Priority Areas - Analgesics: Tramadol

This indicator promotes a prudent approach to prescribing tramadol, taking into account the risks and benefits and encouraging timely review. There is increasing evidence that tramadol has the potential for harm and abuse. Cases of dependency have been described and there are reports of an increasing street value and risk of misuse.

Tramadol is an opioid analgesic licensed for the treatment of moderate to severe pain. Tramadol produces analgesia by two mechanisms: an opioid effect and an enhancement of the serotonergic and adrenergic pathways. It has fewer of the typical opioid side effects (notably, less respiratory depression, less constipation and less addiction potential); however psychiatric reactions have been reported. The unique dual-action pharmacological profile of tramadol increases the risk of adverse effects seen in overdose.

 Analgesics - Tramadol

  • While there is a recognised place in pain management for tramadol, there are concerns regarding abuse, dependence and deaths involving tramadol, in addition to the risks associated with misuse and diversion.
  • The unique dual action pharmacological profile of tramadol increases the risk of adverse effects seen in overdose.
  • Hallucinations, confusion and convulsions as well as rare cases of dependence and withdrawal symptoms have been reported with tramadol at therapeutic doses.
  • Tramadol should be used with caution in patients taking concomitant medicines that can lower the seizure threshold, such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).

Trend in Tramadol prescribing

 Graph 7 Trend in tramaol prescribing

Trend graph key

 

 Tramadol DDDs per 1,000 patients - Quarter ending September 2019

Graph 8 Tramadol Wales England

 Key for graph

If it is appropriate for a patient’s tramadol to be stepped down or stopped, it is important to note that the dose must be reduced slowly to ensure the patient’s safety and to minimise the risk of withdrawal symptoms or adverse reactions. Where physical dependence to tramadol develops, the withdrawal syndrome can be severe, with symptoms typical of opiate withdrawal sometimes accompanied by atypical symptoms including seizures, hallucinations and anxiety.

To encourage patient engagement and concordance, a suggested approach would be to reduce the dose at each reduction step, for example, by one 50 mg dose, and to titrate according to how the patient manages, rather than by setting time limits for the next reduction. Every patient and their circumstances will be different, and a prudent and individually tailored approach is required.

The All Wales Medicines Strategy Group has a range of resources on tramadol which can aid prescribers undertake reviews and implement reduction strategies. These are available to download from www.awmsg.org.

How can changes be made?

  • Use the AWMSG Tramadol Shared Decision Making Toolkit with patients when consideration is being given to prescribing tramadol.
  • Provide patients with the AWMSG Tramadol Patient Information Leaflet where tramadol is initiated.
  • If it is appropriate for a patient’s tramadol to be stepped down or stopped, reduce the dose slowly to ensure the patient’s safety and to minimise the risk of withdrawal symptoms and/or ADRs. Where physical dependence to tramadol develops, the withdrawal syndrome can be severe, with symptoms typical of opiate withdrawal sometimes accompanied by seizures, hallucinations and anxiety.
  • To encourage patient engagement and concordance, a suggested approach would be to reduce the dose at each reduction step, e.g. by one 50 mg dose, and to titrate according to how the patient manages, rather than by setting time limits for the next reduction.
  • Carry out the tramadol audit – AWMSG Tramadol Educational Resource Materials: Audit Materials.

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