Acute toxicity related to misuse (nonmedical use) of tramadol: Experience of the European Drug Emergencies Network Plus

Ten-year analgesic utilization patterns and economic implications in Portugal

AIMS

This study evaluated the 10-year consumption and economic patterns of classical analgesics, adjuvants and opioids in Portugal (2012-2022), and conducted a comparative analysis between Portugal, Spain and Denmark to explore the consumption patterns among these countries for 2022.

METHODS

Data on sales and national health service (NHS) costs were obtained from the Portuguese National Authority of Medicines and Health Products. Sales data were converted to defined daily dose (DDD) per 1000 inhabitants per day according to the Anatomical Therapeutic Chemical (ATC) classification/DDD methodology, while comparisons between Spain and Denmark were evaluated with the chi-square test, when appropriate.

RESULTS

The findings reveal that classical analgesics use in Portugal remained stable during the period 2012-2022, with ibuprofen being the most consumed. Adjuvants, specifically gabapentinoids, experienced an 84% increase in use, primarily attributed to pregabalin. Weak opioids, led by tramadol, witnessed a 117% rise in use, while strong opioid use, led by tapentadol, increased by 618%. Portugal presented the lowest overall opioid consumption when compared to Denmark and Spain in 2022. Economic trends indicated a heightened NHS expenditure on analgesics, primarily driven by increased opioid use. Notwithstanding, there was no significant burden on relative expenditure over the 10-year period.

CONCLUSIONS

Portugal presented a major increase in both weak and strong opioid prescriptions, aligning with the trends for Spain and Denmark. The development and approval of generic medicines and vigilant market monitoring are imperative strategies for managing the escalated costs resulting from heightened consumption, particularly concerning opioids.

Abuse and misuse of tramadol in patients with non-oncologic pain in a region of Southern Europe

Background

Tramadol can cause dependence even within the recommended dose range. Its use has increased recently, especially in patients with chronic pain, and although a growing body of literature identifies a non-therapeutic use, patterns of misuse of tramadol is so far limited.

Methods

Two-year observational and cross-sectional study (January 2020 - December 2021) was conducted in 75 community pharmacies from Catalonia. To estimate the potential abuse and misuse of tramadol by patients visiting community pharmacy, and to establish the demographic characteristics of the tramadol users, a validated questionnaire based on the Finch criteria was designed. A total of 251 cases were registered.

Results

Data show that women were more involved (56.6%) and the highest proportion was found in the age interval of 46-65 years (42.6%). The combination of tramadol and paracetamol was reported in 54.6% of the cases and 73.7% corresponded to immediate-release tablets. In 93.6% of the cases, the request was preceded by previous use. Conversely, young men showed a higher non-prescription request for tramadol, reporting acute pain (p < 0.05). These results indicate that there is non-therapeutic use among patients who visit community pharmacies for information on two profiles.

Conclusion

This study shows that being an aged woman and suffering from chronic pain seems to involve a risk of generating dependence on tramadol. Likewise, a suspicion of recreational use of tramadol by young people has also been identified. There is a need to investigate how to manage chronic pain, given its complexity and take into account the risk of misuse that may come with tramadol. The involvement of characteristics such as gender as well as the pharmaceutical form in the development of tramadol misuse also needs to be analysed deeply. It is mandatory to evaluate the criteria for prescribing tramadol and initiatives to improve the knowledge of the health professionals and the population.

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.

Evaluation of Medicine Abuse Trends in Community Pharmacies: The Medicine Abuse Observatory (MAO) in a Region of Southern Europe

The misuse of medicines is a global public health concern that needs to be taken into consideration and requires actions across all government sectors and society. The aim of this study is to identify trends of drug abuse in Catalonia, a region of Spain located in the South of Europe. For this purpose, a questionnaire-based detection tool was created and implemented in 60 community pharmacies. Out of 548 questionnaires (98.4%), 64.2% of participants were men and the highest age proportion was 25-35 years (31.4%). Potential drug abuse was the highest in urban pharmacies (84.9%). The main drug class involved were benzodiazepines (31.8%), codeine (19.3%), tramadol (7.5%), methylphenidate (5.8%), gabapentinoids (5.8%), cycloplegic drops (4.4%), z-drugs (2.6%), piracetam (2.2%), dextromethorphan (1.6%) and clomethiazole (1.1%). The majority of drugs were requested without prescription (58.6%) and through probably forged prescriptions (23.7%). Slightly less than half (49.8%) of the patients request frequently to the pharmacist, especially in rural and mountain pharmacies (73.3% and 88.5%, respectively). A small proportion (10.8%) were requested with intimidation. Pharmacists only supplied in 21.7% of the cases. This study has demonstrated the suitability of the new detection system, being a useful approach to replicate in other locations with similar needs.

Opioids in the United Kingdom: safety and surveillance during COVID-19

PURPOSE OF REVIEW

Opioid use is prevalent in the United Kingdom and prior to the COVID-19 pandemic it had been recognized that the safety of opioids was an important issue to be monitored by the UK medicines regulatory agency. With the emergence of COVID-19, this requirement has been even greater. This review was undertaken to determine the impact of the pandemic on safety and surveillance of opioids in the United Kingdom.

RECENT FINDINGS

During the COVID-19 pandemic, the surveillance of opioids in the United Kingdom continued, although primary research was often conducted with data prior to the pandemic. Of those studies that were conducted while the pandemic was ongoing, access to opioids (or opioid substitution therapy) and the subsequent effect on patient safety was the main theme.

SUMMARY

In the United Kingdom, changes in accessibility to the healthcare system and how healthcare providers operated during the COVID-19 pandemic may have had unintended consequences on use and safety of opioids, due to the shift in focus to preventing COVID-19 from overwhelming the healthcare system. The findings from this review support the need to continue surveillance in the United Kingdom, including the impact of the COVID-19 pandemic on opioid utilization and safety.

Regional, national and international datasets: How they improve our understanding of the acute harms associated with prescription medicine misuse

Prescription medicine misuse is a significant problem in many areas of the world. Understanding the acute and chronic harms related to misuse of prescription medicines allows healthcare professionals, drug addiction treatment services and legislative authorities to determine what interventions may be beneficial to reduce these harms and protect individuals and society. However, it is difficult to obtain systematic data on the harms associated with prescription medicine misuse because of how patient visits to clinics and hospitals are recorded and coded in regional or national databases. In this review, we discuss how regional, national and international sources of information can help develop a greater understanding of the prevalence and pattern of acute harms related to prescription medicine misuse using data from ambulance attendances, emergency department presentations and poisons information services.