SSRIs and SNRIs with Tramadol

[F0nzie]

What is your guys comfort level with prescribing SSRIs/SNRIs while PCP is giving Tramadol?

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[F0nzie]

I have a patient who has tried alternative pain regimens and does best on Tramadol...but also wants to be on Venlafaxine for depression/anxiety.

 

[Shikima]

It wouldn't stop me. Granted there are levels of abuse vs medical necessity. Educate them on depression contributing to pain but also using the least amount necessary to live comfortably. Could try Paxil vs Cymbalta (which is FDA approved for pain).... Could also augment with Neurontin carefully.

 

[F0nzie]

Our state medicaid is also sending us letters of denial if patients are on these combinations and they cannot be overridden. At the community MH site I am either DCing antidepressants, switching to Wellbutrin, or telling pts to seek alternative pain regimens from their pcps.

I do not have these issues in pp because people will pay for their meds out of pocket. But let's say I go over the risks of Serotonin syndrome with this combination and pt agrees. I prescribe it and pt dies of Serotonin Syndrome. Am I liable?

I feel like I am in the grey zone due to a known interaction between 2 meds vs. discussing known risks of a single agent. It's probably not as bad as meperedine + phenelzine but still...

I like the Gabapentin idea.

 

[wolfvgang22]

What is your guys comfort level with prescribing SSRIs/SNRIs while PCP is giving Tramadol?

I see it done all the time, particularly with older patients here in the VA. You'd probably be amazed at the polypharmacy they get by with! I haven't seen any high rates of serotonin syndrome with Tramodol + SSRIs +SNRI in patients I inherited, though. Its not ideal, of course and I try to avoid it.

 

[shan564]

I don't like tramadol because it has a lot of nonspecific psychiatric effects, but I think it's OK to prescribe an SSRI if the patient is aware of the risks. It's not like an IM doc would hesitate to prescribe linezolid to somebody on tramadol...

 

[PikminOC]

UDS the patient.

 

[Ceke2002]

I have a patient who has tried alternative pain regimens and does best on Tramadol...but also wants to be on Venlafaxine for depression/anxiety.

Just speaking from direct experience, this was the exact combination that landed me in the emergency department with serotonin syndrome (300 mgs Tramadol + 75 mgs Venlafaxine) - not exactly an experience I'd be looking to repeat in a hurry. In my case though I was under the care of a GP not a Psychiatrist at the time, the starting dosage of Venlafaxine was most likely too high, and my GP wasn't aware of the risks of serotonin syndrome at that time.

 

[splik]

tramadol is a dirty drug and certainly best avoided in the elderly. But I also think it is vastly preferable to oxycodone/hydrocodone etc and one of the few opiates that seems to have benefit in neuropathic pain (oxycodone and methadone are the other two). It's not even really an opioid, has very little affinity for opioid receptors. Let's look at this another way: would you hesitate to prescribe trazodone + SSRI/SNRI? My guess is no. They tramadol and trazodone are very similar in terms of serotonergic profile. In terms of risk of SS with this combo it is low, but not non-existent. Typically the people we worry about are people on high doses of these serotonergic drugs. The other group are your poor 2D6 metabolizers. I might be more inclined to avoid this combo of serotonergic drugs in that group. If they have medicare, it will cover genotype testing for psychotropic drug prescribing offered by some companies.

I can tell you I have prescribed SSRIs/SNRIs to pts on tramadol for over 4 years without anyone developing SS. There have been case reports. I don't even typically mention the risk of SS. Even if they developed SS this is usually quite trivial, it is much more irregular for people to develop serious SS, and rarer still for people to die. But this is America, of course you could be held liable if the patient died.

(In ceke's case, speaking in generalities, 300mg tramadol is quite a lot. I don't typically consider 75mg venlafaxine a high starting dose often I whack people straight on 150mg without problems, but everyone is different and some of this depends on individual differences in 2D6 oxidation of the drugs, with it being fairly common for people to be poor metabolizers).

 

[splik]

if you are really concerned about potential for SS, another thing to consider is starting at much lower doses and titrating slowly. Which will mean using the IR version to begin. Personally I never start anyone on venlafaxine because of its high potential for terrible withdrawal syndrome, nor duloxetine because it also has a terrible withdrawal syndrome and doesn't even work.

 

[Ceke2002]

tramadol is a dirty drug and certainly best avoided in the elderly. But I also think it is vastly preferable to oxycodone/hydrocodone etc and one of the few opiates that seems to have benefit in neuropathic pain (oxycodone and methadone are the other two). It's not even really an opioid, has very little affinity for opioid receptors. Let's look at this another way: would you hesitate to prescribe trazodone + SSRI/SNRI? My guess is no. They tramadol and trazodone are very similar in terms of serotonergic profile. In terms of risk of SS with this combo it is low, but not non-existent. Typically the people we worry about are people on high doses of these serotonergic drugs. The other group are your poor 2D6 metabolizers. I might be more inclined to avoid this combo of serotonergic drugs in that group. If they have medicare, it will cover genotype testing for psychotropic drug prescribing offered by some companies.

I can tell you I have prescribed SSRIs/SNRIs to pts on tramadol for over 4 years without anyone developing SS. There have been case reports. I don't even typically mention the risk of SS. Even if they developed SS this is usually quite trivial, it is much more irregular for people to develop serious SS, and rarer still for people to die. But this is America, of course you could be held liable if the patient died.

(In ceke's case, speaking in generalities, 300mg tramadol is quite a lot. I don't typically consider 75mg venlafaxine a high starting dose often I whack people straight on 150mg without problems, but everyone is different and some of this depends on individual differences in 2D6 oxidation of the drugs, with it being fairly common for people to be poor metabolizers).

I do remember being told by my GP at the time that 75mgs was an average starting dosage for Venlafaxine, I just don't think she took into account that average or not the dosage probably should have been adjusted to a lower starting point considering the amount of Tramadol I was taking at the time. This was going back about 7 or 8 years ago though, and she didn't really seem to be aware of there being an issue between Tramadol and SSRI's/SNRI's, not at least until I'd reported what happened with me and she went and did some digging online. I'm still on a daily dosage of 400 mgs of Tramadol now (neuropathic pain), so it does limit me somewhat in terms of antidepressant medication if and when it's needed. I mean I'm sure my Psych has more of a clue in terms of medication and what dosages to start off with when taken in conjunction with the Tramadol (I know considering my past history/reactions with medication he tends to adopt more of a 'start low, go slow' approach), it's just that I wouldn't be prepared to take the risk, not again. I do know other people who have or are currently taking both Tramadol and an SNRI/SSRI (including Venlafaxine) without any issue, so yeah I'm assuming with me it was probably a combination of dosage, possibly my weight at the time being a tad on the low side, plus maybe just the way my body happens to respond to/metabolise different meds.

 

[vistaril]

I don't have any problem prescribing ssris with tramadol. A lot of the times we don't even really know what sort of other meds are patients are taking from their medical providers. And if we think we always do we're fooling ourselves you can bet that

 

[Merovinge]

What is your guys comfort level with prescribing SSRIs/SNRIs while PCP is giving Tramadol?

I have done it multiple times and it is not usual at my institute (similar to trazodone +SSRI/SNRI which I have been doing daily lately). I look at 5-HT burden a bit like anticholinergic burden in that there appears to be an exponential increase in rates of serotonin syndrome / anticholinergic delirium with each additional agent that pressures that system. If the patient is taking >2 serotonergic drugs, I'd be much more cautious, but 1 low potency serotonergic agent + SSRI/SNRI I would rarely be worried about.

 

[F0nzie]

I don't have any problem prescribing ssris with tramadol. A lot of the times we don't even really know what sort of other meds are patients are taking from their medical providers. And if we think we always do we're fooling ourselves you can bet that

Keepin it real

 

[vistaril]

I'm just speaking the truth as I always do. We can sometimes get an idea what controlled substances a patient is taking through state databases(for those that have one and bother to use it), but even that's incomplete as the controlled substances listed on the states page is often only a partial glimpse into what controlleds they are really on.

 

[F0nzie]

I'm just speaking the truth as I always do. We can sometimes get an idea what controlled substances a patient is taking through state databases(for those that have one and bother to use it), but even that's incomplete as the controlled substances listed on the states page is often only a partial glimpse into what controlleds they are really on.

Thats true. I think it can give us a false sense of security. Info is not completely in sync or is not reported by the pharmacies. I recently checked database and caught a random PCP giving Ativan to my patient who was discharged from the hospital on Clonazepam. The rx popped after I had already checked it and there was nothing there before. Called the PCP to warn. Then I called the patient but pt already died of an overdose.

 

[vistaril]

Thats true. I think it can give us a false sense of security. Info is not completely in sync or is not reported by the pharmacies. I recently checked database and caught a random PCP giving Ativan to my patient who was discharged from the hospital on Clonazepam. The rx popped after I had already checked it and there was nothing there before. Called the PCP to warn. Then I called the patient but pt already died of an overdose.

the pt died just from overdose of PO Ativan and Klonopin together?

I'm guessing there may have been a few hundred mgs of roxi or whatever going in their arm or up their nose as well.

But yeah, it's pretty hard to keep it all straight. And as you allude to the state databases usually run a couple weeks behind.

 

[F0nzie]

the pt died just from overdose of PO Ativan and Klonopin together?

I'm guessing there may have been a few hundred mgs of roxi or whatever going in their arm or up their nose as well.

But yeah, it's pretty hard to keep it all straight. And as you allude to the state databases usually run a couple weeks behind.

Limited history prior to her death. I never received the autopsy results but presumably in conjunction with other substances.

 

[whopper]

I don't see what the problem is other than that they are heavily serotonergic and could case S-syndrome. In that case just raise the dosage appropriately over time.

If a doc prescribes Tramadol, I'm not exactly worried. Yes it can be abused but abusers tend to not want that one because it's not as much as a problem vs other meds such as Vicodin or Methadone. It could be a sign that the other doctor is trying to reduce use of opioids by trying one with a lower-risk profile.

It's like a patient who could abuse gabapentin. Most do not because of the drugs or meds of abuse readily out there (e.g. cannabis) have a high that is no-where near as good. In prison it's a different story because one cannot get a hold of almost anything other than prescription meds, so in prison, inmates want anything, I mean anything that could alter the mind. I've nicknamed it the marijuana standard.

You got to look at the complete picture. When patients are on high dosages of benzos or opioids, it's almost always been of concern and I've seen hundreds if not thousands of patients on such a regimen where horrific things happened, but looking at my history of seeing several patients on Tramadol, I cannot at this moment recall any standout serious cases where patients were showing signs of addiction/abuse of that medication.

Still be wary but do not be phobic or paranoid.

 

[F0nzie]

Not too worried about abuse. Pts pcp switched to Oxycodone and pt didn't like it. Back on Tramadol 50mg TID.

 

[Shikima]

Anyone ever worried about the abuse of Seroquel?

 

[vistaril]

Anyone ever worried about the abuse of Seroquel?

No....although I find Seroquel to be a pretty poor med in general. At the doses it is supposedly indicated for for bipolar d/o and schizophrenia- most patients can't tolerate it because of sedation(even if increased very slowly).

 

[F0nzie]

Anyone ever worried about the abuse of Seroquel?

Some extreme addicts will overdose on anything you give them. I worry about them.

I recently had an inpatient doctor that discharged my patient with a substance use disorder on Lithium... after he just accidentally overdosed on Lithium (prescribed by another inpatient doc) and ended up in the ICU. The inpatient doc was like "Lithium will reduce his risk for suicide". I was like "he doesn't have Bipolar disorder and he's never suicidal. He presents anxious and irritable in the context of intoxication and withdrawal. His risk for death is greater on Lithium than without." Told the doc to get him off of Lithium before discharge. I met with the pt post discharge. He looked great. Denied drug use. Drug screen was positive for opiates, amphetamines, and benzodiazepines. Admitted to getting them from a friend. Had a withdrawal seizure at the clinic the following month.

 

[whopper]

The data is out that Seroquel is abused.

http://www.jaapl.org/content/40/4/502.full?sid=c3184025-ddae-43d0-9173-fcffc83f0d8e
http://listverse.com/2010/12/21/top-10-abused-prescription-drugs/

It has a street value, when mixed with opioids or cocaine it can enhance the high. Cocaine users swear it helps with the withdrawal sx of cocaine.

Word of advice. When addicts allege something is going on, to the degree where they are willing to shelve out cash for it, something is probably going on for real. I don't know why Seroquel on a pharmacological level would decrease cocaine withdrawal sx but it apparently does. The only thing I can think of is maybe is allows patients to sleep through their withdrawal, but if that's the case why don't they just want any sleep med?

That said, be open to giving Seroquel but establish appropriate boundaries and logic.
1-Why give Seroquel as a first-line? when there's plenty of other meds in the same class that are cheaper, more efficacious, and with lesser metabolic effects?

2-If you give Seroquel first-line what is the logic? Any med given should be based on an logical algorithm of a-efficacy b-side effects and c-price. On all fronts, for most, Seroquel loses in all three categories. A. CATIE (and other studies) established low-efficacy for psychosis and I see that in real life. B: it's a major offender in metabolic problems and excessive sedation and C. It's by far not one of the cheaper atypicals.

The only valid factor I can think of for first-line consideration is if the person is extremely D2-blockage sensitive. The only other reason is there is a recent study showing it is one of the only meds out there shown to reduce sx of borderline PD at 150 mg (but really not more than that demonstrated by it also being given at 300 mg with no added benefit).
http://www.ncbi.nlm.nih.gov/pubmed/24968985
Due to the above study I am now open to giving it first-line for borderline PD but will still refer and use DBT for borderline PD patients.

3-Is your patient in a demographic where you would suspect abuse? (E.g. in prison, substance abuse history, history of selling meds). If so, consider not giving Seroquel first, second, or even third-line.

 

[slappy]

The data is out that Seroquel is abused.

http://www.jaapl.org/content/40/4/502.full?sid=c3184025-ddae-43d0-9173-fcffc83f0d8e
http://listverse.com/2010/12/21/top-10-abused-prescription-drugs/

It has a street value, when mixed with opioids or cocaine it can enhance the high. Cocaine users swear it helps with the withdrawal sx of cocaine.

Word of advice. When addicts allege something is going on, to the degree where they are willing to shelve out cash for it, something is probably going on for real. I don't know why Seroquel on a pharmacological level would decrease cocaine withdrawal sx but it apparently does. The only thing I can think of is maybe is allows patients to sleep through their withdrawal, but if that's the case why don't they just want any sleep med?

Anecdotally, I've been told by a few patients that they use Seroquel as a downer. When you're using uppers like cocaine, you tend to not feel as high as when you take it after you've been clean for a while. Seroquel helps bring you down so you can get the full value for money for your cocaine when you use it. So, it's not so much for withdrawal, and it's not quite used mixed with coke. At least that's what I've been told by those who use them.

 

[Ceke2002]

Anecdotally, I've been told by a few patients that they use Seroquel as a downer. When you're using uppers like cocaine, you tend to not feel as high as when you take it after you've been clean for a while. Seroquel helps bring you down so you can get the full value for money for your cocaine when you use it. So, it's not so much for withdrawal, and it's not quite used mixed with coke. At least that's what I've been told by those who use them.

I knew a few people back in the day who would also use it with the idea that it would afford them protection from drug induced psychosis, and therefore allow them to use more of the drug and/or allow them to use on a daily basis for longer periods of time. And yeah it's also not uncommon for any sort of downers to be used in conjunction with something like speed or cocaine just to even out the ride a bit, so to speak.

Not too worried about abuse. Pts pcp switched to Oxycodone and pt didn't like it. Back on Tramadol 50mg TID.

I actually checked with some of my support group friends who are on a combo of Tramadol + SSRI's/SNRI's. I forgot to ask them what dosage of antidepressants they were on, but none of them are taking any higher dosage than 200mgs when it comes to the Tramadol, and they've reported no ill effects whatsoever. They were made aware of the risks, and what to watch out for in terms of symptoms and stuff like that, but they've been fine and they all report tolerating the combination of medication quite well. Not sure if that's helpful to you or not.

 

[whopper]

Update on my previous post. The price of quietapine is actually competitive now with some other atypicals that have recently gone generic.

Still, I have reservations on giving it unless there's D2 blockage sensitivity.

I knew a few people back in the day who would also use it with the idea that it would afford them protection from drug induced psychosis, and therefore allow them to use more of the drug and/or allow them to use on a daily basis for longer periods of time.

The above could be true but the reason why I'm having doubts with it (hey it's not like I really know the answer cause I never used a "Q-ball") is that several other antipsychotics have been around for decades and haven't garnered quite the same rep as Seroquel has for abuse.

Anecdotally, I've been told by a few patients that they use Seroquel as a downer. When you're using uppers like cocaine, you tend to not feel as high as when you take it after you've been clean for a while. Seroquel helps bring you down so you can get the full value for money for your cocaine when you use it. So, it's not so much for withdrawal, and it's not quite used mixed with coke. At least that's what I've been told by those who use them.

The above actually kind of makes sense. I guess it's like sucking on the lime after a Corona with salt.
Now that I've done.

 

[Ceke2002]

The above could be true but the reason why I'm having doubts with it (hey it's not like I really know the answer cause I never used a "Q-ball") is that several other antipsychotics have been around for decades and haven't garnered quite the same rep as Seroquel has for abuse.

Obviously I can't speak for the situation in the US, and I'm not actually sure what things are like in South Australia at this time (I would hope they've tightened up prescribing practices), but going back 10,15 years ago Seroquel became popular among meth users especially, because it was easy to obtain and didn't really have the same stigma or reputation as other antipsychotics did at the time. Back then you didn't need to purchase it on the street, GPs were more or less prescribing it hand over fist - name an off label use, no matter how flimsy or obscure, and chances are you'd find a GP/PCP who would be willing to write out a script.

 

[Merovinge]

The data is out that Seroquel is abused.

Seroquel reminds me of a pimpled fat kid amungst the 2nd generation neuroleptics when discussed by psychiatrists and while its absolutely not the usual choice for classic psychosis, it's data is pretty good amoung 2 populations. First, in acute Bipolar disease, both for mania and depression it ranks near the top in efficacy from recent studies. Second, in pregnant patients specifically with bipolar its tolerability is better than alternatives in addition to being effective. I feel like many academic psychiatrists Ive met love to hate on Abilify and Seroquel but they definitely have evidence based uses, even if they are not what the chemists had in mind when creating the meds.

 

[vistaril]

The data is out that Seroquel is abused.

http://www.jaapl.org/content/40/4/502.full?sid=c3184025-ddae-43d0-9173-fcffc83f0d8e
http://listverse.com/2010/12/21/top-10-abused-prescription-drugs/

It has a street value, when mixed with opioids or cocaine it can enhance the high. Cocaine users swear it helps with the withdrawal sx of cocaine.

as you implied in another post, pretty much *any* drug that produces any sort of effect has some abuse potential:

1) in the right population
2) if nothing else is available

Seroquel fits in this category imo in much the same way as sedating antihistamines do. yeah, some cocaine people take Seroquel with their cocaine. I've also seen cocaine people do the same with diphenhydramine and such. It's not something Im going to worry about.

 

[Indodo]

I don't know if anyone has already posted this, I didn't read all the posts. However, have you tried mirtazapine?

I have heard tales that good ole rim-ron can be protective against serotonin syndrome.

 

[jettavr6]

Seroquel is starting to become more problematic. Watch out for patients who are taking opioids, especially methadone, who ask for Seroquel.

 

[Wilf]

Just speaking from direct experience, this was the exact combination that landed me in the emergency department with serotonin syndrome (300 mgs Tramadol + 75 mgs Venlafaxine) - not exactly an experience I'd be looking to repeat in a hurry. In my case though I was under the care of a GP not a Psychiatrist at the time, the starting dosage of Venlafaxine was most likely too high, and my GP wasn't aware of the risks of serotonin syndrome at that time.

I would be curious as to whether you truly had serotonin syndrome.

 

[Ceke2002]

I would be curious as to whether you truly had serotonin syndrome.

Hmmm, let's see - extreme confusion, agitation, sweating, muscle rigidity, myoclonic jerking, blurred vision, racing heart, blood pressure through the roof, spent several hours (or more, I was kind of in and out a bit) being stabilised/treated in hospital as a priority 1 emergency, and it was actually explained to me what I was being treated for. So yes, serotonin syndrome.

 

[splik]

I would be curious as to whether you truly had serotonin syndrome.

why? it's not like there is some mass overdiagnosis of serotonin syndrome, it is underrecognized, and she was on a combination of drugs known to cause SS. It is this kind of denial/invalidation of the toxicity of our drugs that gives psychiatry a bad name and makes you look silly.

 

[whopper]

I've also seen cocaine people do the same with diphenhydramine and such. It's not something Im going to worry about.

It could be that in your area this is something that's fine and dandy (no sarcasm meant). Abuse patterns can vary per locality.

The data is also out that simply mixing any antihistamine with an opioid ought to spike it's effect. Forgot which one but one opioid that used to be common already had the antihistamine mixed in it. That specific med is hardly used these days.

That said, in many areas, drug abusers aren't demanding diphenydramine anything like their demands of Seroquel. I recently had a talk with a top guy in the forensic field and he told me that when he was the psychiatrist at the St. Louis County Jail whenever he took someone off of Seroquel that didn't need to be on it, they'd fight him, even get lawyers to write threatening letters to keep them on it. He's not the only one I've who's told me this type of data. While in Atlantic City and Cincinnati the same thing was going on.

I've known no one ever to have that problem with diphenhydramine. While someone could argue that it's because diphenydramine is generic, so why fight over it, then why not simply stop the Seroquel and use diphenhydramine instead to mix with cocaine or opioids? Why would there be a street value for Seroquel if it's abuse effects are simply due to the anithistamine effect when there's already diphenhydramine out there OTC?

It's got to be at least one of the following reasons 1-Drug abusers haven't figured it out (I doubt that. Several drug abusers are quite savvy and know about the antihistamine thing with Seroquel). 2-There's something about Seroquel that on a pharmacological level doing something with abuse.

Personally I would worry about it, though if you readily provided Seroquel to an abuser you'd probably get away with it because so many psychiatrists have no idea it's being abused and give it out like it's candy and no one ever slaps them with a fine or other reprimand.

 

[Ceke2002]

why? it's not like there is some mass overdiagnosis of serotonin syndrome, it is underrecognized, and she was on a combination of drugs known to cause SS. It is this kind of denial/invalidation of the toxicity of our drugs that gives psychiatry a bad name and makes you look silly.

Thank you In fairness to Wilf though some patients do have a tendency to overestimate or exaggerate reactions to medication, and as far as I'm aware serotonin syndrome might be underrecognised but it is still a reasonably uncommon presentation, so I do understand the questioning of my claims. Having said that I totally agree that the toxicity of psych meds, and especially med combinations does need to be validated and recognised more (and actually explained clearly to the patient as well). I had no idea such a thing as serotonin syndrome even existed, until I'd been stabilised enough for the Doctor who was treating me to come in and explain what had happened and what the likely cause was - at which point I was able to take that information to my GP and have her do some research of her own online to see exactly what the risk factors were for her other patients. Had I, or my GP already known there was a risk of serotonin syndrome with a particular combination of meds, no matter how remote the actual risk, I may very well have opted to try a different medication, or we may have been able to agree together to perhaps adopt a different approach when it came to the starting dose, or I might have chosen to try lowering my dosage of Tramadol to a less riskier level before starting a certain medication. Unfortunately those options were closed off to me because there wasn't the awareness or recognition that things could go quite scarily wrong if you combine these two medications - at least not until I ended up in the ED having fluids pumped into me, and various medications pushed through the IV and getting to watch a bunch of Doctor's and Nurses go into a state of, 'excuse me whilst the colour drains from my face after I've just seen the results of your vital signs, we'll be switching into priority one emergency mode right about now'.

 

[Wilf]

why? it's not like there is some mass overdiagnosis of serotonin syndrome, it is underrecognized, and she was on a combination of drugs known to cause SS. It is this kind of denial/invalidation of the toxicity of our drugs that gives psychiatry a bad name and makes you look silly.

But it's very possible to look silly being overly cautious.
We had one case of serotonin syndrome here last year and when the psychiatrist told the anesthesia resident and attending the diagnosis, neither one of them even knew what it was.