Clinical pharmacology of tramadol

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear.

DESIGN

Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment.

SETTING

Postoperative pain treatment.

PATIENTS

Adult patients undergoing visceral cancer surgery.

INTERVENTIONS

Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques.

MEASUREMENTS

Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus.

MAIN RESULTS

59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA.

CONCLUSIONS

Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

The role of the methoxy group in approved drugs

The methoxy substituent is prevalent in natural products and, consequently, is present in many natural product-derived drugs. It has also been installed in modern drug molecules with no remnant of natural product features because medicinal chemists have been taking advantage of the benefits that this small functional group can bestow on ligand-target binding, physicochemical properties, and ADME parameters. Herein, over 230 methoxy-containing small-molecule drugs, as well as several fluoromethoxy-containing drugs, are presented from the vantage point of the methoxy group. Biochemical mechanisms of action, medicinal chemistry SAR studies, and numerous X-ray cocrystal structures are analyzed to identify the precise role of the methoxy group for many of the drugs and drug classes. Although the methoxy substituent can be considered as the hybridization of a hydroxy and a methyl group, the combination of these functionalities often results in unique effects that can amount to more than the sum of the individual parts.

Simultaneous determination of methadone and tramadol in serum samples by ultrasonic-assisted micro solid phase extraction and gas chromatography-mass spectrometry

Ultrasonic-assisted dispersive micro solid phase extraction (UA-DMSPE) is proposed as a fast and easy technique for the extraction and preconcentration of methadone and tramadol from serum samples. Different sorbents including carbon nanotubes, oxidized carbon nanotubes, and TiO2 nanoparticles were compared to extract methadone and tramadol. The best performance was obtained using oxidized carbon nanotubes due to the strong affinity between the drugs and carbon nanotube adsorbents. Final analysis of drugs performed by using gas chromatography-mass spectrometric detection. Different parameters affecting the extraction efficiency, such as the sample volume, amount of adsorbent, desorption solvent type and volume, centrifugation time, and speed were investigated and optimized. The striking features of this technique are correlated to its speed and the small volumes of sample (about 1 mL), desorption solvent (about 50 μL), and adsorbent (about 0.001 g) for analysis of drugs, and finally, milder centrifugation conditions relative to the previously reported adsorbent. The optimal parameters were achieved as follows: pH value was set at 9, the sample volume was adjusted to 1200 µL, the amount of adsorbent used was 1 mg, the extraction time was set at 5 min, and the volume of the desorption solvent was adjusted to 50 µL. The limits of detections (0.5 and 0.8 ng mL-1) and quantifications (1.5 and 2.5 ng mL-1) were obtained for methadone and tramadol, respectively. The developed method also showed good repeatability, relative standard deviation (RSD) of 9.49 % and 7.47 % (n = 5), for the spiked aqueous solution at the concentration level of 10, 50, and 100 ng mL-1 for analytes, and linearity, R ≥ 0.9809. The results showed that UA-DMSPE is a quick, relatively inexpensive, and environmentally friendly alternative technique for the extraction of opiate drugs from serum samples.

Efficacy of Co-Crystal of Tramadol-Celecoxib (CTC) in Patients with Acute Moderate-to-Severe Pain: A Pooled Analysis of Data from Two Phase 3 Randomized Clinical Trials

BACKGROUND AND OBJECTIVES

New acute pain medications are needed that provide effective analgesia while minimizing side effects and opioid exposure. Clinical trials of co-crystal of tramadol-celecoxib (CTC) have demonstrated an improved benefit/risk profile versus tramadol or celecoxib alone. We pooled data from two phase 3 clinical trials to evaluate the efficacy of CTC 200 mg twice daily (BID) in acute moderate-to-severe pain.

METHODS

Efficacy data were pooled from STARDOM1 [acute pain following oral surgery (NCT02982161)] and ESTEVE-SUSA-301 [acute pain following bunionectomy (NCT03108482)]. The primary efficacy outcome was sum of pain intensity difference from 0 to 48 h (SPID0-48).

RESULTS

A total of 344 patients received CTC 200 mg BID, 342 received tramadol 50 or 100 mg four times a day, 181 received celecoxib 100 mg BID, and 172 received placebo. The least-squares mean difference in SPID0-48 was -21.8 (p = 0.002) for CTC versus tramadol and -72.8 (p < 0.001) for CTC versus placebo. A similar pattern of SPID0-48 was observed with CTC versus comparator whether patients had moderate or severe pain at baseline. Reduction in pain intensity was faster and reached mild intensity earlier with CTC versus comparators. Patients were significantly (p ≤ 0.005) less likely to receive rescue medication within 4 or 48 h with CTC compared with tramadol or placebo.

CONCLUSIONS

This pooled analysis reinforces the efficacy profile of CTC versus tramadol and, given that CTC permits lower daily tramadol dosing and thereby reduces unnecessary opioid use, this highlights its improved benefit/risk profile and its potential for the management of moderate-to-severe pain.

Spectrophotometric determination of celecoxib and tramadol in the new approved formulated dosage form using principle component regression assistive model

Celecoxib and tramadol have been combined in a novel FDA-approved medication to address acute pain disorders requiring opioid treatment when other analgesics proved either intolerable or ineffective. The absorbance spectra of celecoxib and tramadol exhibit significant overlap, posing challenges for their individual quantification. This study introduces a spectrophotometric quantification approach for celecoxib and tramadol using a principle component regression assistive model to assist resolving the overlapped spectra and quantifying both drugs in their binary mixture. The model was constructed by establishing calibration and validation sets for the celecoxib and tramadol mixture, employing a five-level, two-factor experimental design, resulting in 25 samples. Spectral data from these mixtures were measured and preprocessed to eliminate noise in the 200-210 nm range and zero absorbance values in the 290-400 nm range. Consequently, the dataset was streamlined to 81 variables. The predicted concentrations were compared with the known concentrations of celecoxib and tramadol, and the errors in the predictions were evidenced calculating root mean square error of cross-validation and root mean square error of prediction. Validation results demonstrate the efficacy of the models in predicting outcomes; recovery rates approaching 100 % are demonstrated with relative root mean square error of prediction (RRMSEP) values of 0.052 and 0.164 for tramadol and celecoxib, respectively. The selectivity was further evaluated by quantifying celecoxib and tramadol in the presence of potentially interfering drugs. The model demonstrated success in quantifying celecoxib and tramadol in laboratory-prepared tablets, producing metrics consistent with those reported in previously established spectrophotometric methods.

Management of Pain Medication in Patients With a History of Bariatric Surgery: A Systematic Review

CONTEXT

Obesity prevalence is persistently increasing worldwide. Among surgical therapeutic procedures, bypass surgery and sleeve gastrectomy have shown the best results regarding weight loss, prevention, and treatment of secondary complications. However, these surgeries are associated with an increased risk of malabsorption and metabolic changes that could further affect the pharmacokinetics of drugs. On the other hand, patients with a history of such surgeries are more likely to experience pain and request analgesic initiation or adaptation. The question of how to manage pain medication in these patients is challenging due to their narrow therapeutic indexes.

OBJECTIVES

To summarize the current literature on the impact of bariatric surgery on the subsequent pharmacokinetics of analgesics and propose a multidisciplinary therapeutic attitude to optimize pain management in these patients.

METHODS

We conducted a systematic review that included all pharmacological studies published after 2000.

RESULTS

Unexpectedly, these surgeries seem to increase the bioavailability of drugs by long-term improvement of hepatic function. Yet, the medical community drastically lacks robust guidelines for pain management in those patients. This systematic review aims to bring together pharmacological studies related to the use of pain treatments in patients who underwent bypass surgery or sleeve gastrectomy.

CONCLUSIONS

Caution should be exercised regarding the risk of overdose in every circumstance: treatment initiation, change of doses, or change of molecule. More prospective trials comparing the pharmacokinetics of medications in obese patients with and without prior bariatric surgery are needed.

Efficacy and safety of parenteral and local application of tramadol in mandibular third molar extraction: a qualitative systematic review of current evidence

PURPOSE

To assess the efficacy and safety of perioperative parenteral administration or submucosal infiltration of tramadol for perioperative pain control on the basis of pain intensity or analgesics consumption and perioperative outcomes in mandibular third molar surgery.

MATERIAL-METHODS

An electronic database search was conducted up to 10 November 2022 to retrieve all randomized controlled trials (RCTs), assessing the analgesic efficacy of parenteral use of tramadol implemented as an adjunct to local anesthesia or intraoperative sedation/general anesthesia, in surgical extraction of mandibular third molars. Modified Jadad scale and Cochrane bias tool were used for the qualitative appraisal.

RESULTS

Nineteen RCTs were selected for qualitative analysis. Nine studies involved intravenous, and 5 intramuscular administration of tramadol, while 5 evaluated submucosal infiltration with tramadol. Intravenous or intramuscular tramadol provided a weaker analgesic effect compared with non-steroidal anti-inflammatory drugs (NSAIDs), while intravenous tramadol induced an enhanced analgesic effect than oral tramadol. Parenteral administration of tramadol improved the quality of postoperative analgesia versus placebo. No notable adverse effects were recorded.

CONCLUSIONS

Parenteral or submucosal infiltration of tramadol constitutes an effective and safe alternative analgesic approach in surgical extraction of mandibular third molars, yet the nociceptive effect of this analgesic modality could not supersede that of NSAIDs.

TRIAL REGISTRATION

PROSPERO No CRD42021227574.

Crizotinib inhibits the metabolism of tramadol by non-competitive suppressing the activities of CYP2D1 and CYP3A2

Objectives

To investigate the interaction between tramadol and representative tyrosine kinase inhibitors, and to study the inhibition mode of drug-interaction.

Methods

Liver microsomal catalyzing assay was developed. Sprague-Dawley rats were administrated tramadol with or without selected tyrosine kinase inhibitors. Samples were prepared and ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) was used for analysis. Besides, liver, kidney, and small intestine were collected and morphology was examined by hematoxyline-eosin (H&E) staining. Meanwhile, liver microsomes were prepared and carbon monoxide differential ultraviolet radiation (UV) spectrophotometric quantification was performed.

Results

Among the screened inhibitors, crizotinib takes the highest potency in suppressing the metabolism of tramadol in rat/human liver microsome, following non-competitive inhibitory mechanism. In vivo, when crizotinib was co-administered, the AUC value of tramadol increased compared with the control group. Besides, no obvious pathological changes were observed, including cell morphology, size, arrangement, nuclear morphology with the levels of alanine transaminase (ALT) and aspartate transaminase (AST) increased after multiple administration of crizotinib. Meanwhile, the activities of CYP2D1 and CYP3A2 as well as the total cytochrome P450 abundance were found to be decreased in rat liver of combinational group.

Conclusions

Crizotinib can inhibit the metabolism of tramadol. Therefore, this recipe should be vigilant to prevent adverse reactions.

Relations Between Self-Reported Prescription Hydrocodone, Oxycodone, and Tramadol Use and Unintentional Injuries Among Those With Spinal Cord Injury

OBJECTIVE

To identify the relations of 3 frequently used prescription opioids (hydrocodone, oxycodone, tramadol) with unintentional injuries, including fall-related and non-fall-related injuries among adults with chronic, traumatic spinal cord injury (SCI).

DESIGN

Cross-sectional cohort study.

SETTING

Community setting; Southeastern United States.

PARTICIPANTS

Adult participants (N=918) with chronic traumatic SCI were identified from a specialty hospital and state population-based registry and completed a self-report assessment.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported fall-related and non-fall-related unintentional injuries serious enough to receive medical care in a clinic, emergency room, or hospital within the previous 12 months.

RESULTS

Just over 20% of participants reported ≥1 unintentional injury in the past year, with an average of 2.16 among those with ≥1. Overall, 9.6% reported fall-related injuries. Only hydrocodone was associated with any past-year unintentional injuries. Hydrocodone taken occasionally (no more than monthly) or regularly (weekly or daily) was related to 2.63 (95% confidence interval [CI], 1.52-4.56) or 2.03 (95% CI, 1.15-3.60) greater odds of having ≥1 unintentional injury in the past year, respectively. Hydrocodone taken occasionally was also associated with past-year non-fall-related injuries (OR, 2.20; 95% CI, 1.12-4.31). Each of the 3 opioids was significantly related to fall-related injuries. Taking hydrocodone occasionally was associated with 2.39 greater odds of fall-related injuries, and regular use was associated with 2.31 greater odds. Regular use of oxycodone was associated with 2.44 odds of a fall-related injury (95% CI, 1.20-4.98), and regular use of tramadol was associated with 2.59 greater odds of fall-related injury (95% CI, 1.13-5.90).

CONCLUSIONS

Injury prevention efforts must consider the potential effect of opioid use, particularly hydrocodone. For preventing fall-related injuries, each of the 3 opioids must be considered.

The psychophysiology of music-based interventions and the experience of pain

In modern times there is increasing acceptance that music-based interventions are useful aids in the clinical treatment of a range of neurological and psychiatric conditions, including helping to reduce the perception of pain. Indeed, the belief that music, whether listening or performing, can alter human pain experiences has a long history, dating back to the ancient Greeks, and its potential healing properties have long been appreciated by indigenous cultures around the world. The subjective experience of acute or chronic pain is complex, influenced by many intersecting physiological and psychological factors, and it is therefore to be expected that the impact of music therapy on the pain experience may vary from one situation to another, and from one person to another. Where pain persists and becomes chronic, aberrant central processing is a key feature associated with the ongoing pain experience. Nonetheless, beneficial effects of exposure to music on pain relief have been reported across a wide range of acute and chronic conditions, and it has been shown to be effective in neonates, children and adults. In this comprehensive review we examine the various neurochemical, physiological and psychological factors that underpin the impact of music on the pain experience, factors that potentially operate at many levels - the periphery, spinal cord, brainstem, limbic system and multiple areas of cerebral cortex. We discuss the extent to which these factors, individually or in combination, influence how music affects both the quality and intensity of pain, noting that there remains controversy about the respective roles that diverse central and peripheral processes play in this experience. Better understanding of the mechanisms that underlie music's impact on pain perception together with insights into central processing of pain should aid in developing more effective synergistic approaches when music therapy is combined with clinical treatments. The ubiquitous nature of music also facilitates application from the therapeutic environment into daily life, for ongoing individual and social benefit.

Exploring the potential use of melatonin as a modulator of tramadol-induced rewarding effects in rats

Background

Melatonin is responsible for regulating the sleep-wake cycle and circadian rhythms in mammals. Tramadol, a synthetic opioid analgesic, is used to manage moderate to severe pain but has a high potential for abuse and dependence. Studies have shown that melatonin could be a potential modulator to reduce tramadol addiction.

Methods

Male Wistar rats were used to investigate the effect of melatonin on tramadol-induced place preference. The rats were divided into four groups: control, tramadol, tramadol + melatonin (single dose), and tramadol + melatonin (repeated doses). Tramadol was administered intraperitoneally at 40 mg/kg, while melatonin was administered at 50 mg/kg for both the single dose and repeated-dose groups. The study consisted of two phases: habituation and acquisition.

Results

Tramadol administration produced conditioned place preference (CPP) in rats, indicating rewarding effects. However, melatonin administration blocked tramadol-induced CPP. Surprisingly, repeated doses of melatonin were ineffective and did not reduce the expression of CPP compared to that of the single dose administration.

Conclusion

The study suggests that melatonin may be a potential therapeutic option for treating tramadol addiction. The results indicate that melatonin attenuates the expression of tramadol-induced CPP, supporting its uses as an adjunct therapy for managing tramadol addiction. However, further studies are needed to investigate its effectiveness in humans.

Intraoperative Music to Promote Patient Outcome (IMPROMPTU): A Double-Blind Randomized Controlled Trial

INTRODUCTION

Perioperative music can have beneficial effects on postoperative pain, anxiety, opioid requirement, and the physiological stress response to surgery. The aim was to assess the effects of intraoperative music during general anesthesia in patients undergoing surgery for esophagogastric cancer.

MATERIALS AND METHODS

The IMPROMPTU study was a double-blind, placebo-controlled, randomized multicenter trial. Adult patients undergoing surgery for stage II-III esophagogastric cancer were eligible. Exclusion criteria were a hearing impairment, insufficient Dutch language knowledge, corticosteroids use, or objection to hearing unknown music. Patients wore active noise-cancelling headphones intraoperatively with preselected instrumental classical music (intervention) or no music (control). Computerized randomization with centralized allocation, stratified according to surgical procedure using variable block sizes, was employed. Primary endpoint was postoperative pain on the first postoperative day. Secondary endpoints were postoperative pain during the first postoperative week, postoperative opioid requirement, intraoperative medication requirement, the stress response to surgery, postoperative complication rate, length of stay, and mortality, with follow-up lasting 30 d.

RESULTS

From November 2018 to September 2020, 145 patients were assessed and 83 randomized. Seventy patients (music n = 31, control n = 39) were analyzed. Median age was 70 [IQR 63-70], and 48 patients (69%) were male. Music did not reduce postoperative pain (numeric rating scale 1.8 (SD0.94) versus 2.0 (1.0), mean difference -0.28 [95% CI -0.76-0.19], P = 0.236). No statistically significant differences were seen in medication requirement, stress response, complication rate, or length of stay.

CONCLUSIONS

Intraoperative, preselected, classical music during esophagogastric cancer surgery did not significantly improve postoperative outcome and recovery when compared to no music using noise-cancelling headphones.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids

BACKGROUND

Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve.

METHODS

Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared.

RESULTS

A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not.

CONCLUSION

Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Shaping the Anesthetic Approach to TricValve Implantation: Insights From a Case Series

OBJECTIVES

Caval valve implantation (CAVI) represents a minimally invasive strategy for managing severe tricuspid regurgitation in high-risk patients unsuitable for surgical or transcatheter tricuspid valve implantation. This case series aimed to assess the anesthesia management challenges and outcomes associated with this procedure, seeking to generate insights that can inform and refine anesthesia protocols.

DESIGN

A case series.

SETTING

At a cardiac catheterization laboratory of a teaching hospital.

PARTICIPANTS

Eight patients undergoing CAVI with the Tricvalve system INTERVENTIONS: The anesthetic protocol included preprocedural planning, fast-track general anesthesia, and postprocedural debriefing. Intraoperative management involved anesthesia depth monitoring, real-time guidance via transesophageal echocardiography, and hemodynamic stability maintenance. Postoperative analgesia involved preemptive intravenous paracetamol and morphine as needed.

MEASUREMENTS AND MAIN RESULTS

No anesthesia-related or implantation-related complications were observed, with a mean procedure duration of 112 ± 44 minutes. The median hospital stay was 4 days, and only 1 patient required brief intensive care unit monitoring. Postoperative right shoulder pain was reported by half of the patients, and was managed with morphine bolus administration (average dose 4.75 ± 3.6 mg). All patients had the device correctly positioned, as confirmed by postoperative transthoracic echocardiograms. None of the patients required outpatient analgesic therapy upon discharge.

CONCLUSIONS

The authors' study demonstrated the potential of TricValve implantation in effectively managing severe tricuspid regurgitation with no procedure-related complications and a 100% survival rate. A collaborative, interdisciplinary approach and targeted anesthesia management proved crucial for this success. Postoperative shoulder pain emerged as a frequent complication, whose pathogenesis is still not clear, and successfully was managed using targeted analgesic therapy.

Comparative Evaluation of the Local Anesthetic Action of Tramadol Hydrochloride With Adrenaline Versus Lidocaine Hydrochloride With Adrenaline for Maxillary Exodontia: A Randomized Control Trial

BACKGROUND

Tramadol hydrochloride (T-HCl) has demonstrated to have a local anesthetic effect similar to lidocaine hydrochloride (L-HCl) when administered locally for minor oral surgical procedures.

PURPOSE

Our study aimed to compare the anesthetic effect of T-HCl versus L-HCl in maxillary premolar extraction.

STUDY DESIGN, SETTING AND SAMPLE

The study is a split-mouth, double-blind randomized clinical trial at the Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bengaluru, India. The study sample was composed of patients referred for maxillary bicuspid extraction. Patients were excluded from the sample if, allergic to the study drugs, pregnant or lactating females, and smokers.

EXPOSURE VARIABLE

The variable is an anesthetic drug administered for local anesthesia and it is grouped into 2 categories, T-HCl and L-HCl. A supraperiosteal infiltration of T-HCl with adrenaline on one side and L-HCl with adrenaline on the contralateral side was injected.

MAIN OUTCOME VARIABLE

The primary outcome variable was profound anesthesia of T-HCl, where the patient sensed the loss of sensation of touch, temperature, and pain. Secondary outcomes were onset and duration of anesthesia, intraoperative pain, postoperative analgesia, and adverse reactions, were recorded.

ANALYSES

Inferential statistics, the χ2 Test, the Mann-Whitney Test, and the Wilcoxon signed-rank test were used to compare the parameters. The level of significance was set at ≤ 0.05.

RESULTS

A total of 40 patients were included, and 80 teeth were extracted. Profound anesthesia was achieved in all the cases. The mean subjective duration of anesthesia in the T-HCl and L-HCl groups was 130.80 ± 20.01 minutes and 111.40 ± 14.87 minutes, respectively, with a P value of .001. The mean Visual Analogue Scale (VAS) score for pain during the procedure in the T-HCl and L-HCl groups was 0.60 ± 0.67 and 1.10 ± 0.71, respectively, with a P value of .002. The mean Visual Analogue Scale score for pain postoperatively in the T-HCl and L-HCl groups was 0.70 ± 0.72 and 1.40 ± 0.67, respectively, with a P value of .001. Six patients in T-HCl required postoperative analgesia when compared to 18 patients in L-HCl (P value < .003).

CONCLUSIONS AND RELEVANCE

T-HCl provides similar anesthetic outcomes in the extraction of maxillary bicuspids as L-HCl.

Epidural administration of ropivacaine and midazolam is superior to intra-articular administration as postoperative analgesia after isolated arthroscopic anterior cruciate ligament reconstruction with hamstrings autograft: a randomized controlled clinical trial

OBJECTIVE

Reconstructive surgery of the anterior cruciate ligament (ACL) is quite common, previous studies have documented that adequate pain control in the early phases of the postoperative period translates into early mobility and a rapid start of rehabilitation. Therefore, the search for new strategies for postoperative pain control is justified. The aim of this study was to compare intra-articular to the epidural administration of ropivacaine and midazolam as postoperative analgesia after arthroscopic ACL reconstruction with hamstring autograft (HA).

MATERIAL AND METHODS

Double-blinded, prospective randomized clinical trial included 108 consecutive patients aged from 18 to 50 years that had undergone arthroscopic ACL reconstruction with HA. The patients were randomly assigned to 2 groups. The first group received intraarticular ropivacaine and midazolam. The second group received epidural ropivacaine and midazolam. The need for rescue analgesia, the postoperative pain experienced, side effects and complications of the analgesic drugs were evaluated.

RESULTS

The intra-articular group received statistically significantly higher mean doses of rescue analgesia on the first two days (2.8 ​± ​1.0 vs. 1.3 ​± ​0.6 in the epidural group; p ​= ​0.001). Visual Analogue Scale scores at flexion were statistically significantly higher in the intra-articular group over the entire study period. The intra-articular group also reported a statistically significantly lower range-of-motion 87 ​± ​15 vs. 102 ​± ​11 in the epidural group (p ​= ​0.001).

CONCLUSIONS

Epidural administration of ropivacaine combined with midazolam in patients undergoing primary ACL reconstruction with HA was clinically and significantly better relative to rescue analgesia and the intensity of pain in the first 48 postoperative hours when compared to intraarticular administration. There was no difference in terms of adverse effects and complications.

LEVEL OF EVIDENCE: 2

Simultaneous determination of tramadol in earwax and urine samples: effects of age, duration time and sex

Background: This study aims to determine the concentrations of tramadol in earwax (μg/g) and urine (μg/ml) samples taken from postoperative patients, to evaluate the sensitivity of earwax (cerumen) as an alternative analyte and compare it with the findings in urine samples. Results: The results indicated that tramadol concentrations in earwax samples were averaged 45.08 μg/g (range: 13.5-107.7 μg/g), whereas tramadol concentrations in urine samples were averaged 4.97 μg/ml (range: 1.57-10.11 μg/ml). There were significant differences when comparing age groups, duration and sex between earwax and urine samples (p < 0.05). Conclusion: Despite the significant differences between earwax and urine samples, earwax can be used as a bioindicator of tramadol detection.

PHARMACOKINETICS OF TRAMADOL AND O-DESMETHYLTRAMADOL IN GIANT TORTOISES (CHELONOIDIS VANDENBURGHI, CHELONOIDIS VICINA)

The objective of this study was to determine the pharmacokinetics of two orally administered doses of tramadol (1 mg/kg and 5 mg/kg) and its metabolite, O-desmethyltramadol (M1) in giant tortoises (Chelonoidis vandenburghi, Chelonoidis vicina). Eleven giant tortoises (C. vandenburghi, C. vicina) received two randomly assigned, oral doses of tramadol (either 1 mg/kg or 5 mg/kg), with a washout period of 3 wk between each dose. The half-life (t½) of orally administered tramadol at 1 mg/kg and 5 mg/kg was 11.9 ± 4.6 h and 13.2 ± 6.1 h, respectively. After oral administration of tramadol at 1 mg/kg and 5 mg/kg, the maximum concentration (Cmax) was 125 ± 69 ng/ml and 518 ± 411 ng/ml, respectively. There were not enough data points to determine pharmacokinetic (PK) parameters for the M1 metabolite from either dose. Tramadol administered orally to giant tortoises at both doses provided measurable plasma concentrations of tramadol for approximately 48 h with occasional transient sedation. Oral tramadol at 5 mg/kg, on average, achieves concentrations of >100 ng/ml, the reported human therapeutic threshold, for 24 h. Based on the low levels of M1 seen in this study, M1 may not be a major metabolite in this taxon.

Anxious-depressive attack and rejection sensitivity-Toward a new approach to treatment-resistant depression

This paper aimed to find clues to treatment-resistant depression (TRD) solutions. Depression comorbid with anxiety is often treatment-resistant where anxious-depressive attack (ADA) often lurks. ADA is a recently proposed clinical idea for just a psychological version of a panic attack. It mostly begins with an abrupt surge of intense anxiety followed by uninterrupted intrusive thoughts; lasting ruminations about regret or worry produced by violent anxiety, agitation, and loneliness. Acting-out behaviors such as deliberate self-injury and over-dose may also be observed during the attack. As the basic psychopathology of ADA, rejection sensitivity (RS) was revealed by a structural equation model. It is said that the presence of RS in depressive disorders implies a poor prognosis. The following biological markers for RS were reviewed in the literature: first, the involvement of the μ-opioid receptor function in RS and, secondly, hypersensitivity of the dopamine D4 receptor (DRD4) in the medial prefrontal cortex. The latter has been suggested in fear-conditioned animal experiments. Manipulation of the μ-opioid receptor function together with the DRD4 function may culminate in a treatment for RS, which could contribute to the development of a treatment for TRD via the improvement of ADA.

The Effect of Epidural Analgesia on Quality of Recovery (QoR) after Open Radical Nephrectomy: Randomized, Prospective, and Controlled Trial

No studies are currently evaluating the quality of recovery (QoR) after open radical nephrectomy (ORN) and epidural morphine analgesia. This was a randomized, prospective, and controlled study that explored the QoR on the first postoperative day after ORN. Eighty subjects were randomized into two groups. The first group received general anesthesia combined with epidural anesthesia and postoperative epidural analgesia with morphine and ropivacaine. The second group received general anesthesia and continuous postoperative intravenous analgesia with tramadol. Both groups received multimodal analgesia with metamizole. The primary outcome measure was the total QoR-40 score. The secondary outcome measures were QoR-15, QoR-VAS, and the visual analog scale (VAS) for pain, anxiety, and nausea. The median difference in the QoR-40 score after 24 postoperative hours between the two groups of patients was 10 (95% CI: 15 to 5), p < 0.0001. The median score and IQR of QoR-40 during the first 24 postoperative hours in the epidural group was 180 (9.5), and in the control group, it was 170 (13). The general independence test for secondary outcomes between groups was significant (p < 0.01). QoR-VAS was correlated with QoR-40 (r = 0.63, p ≤ 0.001) and with QoR-15 (r = 0.54, p ≤ 0.001). The total QoR-40 and QoR-15 alpha coefficients with a 95% CI were 0.88 (0.85-0.92) and 0.73 (0.64-0.81), respectively. There was a significant difference in the QoR between the epidural and the control groups after ORN. The QoR-40 and QoR-15 showed good convergent validity and reliability.

Slower intravenous tramadol administration can prevent nausea and vomiting and predict postoperative nausea and vomiting: a randomized controlled trial

Objective

Nausea and vomiting are the most common complications in patients who use tramadol for analgesia. This study evaluated the risk of nausea and vomiting related to intravenous tramadol administration.

Methods

In this study, 315 patients who received pre-analgesia before elective surgery were selected, and participants were divided into groups based on the Apfel risk assessment of nausea and vomiting, as follows: high risk (Apfel=4), medium risk (Apfel=2-3), and low-risk (Apfel=1). Tramadol (1.5 mg/kg) was administered intravenously over a duration of 1 min, 2 min, or 3 min before anaesthesia induction to observe preoperative nausea and vomiting reactions within 10 min.

Results

In the low-risk group, the numeric rating scale for postoperative nausea scores and the incidence of nausea and vomiting were significantly lower in the 3-min group than those in the 1-min group, and the incidence of preoperative nausea and vomiting after intravenous administration of tramadol in the 1-min and 3-min groups were significantly related to the incidence of postoperative nausea and vomiting. The incidence of nausea and vomiting during pre-administration in the 1-min and 3-min groups was identified as an independent risk factor for postoperative nausea and vomiting.

Conclusions

In the clinical treatment of pain with tramadol, the slow intravenous application of tramadol within 3 min is worthy of being adopted and promoted by clinicians in their daily work.

Narcotic analgesics

There is documentation of the use of opium derived products in the ancient history of the Assyrians: the Egyptians; in the sixth century AD by the Roman Dioscorides; and by Avicenna (980-1037). Reference to opium like products is made by Paracelsus and by Shakespeare. Charles Louis Derosne and Fredrich Wilhelm Adam Serturner isolated morphine from raw opium in 1802 and 1806 respectively, and it was Sertürner who named the substance morphine, after Morpheus, the Greek God of dreams. By the middle 1800s, Opium and related opioid derived products were the source of a major addiction in USA, and to some extent in the United Kingdom. Opioid products are of major therapeutic value in the treatment of pain from injury, post surgery, intractable pain conditions, and some forms of terminal cancer.

A consideration of CYP2D6 genetic variations in the Ghanaian population as a potential 'culprit' for the tramadol 'abuse crisis'

BACKGROUND

Cytochrome P450 2D6 is involved in the metabolism of several important medicines including opioids. Variations in CYP2D6 have been implicated in drug response and according to the Clinical Pharmacogenetics Implementation Consortium Guideline (CPIC) for CYP2D6, dosing for CYP2D6 substrates should be based on variants carried by individuals. Although CYP2D6 variations in Ghana had been previously recorded, not all variants have been reported in the Ghanaian population. In this exploratory study we set to investigate certain unreported variations in the Ghanaian population in addition to the previously reported ones and use that to understand the tramadol 'abuse' crisis that is currently being experienced in Ghana.

METHODS

This study employed a convenience sampling approach to include 106 unrelated participants who were recruited as part of the PHARMABIOME project. We successfully genotyped 106 samples using Iplex GOLD SNP genotyping protocol after extracting DNA from these individuals. Allele and diplotype frequencies were undertaken by counting from observed genotypes. Comparison of alleles reported from various studies were done.

RESULTS

Unreported alleles such as *3, *9 and *41 which are classified as no function and decreased function were observed in our study cohort. In addition, variants such as (*1, *2, *4, *5, *10, *17 and *29 were observed with different frequencies. Our study showed 26% representation of intermediate metabolizers (IM) and 2% poor metabolizers (PM) in the study population.

CONCLUSION

The implications for informal sector workers who use tramadol for recreational purposes, is that IMs and PMs will overdose as they may have reduced analgesic effects which will translate into increased risks of unforeseen adverse events. We therefore propose that CYP2D6 should be considered in opioid dosage while making use of these observed variations to implement new approaches to tackle the tramadol 'abuse crisis' in Ghana.

Prevalence and health consequences of nonmedical use of tramadol in Africa: A systematic scoping review

Tramadol is a widely prescribed painkiller around the world. As a synthetic opioid, it offers a valuable substitute for morphine and its derivatives in African countries. However, the adverse health effects of tramadol use resulting from illicit trafficking, like those caused by fentanyl and methadone in North America, have not been well-documented in Africa. This scoping review aims to shed light on the nature and scope of the nonmedical use (NMU) of tramadol in Africa and its associated health consequences. To carry out our scoping review, we used Arksey and O'Malley's (2005) five-step approach for exploratory analysis and followed Joanna Briggs Institute guidelines for scoping reviews to ensure systematic and replicable studies. We then searched six databases: Medline, Global Health (EBSCO), Scopus, Web of Science, the African Journals online database, and for grey literature via Google Scholar without any time restriction. The articles were imported into Covidence and reviewed by two independent researchers. Eighty-three studies on NMU of tramadol's prevalence or health consequences were selected from 532 titles/abstracts screened, including 60 cross-sectional and six qualitative studies from 10 African countries. Findings from the included studies highlighted five distinct groups significantly affected by the NMU of tramadol. These groups include: 1) young adults/active populations with varying degrees of prevalence ranging from 1.9% to 77.04%, 2) professionals, where drivers exhibit a relatively high prevalence of tramadol NMU, ranging from 7.2% to 35.1%, and commercial motorcyclists, with a prevalence of 76%, 3) patients, who have a high rate of tramadol NMUs, with prevalence rates ranging from 77.1% to 92%, 4) academics, with a considerable rate of tramadol misuse among substance-using undergraduates (74.2%) and substance-using high school students (83.3%), and 5) other individuals impacted in various ways. The health consequences are classified into four distinct types: intoxication, dependence syndrome, withdrawal syndrome and other symptoms. Despite providing a comprehensive global overview of the phenomenon described in the African literature, this systematic scoping review's main limitations stem from the relatively limited exploration of various consequences of the NMU of tramadol, notably those of a social and economic nature. Our review shows that tramadol misuse affects diverse populations in Africa. The prevalence of misuse varies within sub-populations, indicating the complexity of the issue. Professional and academic groups have different rates of misuse across regions. This highlights the need for targeted interventions to address unique challenges contributing to tramadol misuse. Future studies should focus on the social and economic costs of abuse on households to better understand the impact on well-being. Systematic review registration: Open Science Framework: https://osf.io/ykt25/.

Impact of CYP2D6 and CYP2B6 phenotypes on the response to tramadol in patients with acute post-surgical pain

Tramadol is an important minor opioid prescribed for pain management. In this study, we analyzed the well-known impact of CYP2D6 genetic variation and 60 additional variants in eight candidate genes (i.e., ABCG2, SLCO1B1, CYP2D6, CYP2B6, CYP2C19, CYP2C9, CYP3A5, and CYP3A4) on tramadol efficacy and safety. Some 108 patients with pain after surgery admitted to a post-anesthesia care unit (PACU) and prescribed tramadol were recruited. They were genotyped, and tramadol M1/M2 metabolite concentrations were determined by a newly validated HPLC-MS/MS method. CYP2D6 intermediate (IM) and poor (PM) metabolizers showed lower M1 concentrations adjusted for dose/weight at 30 and 120 min compared to ultrarapid (UM) and normal (NM) metabolizers (univariate p < 0.001 and 0.020, multivariate p < 0.001 and 0.001, unstandardized β coefficients = 0.386 and 0.346, R2  = 0.146 and 0.120, respectively). CYP2B6 PMs (n = 10) were significantly related to a higher reduction in pain 30 min after tramadol intake (univariate p = 0.038, multivariate p = 0.016, unstandardized β coefficient = 0.224, R2  = 0.178), to lower PACU admission time (p = 0.007), and to lower incidence of adverse drug reactions (p = 0.038) compared to the other phenotypes. CYP3A4 IMs and PMs showed a higher prevalence of drowsiness and dizziness (p = 0.028 and 0.005, respectively). Our results suggest that the interaction of CYP2B6 and CYP2D6 phenotypes may be clinically relevant, pending validation of these results in large, independent cohorts. Additional research is required to clarify the impact of CYP3A4 genetic variation on tramadol response.

Ameliorative Potential of Pumpkin Seed Oil (Cucurbita pepo L.) Against Tramadol-Induced Oxidative Stress

Background of the Study

The increase in the therapeutic use of tramadol in the management of moderate to severe pains in some disease conditions and its unregulated access has led to its associated toxicity and there is little or no information on the protection against its associated toxicity.

Aim of the Study

Considering the medicinal value of pumpkin seed oil, its availability, and neglected use, it becomes necessary to evaluate the possible potential of the seed oil in tramadol-induced oxidative stress in Wister Albino rats.

Methods of the Study

This study used fifty-six (56) albino rats to determine the impact of Cucurbita pepo seed oil (CPSO) on tramadol-induced oxidative stress. The rats were grouped into 7. After a week of acclimatization, rats in group 1 (normal control) had access to water and food, while rats in group 2 received 5 mL/Kg (b.w) of normal saline. 100 mg/kg of tramadol (TM) was delivered to groups 3-6 to induce toxicity. The third group (TM control) received no treatment, whilst the other 3 groups (TM-CPSO treatment groups) received 5, 2.5, and 1.5 mL/Kg of CPSO, respectively. Group 7 received only 5 mL/kg CPSO (CPSO group). Similarly, groups 2 through 7 had unrestricted access to food and water for 42 days and received treatments via oral intubation once per day. Indicators of oxidative stress were discovered in the brain homogenate.

Results

TM toxicity was demonstrated by a considerable increase (P < .05) in the brain MDA level and a significant drop (P < .05) in the brain GSH level, as well as a significant reduction (P < .05) in GPx, catalase, SOD, GST, and quinone reductase activities.

Conclusion

The dose-dependent delivery of CPSO was able to restore not only the activity but also the concentrations of the altered markers.

Diabetic Neuropathy: An Overview of Molecular Pathways and Protective Mechanisms of Phytobioactives

Diabetic neuropathy (DN) is a common and debilitating complication of diabetes mellitus that affects the peripheral nerves and causes pain, numbness, and impaired function. The pathogenesis of DN involves multiple molecular mechanisms, such as oxidative stress, inflammation, and pathways of advanced glycation end products, polyol, hexosamine, and protein kinase C. Phytochemicals are natural compounds derived from plants that have various biological activities and therapeutic potential. Flavonoids, terpenes, alkaloids, stilbenes, and tannins are some of the phytochemicals that have been identified as having protective potential for diabetic neuropathy. These compounds can modulate various cellular pathways involved in the development and progression of neuropathy, including reducing oxidative stress and inflammation and promoting nerve growth and repair. In this review, the current evidence on the effects of phytochemicals on DN by focusing on five major classes, flavonoids, terpenes, alkaloids, stilbenes, and tannins, are summarized. This compilation also discusses the possible molecular targets of numerous pathways of DN that these phytochemicals modulate. These phytochemicals may offer a promising alternative or complementary approach to conventional drugs for DN management by modulating multiple pathological pathways and restoring nerve function.

Biological Activity of Hexaazaisowurtzitane Derivatives

Biologically active compounds of natural or synthetic origin have a complex structure and generally contain various structural groups among which polycyclic cage amines are found. Hexaazaisowurtzitanes are representatives of these amines and studies on their biological activity began less than two decades ago, starting with research on the environmental impact of CL-20. This research helped to evaluate the risks of potential pollution in the habitat environments of living organisms and determine whether the chemical compounds in question could be utilized in pesticides, herbicides, fungicides, or medicinal drugs. The nomenclature of hexaazaisowurtzitane compounds has recently been expanded significantly, and some of them have demonstrated promise in the design of medicinal drugs. This paper review studies the pharmacological activity of the acyl derivatives of hexaazaisowurtzitane. Most of the compounds have been found to possess a high analgesic activity, providing a solution to the pressing issue of pain management in current pharmacology. Analgesic drugs currently used in the clinical practice do not meet all of the efficacy and safety requirements (gastro-, nephro-, hepato-, haematotoxicity, etc.). The material presented in the seven sections of this paper highlights information about hexaazaisowurtzitane derivatives. Furthermore, they have been observed to exhibit anti-inflammatory, anticonvulsant, antihypoxic, and antimetastatic activities, which render them highly promising for evaluation in various fields of medicinal practice.

Clinical and Laboratory Factors Related to Seizure and Serotonin Toxicity in Tramadol Intoxication: An Egyptian Study

BACKGROUND AND OBJECTIVES

Tramadol is a centrally acting analgesic with a lower risk of addiction compared to opioids. Tramadol overdose is becoming a health crisis in Egypt and is associated with serious and severe adverse effects. This study aims to identify clinical and laboratory findings associated with tramadol-induced seizure and serotonin toxicity in adult Egyptian patients with tramadol overdose.

METHODS

This prospective study included adult patients admitted for tramadol overdose with or without symptoms of seizure or serotonin toxicity. Basic demographic information, clinical symptoms, laboratory measurements, and plasma tramadol concentrations were collected.

RESULTS

A total of 71 patients (79% males) were included in the study. Seizure occurred in 38% of the subjects and was prevalent in male patients with metabolic acidosis or high tramadol concentrations. Serotonin toxicity occurred in 41% of the subjects and was prevalent in patients with hyperthermia, high pulse rate, and high tramadol levels.

CONCLUSION

Seizure and serotonin toxicity are severe adverse effects of tramadol overdose that occur in high frequency among young Egyptians. High tramadol concentrations in plasma seem to play a key role in prevalence of seizure and serotonin syndrome in tramadol-intoxicated adult Egyptians.

Predictors for the Clinical Efficacy of Tramadol for Cancer Pain

CONTEXT

Tramadol is conditionally recommended for cancer pain and is a less expensive drug compared to strong opioids. Thus, tramadol may help reduce health care costs.

OBJECTIVES

To investigate factors that predict the clinical efficacy of tramadol for cancer pain.

METHODS

A retrospective study using electronic medical records was conducted on patients who received tramadol for cancer pain from January 2016 to December 2020. Patients who continued tramadol for >28 days or discontinued tramadol before 28 days owing to pain improvement were considered as clinical efficacy cases.

RESULTS

We identified 183 eligible patients; 104 cases had clinical efficacy. The median starting tramadol daily dose was 100 mg, and the median administration duration was 22 days. Overall, 169 patients (92.3%) discontinued tramadol; pain improvement was the most common reason (34.9%). Age (>70 years), a performance status of 0-1, and an albumin-bilirubin grade of 1 were independent predictors for the clinical efficacy of tramadol. Patients with multiple predictors had significantly higher achievement rates than those without.

CONCLUSION

Tramadol could have greater clinical efficacy for cancer pain in patients who are elderly, have good performance status, and have good liver function.

Supra-inguinal fascia iliaca block in older-old patients for hip fractures: a retrospective study

BACKGROUND

Pain management in hip fracture patients is of great importance for reducing postoperative morbidity and mortality. Multimodal techniques, including peripheral nerve blocks, are preferred for postoperative analgesia. Older-old hip fracture patients with high ASA scores are highly sensitive to the side effects of NSAIDs and opioids. Our aim was to investigate the effectiveness of the recently popularized Supra-Inguinal Fascia Iliaca Block (SIFIB) in this population.

METHODS

Forty-one ASA III...IV patients who underwent SIFIB...+...PCA (G-SIFIB) or PCA alone (Group Control: GC) after general anesthesia were evaluated retrospectively. In addition to 24-hour opioid consumption, Visual Analog Scale (VAS) scores, opioid-related side effects, block-related complications, and length of hospital stay were compared.

RESULTS

Twenty-two patients in G-SIFIB and 19 patients in GC were evaluated. The postoperative 24-hour opioid consumption was lower in G-SIFIB than in GC (p...<...0.001). There was a statistically significant reduction in VAS scores at the postoperative 1st, 3rd, and 6th hours at rest (p...<...0.001) and during movement (p...<...0.001 for the 1st and 3rd hours, and p...=...0.02 for the 6th hour) in G-SIFIB compared to GC. There was no difference in pain scores at the 12th and 24th hours postoperatively. While there was no difference between the groups in terms of other side effects, respiratory depression was significantly higher in GC than in G-SIFIB (p...=...0.01).

CONCLUSION

The SIFIB technique has a significant opioid-sparing effect and thus reduces opioid-related side effects in the first 24 hours after hip fracture surgery in older-old patients.

Non-operative Treatment Options for Osteoarthritis in the Hip

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

Temporal trends and patterns in initial opioid prescriptions after hospital discharge following colectomy in England over 10 years

BACKGROUND

While opioid analgesics are often necessary for the management of acute postoperative pain, appropriate prescribing practices are crucial to avoid harm. The aim was to investigate the changes in the proportion of people receiving initial opioid prescriptions after hospital discharge following colectomy, and describe trends and patterns in prescription characteristics.

METHODS

This was a retrospective cohort study. Patients undergoing colectomy in England between 2010 and 2019 were included using electronic health record data from linked primary (Clinical Practice Research Datalink Aurum) and secondary (Hospital Episode Statistics) care. The proportion of patients having an initial opioid prescription issued in primary care within 90 days of hospital discharge was calculated. Prescription characteristics of opioid type and formulation were described.

RESULTS

Of 95 155 individuals undergoing colectomy, 15 503 (16.3%) received opioid prescriptions. There was a downward trend in the proportion of patients with no prior opioid exposure (opioid naive) who had a postdischarge opioid prescription (P <0.001), from 11.4% in 2010 to 6.7% in 2019 (-41.3%, P <0.001), whereas the proportions remained stable for those prescribed opioids prior to surgery, from 57.5% in 2010 to 58.3% in 2019 (P = 0.637). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Prescriptions for morphine and oxycodone rose significantly by 76.6% and 31.0% respectively, while tramadol prescribing dropped by 48.0%. The most commonly prescribed opioid formulations were immediate release (83.9%), followed by modified release (5.8%) and transdermal (3.2%). There was a modest decrease in the prescribing of immediate-release formulations from 86.0% in 2010 to 82.0% in 2019 (P <0.001).

CONCLUSION

Over the 10 years studied, there was a changing pattern of opioid prescribing following colectomy, with a decrease in the proportion of opioid-naive patients prescribed postdischarge opioids.

Perioperative Pain Management for Distal Radius Fractures

Distal radius fractures have a high incidence among both young and elderly patients, and in many instances require operative intervention. When operative intervention is employed, adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence. Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies.

Substance abuse and male sexual dysfunction: what lies beneath?

INTRODUCTION

Substance abuse has become a worldwide health problem, leading to numerous consequences such as social problems among family members, abnormal behavior, adverse health effects, and psychological problems as well as economic consequences.

OBJECTIVES

We sought to assess the relationship between substance abuse and male sexual health.

METHODS

A search was carried out in the following databases: PubMed, MeSH (Medical Subject Headings), Science Direct, Scopus, Cochrane Library, EMBASE, CINAHL, Academic Search Complete, and the Egyptian Knowledge Bank. The following keywords were used to assess the outcomes for relevant associations: illicit drugs, addiction, substance abuse, sexual health, erectile dysfunction, ejaculatory disorders, impotence, orgasm disorders, and sexual performance.

RESULTS

The initial literature search identified a total of 148 articles in all searched databases. After removal of duplicate studies and application of inclusion/exclusion criteria, 75 reported studies were retained for review, including 38 case-control studies and 37 cross-sectional studies. These articles were classified into the following categories according to the type of abused substance addressed: cannabis/marihuana, 16 articles; opioids, 13 articles; heroin, 11 articles; cocaine, 5 articles; tramadol, 6 articles; ketamine, 2 articles; ecstasy, 4 articles; amphetamine, 2 articles; khat, 7 articles; androgen anabolic steroids, 2 articles; and polydrugs, 7 articles. Most of these recruited articles demonstrated a negative impact of the addressed substance on male sexual health, with variable levels.

CONCLUSION

Substance abuse has negative impacts on male sexual health that should be addressed. More studies conducted with proper methodological and statistical approaches, including logistic regression analysis, are needed to predict the effects of specific substances, considering the rapidly growing effects of non-substance-use disorders on male sexual health.

Post craniotomy pain management in Copenhagen rat by intraperitoneal or oral dosage of Tramadol: a comparative evaluation

Calvarial craniotomy in animal models involves pain and distress. Moderate to severe pain in laboratory animals requires adequate pain management strategies. According to previous studies, the options available for suitable analgesia for rat calvarial craniotomy are very few. For most analgesic treatments, injectable routes of administration are predominantly used. However, these routes require restraining the animals, which may cause unnecessary pain, distress and suffering. As a well-fare measure, we focused on pain management by oral administration of analgesia. In this particular study, which is a sub-study of a major experiment on bone regeneration with different polymeric scaffold materials, we have compared the analgesic efficacy of intraperitoneal (I/P) and oral administration of tramadol (10 mg/kg) over a period of 96 h post-surgery in rat craniotomy models. The focus of our study is to evaluate the potential pain reduction efficacy of orally administered Tramadol without any restraining involved. We have used various non-invasive methods to assess the pain-alleviating efficacy of tramadol administered through different methods. We found that the efficacy of oral administration of tramadol is comparable to I/P administration in alleviating pain. Additionally, oral administration through drinking water has the benefit of not putting the animal under unwanted restraining stress.

Pain and anxiety in patients with breast cancer treated with morphine versus tramal with virtual reality

The treatment of pain and anxiety in cancer patients includes both pharmaceutical and non-pharmacological approaches. The researchers of this study aimed to compare the effectiveness of morphine versus Tramal with virtual reality therapy (VR) in reducing pain and anxiety in female patients with breast cancer. The sample was composed of 80 women with breast cancer who where treated at a specialized cancer center in Jordan. A quasi-experimental design was used in the study intervention. When used with VR, the tramal analgesics did not differe significactly from the effect of morphine in reducing the pain and anxiety. However, both groups had a significant drop in the level of pain and anxiety. When combined with VR, the use of weak opioids such as Tramal will have nearly the same effect as strong opioids such as Morphine in reducing pain and anxiety in breast cancer patients.

Effect of apatinib on the pharmacokinetics of tramadol and O-desmethyltramadol in rats

Since the combination of anticancer drugs and opioids is very common, apatinib and tramadol are likely to be used in combination clinically. This study evaluated the effects of apatinib on the pharmacokinetics of tramadol and its main metabolite O-desmethyltramadol in Sprague-Dawley (SD) rats and the inhibitory effects of apatinib on tramadol in rat liver microsomes (RLMs), human liver microsomes (HLMs) and recombinant human CYP2D6.1. The samples were determined by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The in vivo results showed that compared with the control group, apatinib increased the AUC(0-t), AUC(0-∞) and Cmax values of tramadol and O-desmethyltramadol, and decreased the values of VZ/F and CLz/F. In addition, the MRT(0-t), MRT(0-∞) values of O-desmethyltramadol were increased. In vitro, apatinib inhibited the metabolism of tramadol by a mixed way with IC50 of 1.927 µM in RLMs, 2.039 µM in HLMs and 15.32 µM in CYP2D6.1. In summary, according to our findings, apatinib has a strong in vitro inhibitory effect on tramadol, and apatinib can increase the analgesic effect of tramadol and O-desmethyltramadol in rats.

Tramadol as a patient-initiated component of multimodal pain management: a pilot study of 364 lower limb arthroplasty cases

BACKGROUND

Multimodal therapy (MMT) for analgesia following joint arthroplasty continues to reduce cost and the requirement of strong opioids post-operatively. Tramadol immediate release is an important MMT component providing synergistic pain relief via dual μ-opioid agonism and serotonin and noradrenaline reuptake inhibition. Case reports have shown tramadol when combined with antidepressants cause serotonin syndrome, but this has yet to be demonstrated in larger studies. We undertook a pilot study assessing the functional outcomes and incidence of side effects associated with tramadol in lower limb arthroplasty patients with a focus on those taking concomitant antidepressants.

METHODS

Primary and revision hip and knee arthroplasties performed in 2018-2019 by a senior surgeon were included (n = 364). Patient records were assessed to determine pain scores, length of hospitalization, prescription of tramadol and antidepressants, self-reported side effects and previous adverse reactions associated with tramadol.

RESULTS

Nine-five percentage of patients had been prescribed tramadol, and 16% had concurrent prescription of tramadol and one or more antidepressants. The total rate of adverse effects associated with tramadol before and during the study was 7% (n = 25) including two cases of concomitant tramadol and antidepressant use. For patients on tramadol, median 2-week post-operative pain score was 1.5 (IQR 1-2.5) out of 10 and hospitalization length was 1 (IQR 1-2) days.

CONCLUSION

Tramadol immediate release appears to be well tolerated among our patient population with no significantly increased prevalence of side effects when co-administered with low and moderate dose antidepressants.

Evaluation of Pupillometry for CYP2D6 Phenotyping in Children Treated with Tramadol

Following the contraindication of codeine use in children, increasing use of tramadol has been observed in pain management protocols. However, tramadol's pharmacokinetics (PK) and pharmacodynamics are influenced by cytochrome P450 (CYP)2D6 activity, similarly to codeine. Previous studies in adults have demonstrated a correlation between pupillary response and tramadol PK. Our objective was to evaluate pupillometry as a phenotyping method to assess CYP2D6 activity in children treated with tramadol. We included 41 children (mean age 11 years) receiving a first dose of tramadol (2 mg/kg) in the emergency room (ER) as part of their routine care. CYP2D6 phenotyping and genotyping were performed. The concentrations of tramadol and its active metabolite, M1, were measured, and static and dynamic pupillometry was conducted using a handheld pupillometer at the time of tramadol administration and during the ER stay. Pupillometric measurements were obtained for 37 children. Tramadol affected pupillary parameters, with a decrease in pupil diameter in 83.8% of children (p = 0.002) (mean decrease 14.1 ± 16.7%) and a decrease in reflex amplitude constriction in 78.4% (p = 0.011) (mean decrease 17.7 ± 34.5%) at T150 compared to T0. We were unable to identify a correlation between pupillometry measurements and CYP2D6 activity. Likely confounding factors include light intensity, pain, and stress, making the procedure less feasible in paediatric emergency settings.

Tramadol for chronic pain in adults: protocol for a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials

BACKGROUND

Chronic pain in adults is a frequent clinical symptom with a significant impact on patient well-being. Therefore, sufficient pain management is of utmost importance. While tramadol is a commonly used pain medication, the quality of evidence supporting its use has been questioned considering the observed adverse events. Our objective will be to assess the benefits and harms of tramadol compared with placebo or no intervention for chronic pain.

METHODS/DESIGN

We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis to assess the beneficial and harmful effects of tramadol in any dose, formulation, or duration. We will accept placebo or no intervention as control interventions. We will include adult participants with any type of chronic pain, including cancer-related pain. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and BIOSIS for relevant literature. We will follow the recommendations by Cochrane and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors ('bias') and random errors ('play of chance') will be assessed. The certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

DISCUSSION

Although tramadol is often being used to manage chronic pain conditions, the beneficial and harmful effects of this intervention are unknown. The present review will systematically assess the current evidence on the benefits and harms of tramadol versus placebo or no intervention to inform clinical practice and future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019140334.

Assessment of renal function indexes in methamphetamine or tramadol intoxication adults to the emergency departments: a systematic review and meta-analysis

BACKGROUND

Renal dysfunction is one of the adverse effects observed in methamphetamine (MET) or tramadol abusers. In this study, we aimed to review articles involving intoxication with MET or tramadol to assess the occurrence of renal dysfunction.

METHODS

Two researchers systematically searched PubMed, Scopus, Web of Sciences, and Google Scholar databases from 2000 to 2022. All articles that assessed renal function indexes including creatine, Blood Urea Nitrogen (BUN), and Creatine phosphokinase (CPK) in MET and tramadol intoxication at the time of admission in hospitals were included. We applied random effect model with Knapp-Hartung adjustment for meta-analysis using STATA.16 software and reported outcomes with pooled Weighted Mean (WM).

RESULTS

Pooled WM for BUN was 29.85 (95% CI, 21.25-38.46) in tramadol intoxication and 31.64(95% CI, 12.71-50.57) in MET intoxication. Pooled WM for creatinine in tramadol and MET intoxication was respectively 1.04 (95% CI, 0.84-1.25) and 1.35 (95% CI, 1.13-1.56). Also, pooled WM for CPK was 397.68(376.42-418.94) in tramadol and 909.87(549.98-1269.76) in MET intoxication. No significance was observed in publication bias and heterogeneity tests.

CONCLUSION

Our findings showed that tramadol or MET intoxication is associated with a considerably increased risk of renal dysfunction that may result in organ failure.

Pharmacological Treatments and Therapeutic Drug Monitoring in Patients with Chronic Pain

Pain is an unpleasant sensory and emotional experience that affects every aspect of a patient's life and which may be treated through different pharmacological and non-pharmacological approaches. Analgesics are the drugs most commonly used to treat pain, and in specific situations, the use of opioids may be considered with caution. These drugs, in fact, do not always induce optimal analgesia in patients, and several problems are associated with their use. The purpose of this narrative review is to describe the pharmacological approaches currently used for the management of chronic pain. We review several aspects, from the pain-scale-based methods currently available to assess the type and intensity of pain, to the most frequently administered drugs (non-narcotic analgesics and narcotic analgesics), whose pharmacological characteristics are briefly reported. Overall, we attempt to provide an overview of different pharmacological treatments while also illustrating the relevant guidelines and indications. We then report the strategies that may be used to reduce problems related to opioid use. Specifically, we focus our attention on therapeutic drug monitoring (TDM), a tool that could help clinicians select the most suitable drug and dose to be used for each patient. The actual potential of using TDM to optimize and personalize opioid-based pain treatments is finally discussed based on recent scientific reports.

Tramadol poisoning and its management and complications: a scoping review

Tramadol (TR) is an opioid agonist (μ-opioid receptors) that also affects the noradrenergic and serotonergic systems. TR is a synthetic analgesic substance with opioid agonist properties that has been approved for pain management by affecting the central nervous system.

OBJECTIVE

The primary objective of this scoping review was to determine the poisoning consequences of TR and its associated symptom management techniques, as well as its effect on opioid and non-opioid receptors, metabolism, and complications on various organ systems.

DISCUSSION

Typically, acute overdose of TR is not considered life threatening, and most fatalities are attributed to polysubstance overdose. TR can cause drowsiness, headaches, seizures, respiratory depression, low heart rate, coma, and even death. Additionally, the prolonged use of TR can lead to addiction, with withdrawal resulting in both common and atypical symptoms.

CONCLUSIONS

Therefore, it is recommended that patients with TR poisoning receive close monitoring of their cardiovascular system, along with a comprehensive management plan for their levels of consciousness and respiratory function.

New Perspective for Drug-Drug Interaction in Perioperative Period

In this review, we aim to discuss current information on drug interactions in the perioperative period. During this period, patients receive several drugs that may interact with each other and affect the efficacy and safety of the treatment. There are three types of drug interactions: pharmacodynamic, pharmacokinetic, and pharmaceutical. It is important to recognize that drug interactions may increase the toxicity of the drug or reduce its efficacy, increasing the risk of complications in the perioperative period. This review describes the most commonly used perioperative drugs approved by the FDA and some of the described interactions between them. Thoroughly reviewing a patient's medication list and identifying potential interactions are essential steps in minimizing risks. Additionally, vigilant monitoring of patients during and after surgery plays a pivotal role in early detection of any signs of drug interactions. This article emphasizes the significance of addressing DDIs in the perioperative period to ensure patient well-being and advocates for the implementation of careful monitoring protocols to promptly identify and manage potential interactions.

EPD1504: a novel μ-opioid receptor partial agonist attenuates obsessive-compulsive disorder (OCD)-like behaviors

Low doses of μ-opioid receptor (MOR) agonists rapidly ameliorate symptoms in treatment-resistant obsessive-compulsive disorder (OCD) patients (10-50% of OCD patients). However, the utility of MOR agonists is limited by their safety liabilities. We developed a novel MOR partial agonist (EPD1540) that has an improved respiratory safety profile when compared to buprenorphine. Buprenorphine is a MOR partial agonist primarily used in the treatment of opiate-use disorder, which in investigator-led trials, has been shown to rapidly ameliorate symptoms in treatment-resistant OCD patients. In this study, we show that doses of EPD1504 and buprenorphine that occupy small fractions of MORs in the CNS (approximately 20%) are as effective as fluoxetine at ameliorating OCD-like behaviors in two different rat models (an operant probabilistic reversal task and marble burying). Importantly, effective doses of EPD1504 did not impair either locomotor activity, or respiration under normoxic or hypercapnic conditions. Additionally, EPD1504 had effects comparable to buprenorphine in the conditioned place preference assay. These results indicate that EPD1504 may provide a safer alternative to buprenorphine for the treatment of OCD patients.

Issues and challenges in diabetic neuropathy management: A narrative review

Diabetic neuropathy (DN) is a devastating disorder with an increasing prevalence globally. This epidemic can pose a critical burden on individuals and com-munities, subsequently affecting the productivity and economic output of a country. With more people living a sedentary lifestyle, the incidence of DN is escalating worldwide. Many researchers have relentlessly worked on ways to combat this devastating disease. Their efforts have given rise to a number of commercially available therapies that can alleviate the symptoms of DN. Unfortunately, most of these therapies are only partially effective. Worse still, some are associated with unfavorable side effects. This narrative review aims to highlight current issues and challenges in the management of DN, especially from the perspective of molecular mechanisms that lead to its progression, with the hope of providing future direction in the management of DN. To improve the approaches to diabetic management, the suggested resolutions in the literature are also discussed in this review. This review will provide an in-depth understanding of the causative mechanisms of DN, apart from the insights to improve the quality and strategic approaches to DN management.

Bibliometric Analysis on Global Analgesia in Labor from 2002 to 2021

Background

Maternal pain during labor is one of the most important factors contributing to increased cesarean delivery rates and poor pregnancy outcomes, and this pain can be managed by labor analgesia. Many studies exist on labor analgesia, and the quantity and quality of these studies have not been reported. Therefore, we aimed to perform a bibliometric analysis of studies from 2002 to 2021.

Methods

We used the Web of Science database to obtain publications related to labor analgesia from January 2002 to December 2021. Various bibliographic information was collected, including country; author; journal; grant; discipline; institution and research hotspot. A total of 4536 papers were included.

Results

A total of 4536 articles were included in the study. The country with the most published articles on labor analgesia and the country of the funding agency was the United States. Most articles were published in the disciplines Anesthesiology and Obstetrics & Gynecology. The journal that published the most articles in this category was International Journal of Obstetric Anesthesia. In addition, we found different research hotspots for labor analgesia in the United States, Japan, and China.

Conclusion

This paper provides a bibliometric analysis of research on labor analgesia and highlights the differences in research hotspots for labor analgesia between countries.

Tramadol Provides Similar Pain Relief and a Better Side Effect Profile than Oxycodone (or Hydrocodone) Alone or in Combination With Tramadol After Anterior Cruciate Ligament Reconstruction or Arthroscopic Knee Debridement

Purpose

To evaluate whether tramadol provides similar postoperative pain relief after anterior cruciate ligament (ACL) reconstruction surgery or arthroscopic debridement surgery compared to oxycodone (or hydrocodone) or a combination of tramadol and oxycodone.

Methods

Patients over the age of 14 undergoing ACL surgery or arthroscopic debridement surgery performed by the same surgeon were provided a postoperative pain diary over the first 10 postoperative days. Patients were either provided tramadol, oxycodone (or hydrocodone), or a combination of tramadol in addition to oxycodone (or hydrocodone). Pain scores were measured on visual analog scale (VAS), including average pain, maximum pain, and minimum pain throughout the day. Additionally, side effects and number of over-the-counter analgesics were recorded.

Results

121 patient surveys were reviewed. Tramadol alone for ACL with autograft provided lower average pain scores on postoperative day 1-3 (VAS 3.3 vs oxycodone 6.1 and hybrid of 5.1) with lowest maximum pain on postoperative day 1 (VAS 5.3 vs oxycodone 6.6 and hybrid 5.1) and the lowest number of average nights awakened by knee pain (3.6 vs oxycodone 6.0 and hybrid 8.5). Tramadol alone provided the lowest number of days of constipation (3 vs oxycodone 4.68 and hybrid 4.08), nausea (0.42 vs oxycodone 1.48 and hybrid 1.72), and dizziness (0.68 vs oxycodone 0.84 vs hybrid 1.28). Individual medication group breakdown of ACL surgery with allograft, as well as arthrosopic knee debridements did not have a large enough quantity to have three separate comparison groups.

Conclusions

Tramadol provides similar, and in most cases better, pain relief for ACL reconstruction and arthroscopic knee debridements compared to oxycodone (or hydrocodone) alone or a combination of tramadol with oxycodone (or hydrocodone), while providing a lower side-effect profile.

Clinical Relevance

Alternative analgesic therapies outside of traditional opioids (like oxycodone and hydrocodone) are lacking in popularity or reputation. This retrospective comparative study cohort evaluation can help provide clinicians an alternative analgesic therapy for various knee surgeries that have comparable pain relief with less addictive properties and less side effects.

Modulation of social and depression behaviors in cholestatic and drug-dependent mice: possible role of opioid receptors

Objectives

Social behavior, a set of motivating activities critical for survival, is disturbed in cholestasis conditions and many substance abusers as well as psychiatric disorders. The documented loss of social interest in cholestatic patients may be associated with depressive symptoms. Interestingly, the endogenous opioid system is involved in the modulation of depression.

Methods in this research

, we assessed the effect of cholestasis and drug dependence on social and depression behaviors using the Three-Chamber Paradigm Test, Forced Swim Test (FST), and Tail Suspension Test (TST) as well as Open Field Test (OFT) in male NMRI mice.

Results

The results indicated that alone administration of morphine and tramadol, as well as co-administration of them, increased social motivation and novelty but decreased depression in bile duct ligated mice. Whereas, alone administration of naloxone (a µ-opioid receptor antagonist) and co-administration of it along with morphine and tramadol decreased social motivation and novelty while enhanced depression in the sham-operated and bile duct ligated mice. These administrations of drugs did not change locomotor activity compared to the control group.

Conclusion

In conclusion, it appears that (i) both cholestasis and drug dependence impaired social motivation behavior, as well as induced depression-like behavior in the bile duct, ligated mice, (ii) alone administration of morphine and tramadol as well as co-treatment of them may protect against cholestasis and drug dependence induced abnormal behaviors, (iii) µ-opioid receptors play an important role in modulation of social motivation and depression behaviors in mice.