An Unbelievable Article

[TweetyPie]

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[TweetyPie]

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[Seaglass]

It's been going on for years, everyone knows about it, and finally the major journals are doing something about it. I believe that just yesterday JAMA, NEJM, Lancet and others stated they would not publish study results of investigations that were/are not registered at the outset in a public database.

 

[EvoDevo]

Great article. Thanks.

 

[Kilgorian]

Neat story. Good point. Acetaminophin is first-line.

 

[erichaj]

Here is what I do:

Plan 1.

tylenol #3 for the first couple of days to take edge off.
Ulram or ultracet is also acceptable.
Valium as a muscle relaxer. Short term.

Not all of the above at once, I pick one or two depending on the presentation.

Ultram is expensive but is not a narcotic and used short term it works well.

Valium is a cheap muscle relaxer, much cheaper than felxeril and works well.

tylenol #3 takes the edge off.

By the way, the DEA does not come after doctors when they give medicine for short term pain control.

Plan 2.

Torodol 60 IM. plus zantac or prevacid samples.

Lortab 7.5 short term.


ALL OF THEM LEAVE WITH AN EXERCISE PLAN FOR BACK CARE AND DIRECT INSTRUCTION TO GET F/U WITH PCP TO BE PLACED IN REHAB FOR BACK OR
PHYSIATRY F/U AS NEEDED.

I PICK THE PLAN BASED ON SEVERITY OF PT.

A note on vioxx and all the other cox-2 medicines.

I agree, they are a myth. But they do have one advantage if you can afford them. They are once per day.

EH.

 

[Sessamoid]

I rarely use Ultram. Very expensive (epocrates says $30.77 for 30 tablets, probably much more at Walgreens). I also recently saw my first otherwise healthy young adult bounce back (not my Rx) because of a seizure probably due to tramadol (it's on the list of adverse effects). Scared the bejeezus out of the patient and family. I couldn't see any reason the patient couldn't have been started on ibuprofen or something similar instead. I use it rarely with patients with both NSAID allergies, pain too severe for acetaminophen alone, and a good reason not to take opioids (rehab patients, for instance).

Valium is great for muscle relaxation. Beats the hell out of the more expensive "muscle relaxants" (i.e. flexeril, soma, etc.).

I can count the number of times I've prescribed a Cox-2I on the fingers of one hand, and those were just refills. They're expensive, they aren't as effective as traditional NSAIDs, their benefits are largely imaginary, and they can trigger heart failure. Yuck.

 

[mikecwru]

I don't believe H2 blockers or PPIs prevent the gatritis/ulcers associated with NSAIDs.

Here is what I do:

Plan 1.

tylenol #3 for the first couple of days to take edge off.
Ulram or ultracet is also acceptable.
Valium as a muscle relaxer. Short term.

Not all of the above at once, I pick one or two depending on the presentation.

Ultram is expensive but is not a narcotic and used short term it works well.

Valium is a cheap muscle relaxer, much cheaper than felxeril and works well.

tylenol #3 takes the edge off.

By the way, the DEA does not come after doctors when they give medicine for short term pain control.

Plan 2.

Torodol 60 IM. plus zantac or prevacid samples.

Lortab 7.5 short term.


ALL OF THEM LEAVE WITH AN EXERCISE PLAN FOR BACK CARE AND DIRECT INSTRUCTION TO GET F/U WITH PCP TO BE PLACED IN REHAB FOR BACK OR
PHYSIATRY F/U AS NEEDED.

I PICK THE PLAN BASED ON SEVERITY OF PT.

A note on vioxx and all the other cox-2 medicines.

I agree, they are a myth. But they do have one advantage if you can afford them. They are once per day.

EH.

 

[edmadison]

I don't believe H2 blockers or PPIs prevent the gatritis/ulcers associated with NSAIDs.

This is correct, I say it in a review in the past few days, I just can't remember where.

 

[ERMudPhud]

Ultram is expensive but is not a narcotic and used short term it works well.

Take a look at the PDR under mechanism of action. It binds opiate receptors which makes it a narcotic in my book. Ultram withdrawl also looks just like opiate withdrawl. It is marketed as being somewhat different because it also has some wellbutrin like reuptake inhibition properties and was marketed as nonaddicting since the initial clinical trials involved only fairly short periods of use. Hell you could probably take oxycontin for 4 or 5 days without getting physically addicted too.

 

[neutropeniaboy]

Take a look at the PDR under mechanism of action. It binds opiate receptors which makes it a narcotic in my book.

Huh?

That's like saying Tylenol is an NSAID because it's been
shown to inhibit COX-3.

 

[starayamoskva]

This is correct, I say it in a review in the past few days, I just can't remember where.

PPI's and H2 blockers don't prevent stomach problems from NSAIDS but Cytotec does. Just don't give it to pregnant women.

 

[Gauss]

Take a look at the PDR under mechanism of action. It binds opiate receptors which makes it a narcotic in my book. Ultram withdrawl also looks just like opiate withdrawl. It is marketed as being somewhat different because it also has some wellbutrin like reuptake inhibition properties and was marketed as nonaddicting since the initial clinical trials involved only fairly short periods of use. Hell you could probably take oxycontin for 4 or 5 days without getting physically addicted too.

narcotic implies it induces narcosis = sleep. It's a bad term with illegal drug connotations. It binds weakly to mu opiate receptor and I have never heard of severe withdrawal from it.

 

[Newdoc2002]

Once again, the ACEP shows its obvious ascension into the unbiased and useful medical journals 🙄 . This rag continually puts out crap like this and while it is absolutely important that you consider SE's and appropriate treatment of chronic conditions, I wouldn't base any of my prescribing on an article such as this with some ill attempt at references and distorted statistics.

PS Tramadol is an opioid. I would know your drug classification among other things before you prescribe it.

 

[Hotsauce21]

PPI's and H2 blockers don't prevent stomach problems from NSAIDS but Cytotec does. Just don't give it to pregnant women.

this is not true. ppi's are FDA approved for prevention, as well as cytotec. PPI's may be slightly less efficacious, however.

also, using valium in older patients and other narcotics have side effects too. i.e. delirium (average increase in stay for delirium is a week) and for narcotics, constipation w/u, mental status changes, etc.
nsaids have the more immediately dangerous complication in gibleeds though. again ppi's give some protection.

also, a cox-2 inhibitor is no better than a non-specific nsaid when it is used in conjunction with other nsaids/steroids/or aspirin. there is data for this.

the point: dont use coxib when you have other cox inhibitors on board, its a waste of money. it may save money, however, if it means you dont have to use a PPI.

 

[fourthyear]

All medications we prescribe should be given with caution and we should inform patients of common side effects or adverse reactions if they are common enough or serious enough to make a special point about, and I think this issue of GI risk is one we should be telling patients about.

However, I do NOT think we should discontinue use of NSAIDS. The truly do help many people. I have seen so many patients who have tried acetominophin and even non-prescription strength ibuprofen with no relief - start them on celebrex/vioxx/ect. and they feel better than ever. Personally I have taken tylenol for pain and felt no releif, but gotten great relief for same pain from a prescription NSAID. I've also used them for post-op patients who were difficult to wean off of IV narcs and onto only PO narc meds - add some toradol or vioxx and you can get a lot of people with pain issues off the morphine earlier. NSAIDS control pain very well.

Acetominophin is not without risks - LIVER TOXICITY, especially in people with already comprimised livers or hepatitis (Hep C is becoming much more prevalent and many people have no idea they have it). Also, if you are giving a narcotic with acetominophen in it you MUST caution patients to not be combining it with tylenol such that the total dosage is toxic.

 

[Sessamoid]

start them on celebrex/vioxx/ect. and they feel better than ever.

Every person is different, but the evidence doesn't support COX2Is being any better than nonselective NSAIDs at pain control, and the supposed GI benefits are illusory, i.e. just hype from big pharm companies.

NSAIDS control pain very well.

No argument there. However, supposed "prescription doses" of NSAIDs haven't been shown to be any more effective at pain relief than lower dosages. There's a cap on the effective dose, after which additional dosage only increases side/adverse effects.

Acetominophin is not without risks - LIVER TOXICITY, especially in people with already comprimised livers or hepatitis (Hep C is becoming much more prevalent and many people have no idea they have it).

Acetominophen's liver toxicity is blown out of all proportion. The therapeutic index for it is fantastic. You have to take a whopping huge dose to hurt your liver, and studies have shown that unless you have active liver disease (not chronic hepatitis), therapeutic doses of acetominophen do not put you at greater risk of liver failure.

 

[ERMudPhud]

narcotic implies it induces narcosis = sleep. It's a bad term with illegal drug connotations. It binds weakly to mu opiate receptor and I have never heard of severe withdrawal from it.

Drug Alcohol Depend. 2003 Apr 1;69(3):233-41.
Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur.

Senay EC, Adams EH, Geller A, Inciardi JA, Munoz A, Schnoll SH, Woody GE, Cicero TJ.

Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA.

In 1994, the Drug Abuse Advisory Committee (DAAC) of the Food and Drug Administration (FDA) concluded that Ultram (tramadol hydrochloride) could be marketed as an analgesic drug without scheduling under the Controlled Substances Act based upon extensive pre-clinical, clinical and European epidemiological data. However, to guard against unexpectedly high levels of abuse in the United States, the DAAC recommended that an independent steering committee (ISC) be appointed to proactively monitor abuse/dependence. In the event that high rates of abuse were found, this ISC was given the authority to immediately recommend to the FDA that Ultram be scheduled. In the course of the surveillance project, the ISC received reports of withdrawal following abrupt discontinuation of Ultram and in some instances, following dose reductions. In most cases, the withdrawal symptoms consisted of classical opioid withdrawal, but in some cases were accompanied by withdrawal symptoms not normally observed in opiate withdrawal, such as hallucinations, paranoia, extreme anxiety, panic attacks, confusion and unusual sensory experiences such as numbness and tingling in one or more extremities. Withdrawal symptoms of either type were one of the more prevalent adverse events associated with chronic Ultram use, comprising nearly 40% of all adverse events reported with Ultram. Most of these consisted of typical opiate withdrawal symptoms, but 1 in 8 cases presented as atypical. These results indicate that physicians and other healthcare professionals need to be aware of the potential of Ultram to induce withdrawal of the classical opioid type, and that atypical withdrawal may also occur.





There are also case reports of fatal isolated ultram overdoses. However, it is a little unclear if this was do to resp depression(narcosis) or other mechanisms since most of them were found dead. There is one case report in the EM literature of respiratory depression in ultram overdose responding to narcan.

Tramadol overdose requiring prolonged opioid antagonism.
Am J Emerg Med. 1997 Mar;15(2):217-8.

Don't assume that because you are giving your patient ultram you aren't really just substituting one opiod for another.

 

[ERMudPhud]

Oh and just for fun here is the original description of the synthesis of a morphine like molecule which subsequently became known as Tramadol.

[On separation of isomeres, structural elucidation and pharmacological characterization of 1-(m-methoxyphenyl)-2-(dimethylaminomethyl)-cyclohexan-1-ol (author's transl)]

[Article in German]

Frankus E, Friderichs E, Kim SM, Osterloh G.

1-(m-Methoxyphenyl)-2-(dimethylaminomethyl)-cyclohexan-1-ol (L 201) was split into the cis- and trans-isomers and the conformations of the two isomers were determined by 13C-NMR-spectroscopy. Molecule models showed that both conformeres were similar to the geometrical structure of morphine. The adaptation of the morphine structure was better with the more active trans-isomer than with the cis-isomer. Tramadol, the trans-isomer, was separated into its optical antipodes. When tested for analgesia in the electro-stimulation test with mice, all compounds showed analgetic activity. The trans-isomer was more active than the cis-isomer and the (+)-form of the trans-isomer was more active than the (--)-form. Given by s.c. route, the (+)-transisomer E 382 was 1/3 as active as morphine. However, the Straub-tail reaction and the withdrawal jumping tests yielded more favourable results with L 201 and tramadol than with E 382.

 

[ERMudPhud]

Huh?

That's like saying Tylenol is an NSAID because it's been
shown to inhibit COX-3.

Nah, it more like saying if a compound is structurally related to morphine, binds opiate receptors, has many of its therapeutic and toxic effects reversed by naloxone, can result in respiratory depression and death in overdose, and gives a dependence and withdrawl picture much like other opiates, then you probably shouldn't think you are providing some sort of unique nonopiate analgesia when you give it to your patients.

 

[Celiac Plexus]

Nah, it more like saying if a compound is structurally related to morphine, binds opiate receptors, has many of its therapeutic and toxic effects reversed by naloxone, can result in respiratory depression and death in overdose, and gives a dependence and withdrawl picture much like other opiates, then you probably shouldn't think you are providing some sort of unique nonopiate analgesia when you give it to your patients.

Who cares if you give the guys an opioid? If the guy is tremendous pain from a muscle strain, then how about just giving him a scrip for 5 days of skittles (percocet) and tell him to f/u with his pcp?

I don't understand the anxiety over prescribing pain medicine to people who are in pain. A patient in extreme pain is not gonna get blazed out on a 5/325 percocet. The percocet is just gonna ease the pain. He's not gonna get addicted to "opioids" and wind up mainlining heroin after taking percocet for a few days. As long as the patient is genuinely in pain, and is not a drug-seeker, then use an appropriate pain pill.

This case seems like a fine example of giving some percocet. Acetaminophen is a neat little drug. I love it. Just add a sprinkle of oxycodone and it's perfect!

 

[ERMudPhud]

Who cares if you give the guys an opioid? If the guy is tremendous pain from a muscle strain, then how about just giving him a scrip for 5 days of skittles (percocet) and tell him to f/u with his pcp?

I don't understand the anxiety over prescribing pain medicine to people who are in pain. A patient in extreme pain is not gonna get blazed out on a 5/325 percocet. The percocet is just gonna ease the pain. He's not gonna get addicted to "opioids" and wind up mainlining heroin after taking percocet for a few days. As long as the patient is genuinely in pain, and is not a drug-seeker, then use an appropriate pain pill.

This case seems like a fine example of giving some percocet. Acetaminophen is a neat little drug. I love it. Just add a sprinkle of oxycodone and it's perfect!

Exactly, the whole discussion started over a discussion about using ultram as a non-narcotic pain reliever. An all to common (mis)perception about Ultram which is encouraged by the manufacturer. I've seen it given to recovering narcotic addicts and known drug seekers by physicians who thing they are not giving an opiate. I give narcotics freely but I tend to choose cheap ones like oxycodone, dilaudid, or morphine.