. All analyses were stratified by individual opioid and potency (strong vs weak).

Findings

There was a significant 177% increase in the rate of calls for opioid-related poisonings (1·4 to 3·9 per 100,000 inhabitants, p<0·001) and a 91·3% increase in opioid sales (from 14,364·0 to 27,477·6 per 100,000 inhabitants, p<0.001). The increase associated with strong opioids was higher when compared to weak opioids, in both poison centre calls and sales. In 2019, tramadol was the most frequently reported opioid in the poison centre data (35·7%, n=133) and sales (37·5%, n=8,863,377), followed by oxycodone calls (24·4%, n=91) and sales 23·4%, n= 552,751). Poisoning calls and sales related to oxycodone increased substantially between 2009 and 2016, as did the rate of poison centre calls requiring medical care.

Interpretation

Calls to the Swiss National poison centre and sales for opioid have increased substantially in Switzerland in the last two-decades. Increases were primarily driven by oxycodone and tramadol; however, sales have attenuated since 2016. Our findings mirror other European countries and stress the importance of surveillance and monitoring.

Funding

The research did not receive external funding. Translation of the abstract in German, French and Italian are available in the Supplementary section.

Antioxidants (selenium and garlic) alleviated the adverse effects of tramadol on the reproductive system and oxidative stress markers in male rabbits

Tramadol has been used by millions of patients as an analgesic drug to relief the severe pain caused by cancers and other diseases. The current study aimed to investigate the protective effects of antioxidants (garlic and selenium) against the toxic effects of tramadol on semen characteristics, steroid hormones, the protein expressions of different cytochrome P450 isozymes [CYP 21A2, CYP 19, and 11A1], and on antioxidant enzyme activities in testes of rabbits. Western immunoblotting, spectrophotometric, and histological methods were used in this study. Tramadol (1.5 mg/kg body weight) was administered orally to male rabbits for up to three months (three times/week), and after pretreatment of rabbits with garlic (800 mg/kg) and/or selenium (1 mg/kg body weight) by 2 h. The present study showed that motilities, semen volumes, morphologies, sperm counts, testosterone, and estrogen levels were significantly decreased after 4, 8, and 12 weeks of tramadol treatment. In addition, the protein expressions of CYP 21A2, CYP 19, and 11A1 were down-regulated in the testes of the tramadol-treated rabbits. On the other hand, pretreatment of rabbits with garlic, selenium, and/or garlic-selenium for 2 h before administration of tramadol restored the downregulated CYP 21A2 and 11A1 to their normal levels after 12 weeks of tramadol treatment. Activities of antioxidant enzymes including glutathione reductase, glutathione peroxidase, glutathione S-transferase, catalase, superoxide dismutase, and levels of glutathione were inhibited in the testes of tramadol-treated rabbits. On the other hand, free radical levels were significantly increased in the testes of tramadol-treated rabbits for 12 weeks. Interestingly, such changes in the activities of antioxidant enzymes as well as free radical levels caused by tramadol were restored to their normal levels in the rabbits pretreated with either selenium, garlic, and/or their combination. Histopathological investigations showed that tramadol caused substantial vacuolization with the presence of damaged immature spermatozoid in the testes. However, selenium and garlic treatments showed an increase in healthy sperm production with normal mitotic and meiotic divisions. The present study illustrated for the first time the mechanisms of low steroid hormone levels in the testes of tramadol-treated rabbits which could be due to the downregulation of CYPs proteins, induction of oxidative stress, and inhibition of antioxidant enzyme activities. In addition, the present data showed that such toxic effects of tramadol were attenuated and restored to their normal levels after pretreatment of rabbits with garlic, selenium, and/or their combination. This finding may pave the way for a new approach to reducing the toxicity of tramadol.

Misappropriation of the 1986 WHO analgesic ladder: the pitfalls of labelling opioids as weak or strong

Opioids have a vital role in alleviating pain from cancer and surgery. Despite good intentions, it is now recognised that the original WHO Cancer Pain Relief guidance from 1986, in which opioids were classified as either weak or strong, has been both inadvertently and purposefully misused, thereby contributing to harm from opioid use and misuse. However, the recommendation in the 2018 update of the WHO analgesic ladder that a combination of a high-potency opioid with simple analgesics is better than alternative analgesics for the maintenance of pain relief is also applicable to patients who require short-term opioids. Furthermore, because potential harm through opioid use and misuse is intrinsic to all opioids, whether weak or strong, we argue that the arbitrary classification of opioids either as weak or strong should be discontinued, as this description is not helpful to either prescribers or consumers.

Tramadol in seized drugs containing non-pharmaceutical fentanyl: Crime lab data from Ohio, USA

Introduction

Non-pharmaceutical fentanyl and related drugs (NPF) have contributed to increases in drug-related overdose mortality in the U.S. More data are needed to track the shifting composition of fentanyl-containing drug mixtures. The key aims of the study are to characterize the crime lab data from Montgomery County, Ohio on the increased cases of seized drugs containing mixtures of NPF and tramadol.

Methods

Crime lab data on seized drugs in Montgomery County, Ohio (2015 - 2020) were analyzed to extract information on cases that tested positive for NPF and tramadol. Descriptive statistics are provided to characterize NPF/tramadol mixtures in terms of the quantity, weight, form of the drug seized (powder, tablet, capsule, residue), and the types of fentanyl analogs and other drugs identified.

Results

In December 2017, the first case of NPF/tramadol mixture was identified in the amount of 0.2 g. Sub-sequently, cases containing NPF/tramadol increased significantly to 149 cases in 2018, 102 in 2019, and 134 in 2020. The total yearly amounts of seized NPF/tramadol mixtures increased to 373.27 g in 2018, 2,601.82 g in 2019, and 13,487.62 g in 2020. The majority (72.6%) of the cases were in powder form. There were 15 other drugs identified along with fentanyl with tramadol mixtures, including heroin (38.8%), 5.7% cocaine (5.7%), and methamphetamine (4.9%).

Conclusions

The addition of tramadol to NPF may be viewed as a harm mitigation strategy but contributes to the overall unpredictability of the illicit drug supply. According to Ohio legal statutes, identification of schedule IV drugs such as tramadol with fentanyl (schedule II) may provide a reduction in drug-related charges from a felony to a misdemeanor. More research is needed to characterize potential sources of tramadol in NPF-containing drugs.

Molecular Network-Based Identification of Tramadol Metabolites in a Fatal Tramadol Poisoning

Identification of xenobiotics and their phase I/II metabolites in poisoned patients remains challenging. Systematic approaches using bioinformatic tools are needed to detect all compounds as exhaustively as possible. Here, we aimed to assess an analytical workflow using liquid chromatography coupled to high-resolution mass spectrometry with data processing based on a molecular network to identify tramadol metabolites in urine and plasma in poisoned patients. The generated molecular network from liquid chromatography coupled to high-resolution tandem mass spectrometry data acquired in both positive and negative ion modes allowed for the identification of 25 tramadol metabolites in urine and plasma, including four methylated metabolites that have not been previously reported in humans or in vitro models. While positive ion mode is reliable for generating a network of tramadol metabolites displaying a dimethylamino radical in their structure, negative ion mode was useful to cluster phase II metabolites. In conclusion, the combined use of molecular networks in positive and negative ion modes is a suitable and robust tool to identify a broad range of metabolites in poisoned patients, as shown in a fatal tramadol-poisoned patient.

Tramadol Versus Codeine in Hand Surgery

Introduction

Tramadol and codeine are both commonly prescribed in the setting of surgery or injury to the upper extremity. Despite their comparable strength in terms of opioid receptor affinity, the drugs differ pharmacologically and thus are not completely interchangeable.

Methods

This study analyzes all prescriptions for codeine and tramadol by a group of hand surgeons over a one-year period and tests the central hypothesis that the prescribing and refill patterns of these two drugs would be similar.

Results

Despite similar prescription amounts in terms of morphine equivalents, patients receiving tramadol required prescription refills at a significantly higher amount than those receiving codeine, and these individuals tended to be older. Additionally, patients treated nonoperatively were prescribed significantly more tramadol than those treated surgically.

Conclusion

Our findings suggest that codeine and tramadol are not equivalent in managing upper extremity pain. Further study is needed to articulate the situations in which physicians and patients are better served by tramadol versus codeine.

Tramadol and Codeine Stacking/Boosting Dose Exposure Induced Neurotoxic Behaviors, Oxidative Stress, Mitochondrial Dysfunction, and Neurotoxic Genes in Adolescent Mice

In spite of the increasing epidemic of pharmaceutical opioids (codeine and tramadol) misuse and abuse among the adolescents, little is known about the neurotoxic consequences of the widespread practice of tramadol and codeine abuse involving increasing multiple doses across days, referred to as stacking and boosting. Hence, in this study, we replicated stacking and boosting doses of tramadol, codeine alone, or in combination on spontaneous motor activity and cognitive function in adolescent mice and adduced a plausible mechanism of possible neurotoxicity. Ninety-six adolescent mice were randomly distributed into 4 groups (n = 24 per group) and treated thrice daily for 9 days with vehicle, tramadol (20, 40, or 80 mg/kg), codeine (40, 80, or 160 mg/kg), or their combinations. Exposure of mice to tramadol induced hyperactivity and stereotypic behavior while codeine exposure caused hypoactivity and nootropic effect but tramadol-codeine cocktail led to marked reduction in spontaneous motor activity and cognitive function. In addition, tramadol, codeine, and their cocktail caused marked induction of nitroso-oxidative stress and inhibition of mitochondrial complex I activity in the prefrontal cortex (PFC) and midbrain (MB). Real-time PCR expression profiling of genes encoding neurotoxicity (RT) showed that tramadol exposure upregulate 57 and downregulate 16 neurotoxic genes, codeine upregulate 45 and downregulate 25 neurotoxic genes while tramadol-codeine cocktail upregulate 52 and downregulate 20 neurotoxic genes in the PFC. Findings from this study demonstrate that the exposure of adolescents mice to multiple and increasing doses of tramadol, codeine, or their cocktail lead to spontaneous motor coordination deficits indicative of neurotoxicity through induction of oxidative stress, inhibition of mitochondrial complex I activity and upregulation of neurotoxicity encoding genes in mice.

Effect of tramadol on apoptosis and synaptogenesis in hippocampal neurons: The possible role of µ-opioid receptor

Tramadol is a synthetic opioid with centrally acting analgesic activity that alleviates moderate to severe pain and treats withdrawal symptoms of the other opioids. Like other opioid drugs, tramadol abuse has adverse effects on central nervous system components. Chronic administration of tramadol induces maladaptive plasticity in brain structures responsible for cognitive function, such as the hippocampus. However, the mechanisms by which tramadol induces these alternations are not entirely understood. Here, we examine the effect of tramadol on apoptosis and synaptogenesis of hippocampal neuronal in vitro. First, the primary culture of hippocampal neurons from neonatal rats was established, and the purity of the neuronal cells was verified by immunofluorescent staining. To evaluate the effect of tramadol on neuronal cell viability MTT assay was carried out. The western blot analysis technique was performed for the assessment of apoptosis and synaptogenesis markers. Results show that chronic exposure to tramadol reduces cell viability of neuronal cells and naloxone reverses this effect. Also, the level of caspase-3 significantly increased in tramadol-exposed hippocampal neurons. Moreover, tramadol downregulates protein levels of synaptophysin and stathmin as synaptogenesis markers. Interestingly, the effects of tramadol were abrogated by naloxone treatment. These findings suggest that tramadol can induce neurotoxicity in hippocampal neuronal cells, and this effect was partly mediated through opioid receptors.

The Effect of Preoperative Tramadol Use on Postoperative Opioid Prescriptions After Primary Total Hip and Knee Arthroplasty: An Institutional Experience of 11,000 Patients

BACKGROUND

Preoperative opioid use increases opioid consumption postoperatively, but the effect of tramadol is poorly understood.

METHODS

We retrospectively reviewed 11,667 patients undergoing primary unilateral THA and TKA at a single institution. Preoperatively, there were 8,201 opioid-naïve patients (70.3%), 1,315 on tramadol (11.3%), 1,408 on narcotics (12.1%) and 743 on narcotics and tramadol (6.3%). We compared morphine milligram equivalents (MMEs) used during hospitalization, prescribed at discharge, and refilled during the first 90 days. We used multivariate analysis to assess whether preoperative tramadol use was associated with increased number of refills and total refilled MMEs.

RESULTS

Total in-hospital MMEs and daily MMEs was lowest for the opioid naïve patients and significantly increased for the remaining three groups (total in-hospital use: 119, 152, 211, and 196 MMEs, respectively-P < .001) (daily in-hospital use: 66, 74, 100, and 86 MMEs, respectively-P < .001). Opioid refill rate was significantly higher for all patients who were not opioid naïve (32%, 42%, 41%, and 52%, respectively-P < .001). Total MMEs prescribed after discharge was lowest for opioid naïve patients (477, 528, 590 and 658, respectively-P < .001). Logistic and linear regression controlling for age, sex, history of anxiety/depression revealed that THA patients taking tramadol preoperatively were 2.5 times more likely to require post-discharge refills and refilled 80 additional MMEs than opioid naïve patients (P < .001).

CONCLUSION

Tramadol is not recommended for pain beforeTKA or THA, and surgeons and patients should be aware that it is associated with a substantial increase in postoperative opioid use.

An analog of [d-Trp]CJ-15,208 exhibits kappa opioid receptor antagonism following oral administration and prevents stress-induced reinstatement of extinguished morphine conditioned place preference

Opioid use disorder (OUD) relapse rates are discouragingly high, underscoring the need for new treatment options. The macrocyclic tetrapeptide natural product CJ-15,208 and its stereoisomer [d-Trp]CJ-15,208 demonstrate kappa opioid receptor (KOR) antagonist activity upon oral administration which prevents stress-induced reinstatement of cocaine-seeking behavior. In order to further explore the structure-activity relationships and expand the potential therapeutic applications of KOR antagonism for the treatment of OUD, we screened a series of 24 analogs of [d-Trp]CJ-15,208 with the goal of enhancing KOR antagonist activity. From this screening, analog 22 arose as a compound of interest, demonstrating dose-dependent KOR antagonism after central and oral administration lasting at least 2.5 h. In further oral testing, analog 22 lacked respiratory, locomotor, or reinforcing effects, consistent with the absence of opioid agonism. Pretreatment with analog 22 (30 mg/kg, p.o.) prevented stress-induced reinstatement of extinguished morphine conditioned place preference and reduced some signs of naloxone-precipitated withdrawal in mice physically dependent on morphine. Collectively, these data support the therapeutic potential of KOR antagonists to support abstinence in OUD and ameliorate opioid withdrawal.

Tramadol Use in United States Emergency Departments 2007-2018

BACKGROUND

Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids.

OBJECTIVE

Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates.

RESULTS

Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018.

CONCLUSIONS

Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.

Military Health System Opioid, Tramadol, and Gabapentinoid Prescription Volumes Before and After a Defense Health Agency Policy Release

BACKGROUND

Clinical practice guidelines (CPGs) and health system policies to mitigate inappropriate opioid prescribing practices may have an extended impact on low-dose opioid (e.g., tramadol) and non-opioid (e.g., gabapentinoid) pain medication prescribing practices.

OBJECTIVE

To evaluate changes in opioid, tramadol, and gabapentinoid prescribing rates from January 2016 to February 2020 within the Military Health System, including the degree to which prescribing rates changed after release of a US Defense Health Agency Procedural Instruction.

METHODS

In this observational health services research study, opioid, tramadol, and gabapentin prescription dispense events of US Military Health System beneficiaries enrolled in care at military treatment facilities prior to US Defense Health Agency Procedural Instruction release (January 2016-May 2018) were used to forecast values from the post-intervention period (June 2018-February 2020).

RESULTS

The median opioid and tramadol prescribing rates decreased from January 2016 to February 2020, aside from tramadol prescribing in Surgery Clinics, which increased. Gabapentinoid prescribing rate changes were mixed. In Bayesian time series models, the forecasted proportion of patients receiving each of the three medications, regardless of age group or clinic type, did not significantly vary from the actual prescribing rates in the post-intervention period.

CONCLUSION

Overall, CPGs and policies targeting opioid prescribing practices may have provided the maximal impetus for providers to re-evaluate their prescribing practices, as the policy did not appear to change the slope in prescribing rates. However, it is unclear whether the policies mitigated the likelihood of plateaus in prescribing rates. Further work is needed to assess the degree to which providers simultaneously altered other non-opioid pain medication prescribing practices, self-management recommendations, and non-pharmacological therapy referrals.

CYP2D6 phenotypes and opioid metabolism: the path to personalized analgesia

INTRODUCTION

Opioids play a fundamental role in chronic pain, especially considering when 1 of 5 Europeans adults, even more in older females, suffer from it. However, half of them do not reach an adequate pain relief. Could pharmacogenomics help to choose the most appropriate analgesic drug?

AREAS COVERED

The objective of the present narrative review was to assess the influence of cytochrome P450 2D6 (CYP2D6) phenotypes on pain relief, analgesic tolerability, and potential opioid misuse. Until December 2021, a literature search was conducted through the MEDLINE, PubMed database, including papers from the last 10 years. CYP2D6 plays a major role in metabolism that directly impacts on opioid (tramadol, codeine, or oxycodone) concentration with differences between sexes, with a female trend toward poorer pain control. In fact, CYP2D6 gene variants are the most actionable to be translated into clinical practice according to regulatory drug agencies and international guidelines.

EXPERT OPINION

CYP2D6 genotype can influence opioids' pharmacokinetics, effectiveness, side effects, and average opioid dose. This knowledge needs to be incorporated in pain management. Environmental factors, psychological together with genetic factors, under a sex perspective, must be considered when you are selecting the most personalized pain therapy for your patients.

Evaluation of Low-Dose Versus High-Dose Opioid Pathway in Opioid-Naïve Patients After Total Knee Arthroplasty

Background

Pain control after total knee arthroplasty (TKA) remains challenging. Tramadol is a weak opioid with potentially lower side effects and risk for dependency than stronger opioids. The purpose of this study was to evaluate efficacy and safety of tramadol after TKA in opioid-naïve patients compared with stronger opioids.

Methods

A retrospective review of patients who underwent primary TKA was performed. In September 2018, opioid-naïve patients were prescribed tramadol instead of oxycodone. Patients receiving tramadol (low-opioid group) were matched to patients discharged with oxycodone before this transition (high-opioid group). We compared morphine milligram equivalent (MME) consumption and outcomes up to 3 months postoperatively.

Results

Two-hundred and five patients underwent TKA, with 126 receiving tramadol. Fourteen patients were converted to stronger opioid (11.2% conversion rate). Seventy patients from the low-opioid group were matched to 70 patients in the high-opioid group. Average daily inpatient MME consumption was higher in the high-opioid group (40.0 ± 27.4 vs 16.3 ± 10.9, P = .000). Outpatient prescribed MME was significantly higher in the high-opioid group (135.5 ± 71.5 vs 75.3 ± 51.3, P = .000) along with a higher number of refills (0.53 ± 1.1 vs 0.886 ± 0.94, P = .041). Knee range of motion was not statistically different at any timepoint postoperatively. There was higher adverse event rate in the low-opioid group (8.6% vs 5.7%) but not statically significant.

Conclusions

Low opioid regimen following TKA showed lower MME consumption than high opioid regimen with no effect on outcomes up to 3 months. Use of low opioid regimen should be considered for TKA surgery.

Increase of high-risk tramadol use and harmful consequences in France from 2013-2018: evidence from the triangulation of addictovigilance data

Aims

The aim of this paper is to assess recent developments in non‐medical tramadol use, tramadol use disorder, illegal procurement and deaths.

Methods

This study used repeated cross‐sectional analysis of data collected nationwide from 2013 to 2018. Analysis was conducted through multisource monitoring of the French Addictovigilance Network of: (1) validated reports of high‐risk tramadol use, (2) record systems collecting information from toxicology experts investigating analgesic‐related deaths (DTA) and deaths related to substance abuse (DRAMES), and pharmacists for forged prescriptions (OSIAP), and (3) survey of drug users, with investigation of patterns of use while visiting addiction‐specialised institutions (OPPIDUM).

Results

Despite a plateauing level of tramadol exposure in the French population, the proportion of tramadol reports increased 1.7‐fold (187 cases in 2018, 3.2% (95% confidence interval [CI]: 2.74–3.63%), versus 1.9% (95% CI: 1.49–2.42% in 2013). Trends were similar in OSIAP: 11.9% of forged prescriptions in 2018 (95% CI: 10.56–13.45%); 1.7‐fold increase; in OPPIDUM: 0.76% (95% CI: 0.55–1.02); 2.2‐fold increase; and DRAMES: 3.2% of drug abuse‐related deaths in 2018 (95% CI: 1.89–5.16) versus 1.7% in 2013 (95% CI: 0.65–3.84). Tramadol was the primary opioid in analgesic‐related deaths in DTA (45% in 2018). Two profiles of high‐risk tramadol users were identified: (1) patients treated for pain or with tramadol persistence when pain disappeared (mainly women; mean age 44 years), and (2) individuals with non‐medical use for psychoactive effects (mainly men; mean age 36 years).

Conclusion

The triangulation of the data obtained through addictovigilance monitoring evidenced a recent increase in high‐risk tramadol use. These findings have a practical impact on the limitation of the maximal duration of tramadol prescriptions.

Effects of selective orexin receptor-2 and cannabinoid receptor-1 antagonists on the response of medial prefrontal cortex neurons to tramadol

Tramadol is widely used to control pain in various diseases, but the relevant mechanisms are less known despite the severe risks of abuse. The medial prefrontal cortex (mPFC) is one of the critical centers of the reward system. Studies have shown that orexins and endocannabinoids are likely to play an important role in addiction. In this study, the effect of orexin receptor-2 (OX2R) and endocannabinoid receptor-1 (CB1R) blockade on the neuronal activity of mPFC was investigated in response to tramadol in male rats. Tramadol was injected intraperitoneally, and its effects on the firing of mPFC pyramidal neurons were investigated using in vivo extracellular single-unit recording. Tramadol affected the pyramidal neuronal activity of the mPFC. AM251 (18 nmol/4 μl), as a selective CB1R antagonist, and TCS-OX2-29 (50 nmol/4 μl), as a selective OX2R antagonist, individually or simultaneously were microinjected into the lateral ventricle of the brain (intracerebroventricular, ICV). The results showed that the ratio of neurons with the excitatory/inhibitory or no responses was significantly changed by tramadol (p < .05). These changes were prevented by blockade of CB1Rs alone or blockade of OX2Rs and CB1Rs simultaneously (p < .05). However, blockade of these receptors in the vehicle group had no significant effect on neuronal activity. The findings of this study indicate the potential role of orexin and endocannabinoid systems in mediating the effects of tramadol in mPFC and the possible interaction between the two systems via OX2 and CB1 receptors. However, further studies are needed to identify these effects by examining intracellular signaling.

The Effect of Ondansetron on the Analgesic Efficacy of Tramadol in Patients Undergoing Laparoscopic Cholecystectomy

Purpose

Investigating the effect of ondansetron on the efficacy of tramadol in patients undergoing laparoscopic cholecystectomy.

Methods

Sixty American Society of Anesthesiologists (ASA) I-II patients over the age of 18 who underwent laparoscopic cholecystectomy were included in this study. All patients were given 1 mg/kg tramadol intravenously (iv) during the intraoperative period. Patients were randomly assigned to receive either 4 mg ondansetron (Group O) or 2 mL saline (Group S). Postoperative tramadol consumption, pain score (NRS), intensity of nausea (NRS), presence of vomiting, consumption of rescue analgesics and antiemetics, and patient satisfaction were recorded.

Results

A total of 60 patients were enrolled in the study; five patients were excluded due to deviation from the protocol. Data from 55 patients (Group O: 28 patients, Group S: 27 patients) were evaluated in the study. No differences between the two groups were detected for postoperative consumption of tramadol, pain score (NRS), intensity of nausea (NRS), presence of vomiting, consumption of rescue analgesics and antiemetics, and patient satisfaction.

Conclusions

The results showed that coadministration of tramadol and ondansetron did not change tramadol consumption during the postoperative 24 hours after laparoscopic cholecystectomy. Clinical trial registration number is as follows: https://clinicaltrials.gov/ct2/show/NCT04745273-01/31/2021.

Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) can reduce the length of hospital stay, incidence of surgery-related complications, and postoperative pain. We aimed to demonstrate the implementation of an ERAS pathway in the treatment of uterine fibroids with focused ultrasound ablation surgery (FUAS).

MATERIALS AND METHODS

A retrospective data analysis was performed on clinical outcomes encompassing the following three phases: before ERAS (pre-ERAS), during adjustment of ERAS (interim-ERAS), and after the introduction of an ERAS program (post-ERAS). The purpose of describing the interim-ERAS was to provide references for the formulation of the program during the course of FUAS by describing the adjustment processes. Data from patients admitted to the hospital from September 2019 to December 2019 and April 2020 to November 2020 and who met the criteria for FUAS in the treatment of their uterine fibroids were examined. Length of stay, cost of surgery, postoperative pain score, utilization of postoperative analgesics, and incidence of postoperative adverse events were compared across the abovementioned three phases.

RESULTS

Compared with the pre-phase, the cost of treatment and length of stay were reduced after the implementation of ERAS. The use of analgesics before leaving the operating room, as well as the incidence of postoperative nausea and vomiting, were also reduced.

CONCLUSION

The implementation of an ERAS protocol might benefit patients with uterine fibroids treated with FUAS in terms of requiring a shorter hospitalization period, lower costs, and reduced opioid use.

Effects of imidazoline agents in a rat conditioned place preference model of addiction

Agmatine (AG), idazoxan (IDZ), and efaroxan (EFR) are imidazoline receptor ligands with beneficial effects in central nervous system disorders. The present study aimed to evaluate the interaction between AG, IDZ, and EFR with an opiate, tramadol (TR), in a conditioned place preference (CPP) paradigm. In the experiment, we used five groups with 8 adult male Wistar rats each. During the condition session, on days 2, 4, 6, and 8, the rats received the drugs (saline, or TR, or IDZ and TR, or EFR and TR, or AG and TR) and were placed in their least preferred compartment. On days 1, 3, 5, and 7, the rats received saline in the preferred compartment. In the preconditioning, the preferred compartment was determined. In the postconditioning, the preference for one of the compartments was reevaluated. TR increased the time spent in the non-preferred compartment. AG decreased time spent in the TR-paired compartment. EFR, more than IDZ, reduced the time spent in the TR-paired compartment, but without statistical significance. AG reversed the TR-induced CPP, while EFR and IDZ only decreased the time spent in the TR-paired compartment, without statistical significance.

Tramadol Use in Perioperative Care and Current Controversies

PURPOSE OF REVIEW

The aim of this review is to discuss the use of tramadol in the perioperative period. There is no doubt that tramadol has revolutionized pain treatment, making it important to understand the pharmacokinetics and pharmacodynamics in order to provide patients with the safest and most effective analgesia.

RECENT FINDINGS

Tramadol is a centrally acting synthetic analgesic with a multimode of action used to help treat moderate to severe pain. Pharmacologically, the unique opioid acts as a serotonin-norepinephrine reuptake inhibitor, while its metabolite, O-desmethyltramadol, acts on the μ-opioid receptor. The analgesic strength of tramadol is about one-tenth that of morphine, making it a relatively safe analgesic. Potential side effects of tramadol include nausea, vomiting, constipation, pruritus, and respiratory depression; however, the severity of these symptoms is minimal compared to traditional opioids. Although some of the perioperative uses of tramadol may be rare, it is a pain management option to consider when alternatives have proved ineffective.

Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

OBJECTIVE

To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery.

STUDY DESIGN

Retrospective cohort study.

SETTING

County hospital otolaryngology practice.

METHODS

A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use.

RESULTS

We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids.

CONCLUSION

Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

Comparison of Online Patient Reviews and National Pharmacovigilance Data for Tramadol-Related Adverse Events: Comparative Observational Study

BACKGROUND

Tramadol is known to cause fewer adverse events (AEs) than other opioids. However, recent research has raised concerns about various safety issues.

OBJECTIVE

We aimed to explore these new AEs related to tramadol using social media and conventional pharmacovigilance data.

METHODS

This study used 2 data sets, 1 from patients' drug reviews on WebMD (January 2007 to January 2021) and 1 from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS; January 2016 to December 2020). We analyzed 2062 and 29,350 patient reports from WebMD and FAERS, respectively. Patient posts on WebMD were manually assigned the preferred terms of the Medical Dictionary for Regulatory Activities. To analyze AEs from FAERS, a disproportionality analysis was performed with 3 measures: proportional reporting ratio, reporting odds ratio, and information component.

RESULTS

From the 869 AEs reported, we identified 125 new signals related to tramadol use not listed on the drug label that satisfied all 3 signal detection criteria. In addition, 20 serious AEs were selected from new signals. Among new serious AEs, vascular disorders had the largest signal detection criteria value. Based on the disproportionality analysis and patients' symptom descriptions, tramadol-induced pain might also be an unexpected AE.

CONCLUSIONS

This study detected several novel signals related to tramadol use, suggesting newly identified possible AEs. Additionally, this study indicates that unexpected AEs can be detected using social media analysis alongside traditional pharmacovigilance data.

The effect of orexin-2 and endocannabinoid-1 antagonists on neuronal activity of hippocampal CA1 pyramidal neurons in response to tramadol in rats

Background:

CA1, as a major structure involved in learning and memory, has been shown to be affected by tramadol addiction. Both orexin and endocannabinoid receptors express in CA1 and play an important role in drug dependency. The aim of this study was to evaluate the modulatory effects of orexin-2 (OX2R) and endocannabinoid-1 (CB1R) receptors on neuronal activity in CA1, in response to tramadol in rats.

Materials and Methods:

Male Wistar rats were divided into 8 groups (n = 6–7); saline-dimethyl sulfoxide (DMSO), tramadol-DMSO, saline-TCS-OX2-29, saline-AM251, tramadol-TCS-OX2-29, tramadol-AM251, saline-TCS-OX2-29-AM251, tramadol-TCS-OX2-29-AM251. Tramadol was injected intraperitoneally, and then, AM251 (1 nmol/0.3 μL), CB1R antagonist and TCS-OX2-29 (1 nmol/0.3 μL), OX2R antagonist, were microinjected individually or concurrently into the CA1. Using in vivo extracellular single-unit recording, the firing of CA1 pyramidal neurons was investigated.

Results:

Tramadol decreased neuronal activity in CA1 (P < 0.01) but increased it after micro-injection of DMSO. TCS-OX2-29 increased neuronal activity in saline group (P < 0.05) but decreased it in tramadol group. AM251 had no effect on saline group but decreased neuronal activity in tramadol group (P < 0.05). Concurrent micro-injection of TCS-OX2-29 and AM251 had no effect on saline group but decreased neuronal activity in tramadol group (P < 0.05).

Conclusions:

Our findings suggest that neural activity in CA1 is rapidly affected by acute use of tramadol, and some of these effects may be induced through the endocannabinoid and orexin systems. Thus, the function of endocannabinoid and orexin systems in CA1 may play a role in tramadol addiction.

The acute effects of different doses of tramadol on neuronal activity of medial prefrontal cortex in rats

Background:

Tramadol is an opioid analgesic with monoamine reuptake inhibitory effects. Although tramadol has been widely used to control pain, there is controversy about the risk of abuse. Therefore, in the present study, the acute effects of tramadol on neuronal activity in the medial prefrontal cortex (mPFC), which is one of the important centers of the reward system, were investigated electrophysiologically.

Materials and Methods:

Tramadol was injected interperitoneally (12.5 and 25 mk/kg) or subcutaneously (40 mg/kg) and its effect on the firing of mPFC neurons was investigated, using in vivo extracellular single unit recording.

Results:

Tramadol could not significantly affect neural activity in mPFC, suggesting no acute and rapid effect on mPFC.

Conclusions:

The present results showed that neural activity in mPFC was not rapidly affected by acute application of tramadol. Since the role of mPFC in tramadol addiction has been elucidated, it can be concluded that these effects may be due to delayed responses or chronic use of tramadol.

Evaluation of the postoperative morphine-sparing effect of oral premedicants used as pre-emptive analgesics in breast-conserving cancer surgeries: A randomised placebo-controlled trial

Background and Aims:

Breast cancer surgeries are associated with both nociceptive and neuropathic pain, requiring strong analgesics. We aimed to evaluate the postoperative morphine-sparing effect of pre-emptive oral premedication with tramadol versus pregabalin in patients undergoing breast-conserving cancer surgeries (BCCS).

Methods:

This prospective, randomised, placebo-controlled trial was carried out at tertiary care centre on 90 patients undergoing BCCS randomised into three groups of 30 each. Group C received placebo, Group T received tramadol 100 mg and Group P received pregabalin 75 mg as oral premedication, 1 hour before surgery. General anaesthesia was administered. Postoperatively morphine 1 mg.h^-1 through intravenous PCA was started at a visual analogue scale score ≥4. Total morphine consumption in 24 hours was calculated and its sparing effect was evaluated as the primary outcome.

Results:

The median with interquartile range (IQR) of total postoperative morphine consumed in 24 hours, was found to be 22 mg (IQR 0-25.77), 15 mg (IQR 0-16) and 17.50 mg (IQR 0-19.25) in groups C, T, P respectively, (P = 0.000, 0.003, 0.060). The median duration of analgesia in group C was 5.40 hours (IQR 3.30-11.40), 11.6 hours (IQR 9.30-24.0) in group T and 8.60 hours (IQR 6.97-16.27) in group P (P value C/T = 0.000, C/P = 0.007, T/P = 0.002). The postoperative side effects were comparable.

Conclusion:

Oral tramadol 100 mg and oral pregabalin 75 mg as premedication reduced the 24 hours postoperative morphine requirement as compared to placebo in BCCS. However, tramadol 100 mg provided superior analgesia for longer duration than pregabalin 75 mg and was associated with more side effects.

Comparative Multimodal Palliative efficacy of gabapentin and tramadol By Using Two Pain Scoring Systems in Cats Undergoing Ovariohysterectomy

The analgesic efficacy of the gabapentin-tramadol combination was compared with meloxicam-tramadol and tramadol perioperative analgesic regimens in cats brought to the clinic for ovariohysterectomy. Thirty adult cats belonging to comparable demographics (age, body weight), were enrolled into a randomized, blinded study after due consent from their owners into four treatment groups. A Gabapentin-Tramadol group (GT-group, n = 10), Meloxicam-Tramadol group (MT-group, n = 10), and a Tramadol group (T-group, n = 10) were formed. Gabapentin capsules at 50 mg were administered orally 2 hours before surgery while the rest received a placebo dose. Tramadol (2 mg/kg, IM) and meloxicam at (0.2 mg/kg, SC) were injected immediately prior to anesthetic premedication. Anesthetic protocol involved premedication with ketamine and xylazine, while anesthesia was induced using propofol. Inhalant isoflurane anesthesia was used to maintain a surgical plane. GT group scored lower on IVAS as well as CPS than MT group, and T group for up to 8 hours after surgery. The mechanical nociceptive threshold remained higher (98±0) for up to 12 hours postoperatively a nd serum cortisol concentrations remained significantly lower during the 24hr period. The addition of gabapentin to the tramadol regimen significantly improved analgesia and mechanical nociceptive threshold than when used on its own.

Multimodal Analgesia in the Era of the Opioid Epidemic

This article attempts to review the key components of a multimodal analgesic regimen for the treatment of acute pain. Adhering to these key components will help reduce the opioid burden to surgical patients while reducing acute pain. As well, this regimen is intended to reduce further negative contributions to the opioid crisis.

Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan

Background One of the major barriers to adequate cancer pain management in Taiwan is the limited prescription options regarding strong opioids. Internationally recommended strong opioids, including oxycodone and hydromorphone, were not introduced in Taiwan until late 2014. We analysed the patterns in opioid prescription for cancer pain management, after the introduction of new opioid options. Methods All inpatient and outpatient clinical visits from January 1, 2012, to December 31, 2017, with the diagnosis of cancer and the analgesic prescriptions were collected from the database of National Health Insurance, Taiwan, and analysed. Opioids were grouped into strong opioids, weak opioids, and guideline non-recommended opioids. Findings A total of 1, 292, 905 patients with cancers were included. Approximately 50% of patients used analgesics, 50% of which were opioids; the proportions were stable during the study period. The annual cumulative opioid use per patient (defined daily dose, DDD) significantly decreased from 36•41±102•59 (Mean±SD) in 2012 to 32•42±100•99 in 2017 (p < •001). The annual cumulative strong opioid use per patient increased significantly from 17•54±89•23 in 2012 to 19•28±94•97 in 2017 (+9•90%, p < •001). In parallel, the annual cumulative weak opioids use per patient decreased from 18•64±40•81 in 2012 to 13•04±26•79 in 2017 (-30•04%, p < •001). Among extended-release strong opioids, the use of transdermal fentanyl significantly decreased after oxycodone and hydromorphone were introduced (p < •001). Interpretation Increased therapeutic options in strong opioid prescriptions led opioid prescription patterns to evolve towards international cancer pain management guidelines. In addition, increased accessibility to a wider range of different strong opioids may facilitate more efficient opioid titration and rotation - and thus decrease, not increase, the opioid usage. Funding This study was supported by Ministry of Science and Technology, Taiwan (MOST-106-2314-B-002-213 and MOST-108-2314-B-002-072-MY3), Ministry of Health and Welfare, Taiwan (MOHW109-TDU-B-211-114002), National Taiwan University Hospital, Taipei, Taiwan (NTUH-103-002314 and NTUH. 105-S2954), and National Center of Excellence for Clinical Trial & Research, National Taiwan University Hospital, Taipei, Taiwan (NCTRC201208 and NCTRC201603).

Are the N-demethylated metabolites of U-47700 more active than their parent compound? In vitro μ-opioid receptor activation of N-desmethyl-U-47700 and N,N-bisdesmethyl-U-47700

Studies on the tissue distribution of the new synthetic opioid U-47700 and its main metabolite N-desmethyl-U-47700 revealed about sixfold higher metabolite concentrations in pig brain as compared with the parent compound. To better assess the toxic potential of this drug, the aim of this study was to assess the in vitro μ-opioid receptor (MOR) activation potential of the main metabolites of U-47700, N-desmethyl-U-47700, and N,N-bisdesmethyl-U-47700, using a live cell-based reporter assay based on NanoLuc Binary Technology®. Cells stably expressing human MOR and β-arrestin 2 (βarr2), each fused via a flexible linker to two complementary inactive subunits of the nanoluciferase, were seeded on poly-d-lysine-coated 96-well plates and treated with N-desmethyl-U-47700, N,N-bisdesmethyl-U-47700, U-47700, or hydromorphone as reference standard. MOR activation results in functional complementation of the nanoluciferase, which can be assessed via luminescence monitoring. The potency of the metabolites is lower than that of U-47700 (EC₅₀ of 186 nM for U-47700, 3770 nM for N-desmethyl-U-47700, and >5 μM for N,N-bisdesmethyl-U-47700). The maximal efficacy (E_max ) observed (relative to hydromorphone, set arbitrarily at 100%) decreased from 183% to 127% and 39.2% for U-47700, N-desmethyl-U-47700, and N,N-bisdesmethyl-U-47700, respectively. Thus, the loss of one or two methyl groups reduced the MOR activation potential, which was more pronounced if both methyl groups were removed. It is thus anticipated that the impact on MOR exerted by the higher metabolite concentration in brain has only little-if any relevance for the strong toxic effects of U-47700.

Molecular docking analysis of modified gedunin from neem with snake venom enzymes

Snakebites are a problem due to the increasing number of deaths and permanent disabilities. There is currently a shortage of antidotes for snakebite. The existing antibody antidote, produced from horse/sheep plasma/sera is expensive, species-dependent, and causes fatal side effects. Therefore, it is of interest use of natural flavonoid named gedunin from the Azadirachta indica (Neem) plant species to combat snakebites. Thus, we show the molecular docking analysis of gedunin (C26H31N2O6F) with enzymes (common in snake species) such as 5-nucleotidase, acetyl cholinesterase, L-aao, metalloproteinase, serine, thrombin and phospholipase A2. The modified gedunin in the enzyme pocket showed improved pharmacological properties for further consideration in combating snakebites.

Chronic exposure to tramadol induces cardiac inflammation and endothelial dysfunction in mice

Tramadol is an opioid extensively used to treat moderate to severe pain; however, prolonged therapy is associated with several tissues damage. Chronic use of tramadol was linked to increased hospitalizations due to cardiovascular complications. Limited literature has described the effects of tramadol on the cardiovascular system, so we sought to investigate these actions and elucidate the underlying mechanisms. Mice received tramadol hydrochloride (40 mg/kg body weight) orally for 4 successive weeks. Oxidative stress, inflammation, and cardiac toxicity were assessed. In addition, eNOS expression was evaluated. Our results demonstrated marked histopathological alteration in heart and aortic tissues after exposure to tramadol. Tramadol upregulated the expression of oxidative stress and inflammatory markers in mice heart and aorta, whereas downregulated eNOS expression. Tramadol caused cardiac damage shown by the increase in LDH, Troponin I, and CK-MB activities in serum samples. Overall, these results highlight the risks of tramadol on the cardiovascular system.

Valoración del riego de adicción a tramadol en pacientes con dolor crónico no oncológico

Objetivo El manejo del dolor crónico no oncológico con analgésicos opioides ha sido de importancia para el control de los síntomas y el restablecimiento de la actividad, sin embargo, el riesgo de adicción asociado a estos medicamentos es ampliamente conocido y evaluado. Este estudio evalúa el riesgo de adicción que presentaban los pacientes con manejo de tramadol describiendo los factores mas frecuentes en la muestra estudiada frente a lo reportado en la literatura. Métodos Una muestra de 76 pacientes de una clínica de dolor que están en manejo con tramadol y se les administra un cuestionario con características demográficas y con la escala Opioid Risk Tool para el riesgo de adicción. Resultados El 57,89% de los sujetos fueron mujeres, el 55,20% se encontraba entre los 29 y 59 años. El riesgo de adicción moderado se encontró en el 9,09% de las mujeres y en el 37,05% de los hombres. La inclusión de otras enfermedades como ansiedad y trastorno de estrés postraumático aumenta el riesgo de adicción a severo en 6,06% de los hombres. Conclusiones La valoración del riesgo de adicción a opioides debe tener en cuenta los factores encontrados en la población colombiana.

Nonmedical use of tramadol among secondary school students in Benin, Africa

Background: Nonmedical use of tramadol among the young Beninese population is an increasing public health concern. However, there is little research on tramadol use in West Africa.Objectives: This study aimed to assess the prevalence, factors associated with nonmedical use of tramadol and to determine the level of therapeutic intervention needed.Methods: A cross-sectional study design and multi-stage sampling method was used among 384 secondary school students, within the age group of 10-24 years old who gave their consent/assent. An interviewer-administered modified questionnaire based on ASSIST was administered. Urinary toxicological test was performed using NarcoCheck® quick for qualitative detection of tramadol or its metabolites. Logistic regression analysis was performed to identify factors associated with nonmedical use of tramadol.Results: The average age of our respondents was 17 ± 2 SD years old; 58.3% were males and 41.7% females. The lifetime prevalence of nonmedical use of tramadol was 9.6% (95% CI: 6.7-12.6) (13.4% males and 4.4% females) and the average age at onset was 14.8 ± 1.8 years old. Only 1.4% (n = 4) were using tramadol as shown by urine screen. Among users, 45.9% reported a hazardous level of use and required a brief intervention. In a multivariate logistic regression model, tobacco (P < .001), cannabis (p = .023) and amphetamine (p = .037) were significantly associated with nonmedical use of tramadol. The most prevalent motives for nonmedical use of tramadol was experimentation (45.9%) and the leading source for obtaining tramadol was street-level markets (86.5%).Conclusion: These results indicate that nonmedical use of tramadol affects young in Benin and represent a considerable concern among secondary school students.

Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol

OBJECTIVE

To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures.

METHODS

We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population.

RESULTS

Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort.

CONCLUSION

Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.