Should Tramadol Go Schedule II: Implications for Pain Patients

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Should Tramadol Go Schedule II?

  • No, it's bad for patients...

    Votes: 20 64.5%

  • Yes, it's about friggin time!

    Votes: 11 35.5%
  • Total voters
    31
drusso

drusso

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"Public Citizen filed a petition with the Drug Enforcement Administration and the Food and Drug Administration to reclassify Tramadol, an opioid that is used to treat severe pain in adults. The advocacy wants Tramadol designed a Schedule II controlled substance because it is overprescribed, often misused, highly addictive, and potentially deadly — and therefore, contributes to the opioid crisis. Currently, the drug is listed as a Schedule IV drug, which are those with a low potential for abuse and a low risk of dependence."
 
It's "overprescribed" because doctors are looking for a pain medication that isn't schedule II.

Doubt it's actually addicting considering how many patients complain it doesn't work.

"Often misused" - is there data on this?
 
Anyone want to look at the numbers for deaths associated with Motrin versus tram at all. I think that 8000 for Motrin and maybe five for tramadol would be likely. That is outside of polysubstance overdose or tramadol is in the mix but did not kill anybody.
 
Had few patients in fellowship who told us they were buying tramadol off street and using a 50mg tab 2-3 days per week. Strangely, all employed, mostly working well paying but hard labor jobs full time and reported they used this to continue working. Essentially the poor man's opioid. Surprise why they couldn't just get a pcp to write for it. Didnt write for and didn't recommend continued use of street tramadol.

Also strange is that we get a lot of pcp referrals and outside pain provider "opiate dumps" on norcos, oxys. Very rare to see them on tramadol coming to our clinic. Maybe one who was on tramadol 200 mg extended release for years without abberancy and overall poor candidate for interventions.

Is becoming a popular drug of abuse in third world countries and the middle east. Vice had a piece about this a few months back.
 
Relative to other opioids, tramadol has been reported as a weak agonist of the µ-opioid receptor, binding to the human µ-opioid receptor with an affinity constant (Ki) of 2.4 micromolar (µM) in vitro. 11,12 However, the (+)-enantiomer of its M1 metabolite shows a nearly 700-fold higher affinity (Ki=3.4 µM) for the human µ-opioid receptor in vitro than the parent compound.13

Other studies report d-tram is 200x more affinity than tram. So where is codeine? Trezix? Butrans? Belbuca? Suboxone?

This does not add up.

It is the person and not the drug. Especially not this drug.
 
Anecdotally speaking, Tramadol seems to be one of the hardest meds to wean off in long-time users in my experience.
 
lobelsteve said:
It is the person and not the drug. Especially not this drug.
Click to expand...

Gabapentin is being reported here and there as a drug of abuse. I've seen this once. I'll put tramadol somewhere on the spectrum between gabapentin and Norco. It is still an opioid and addictive. I see this more in my Medicaid/county population in people who are looking at it as a replacement for Norco. I have other patients who have been on it years taking it from a few times a month to 2x a day.
 
Wasn’t there talk among medical societies to try to schedule muscle relaxers?(besides soma). Not sure if that fell through
 
TheLoneWolf said:
Had few patients in fellowship who told us they were buying tramadol off street and using a 50mg tab 2-3 days per week. Strangely, all employed, mostly working well paying but hard labor jobs full time and reported they used this to continue working. Essentially the poor man's opioid. Surprise why they couldn't just get a pcp to write for it. Didnt write for and didn't recommend continued use of street tramadol.

Also strange is that we get a lot of pcp referrals and outside pain provider "opiate dumps" on norcos, oxys. Very rare to see them on tramadol coming to our clinic. Maybe one who was on tramadol 200 mg extended release for years without abberancy and overall poor candidate for interventions.

Is becoming a popular drug of abuse in third world countries and the middle east. Vice had a piece about this a few months back.
Click to expand...
Why can't any doc write for? Why does it have to be a PCP?
 
It’s possible to abuse Tramadol. It just takes a lot more work ... like take 10 tabs, wait 20 minutes, take another 10 tabs, wait another 20 minutes, and repeat until you feel “high.” It explained why my squirrelly patient went and filled 240 tabs from his PCP a week after I gave him 120.
 
Agast said:
It’s possible to abuse Tramadol. It just takes a lot more work ... like take 10 tabs, wait 20 minutes, take another 10 tabs, wait another 20 minutes, and repeat until you feel “high.” It explained why my squirrelly patient went and filled 240 tabs from his PCP a week after I gave him 120.
Click to expand...
When i was on psych rotation as a third year Med student, the first drug abuse consult we got was for Benadryl abuse in a 90 year old. People will abuse anything
 
People will abuse anything including OTC meds. I’m sure there are probably some cases of tramadol abuse but I’ve been out on my own for 4 yrs now and have yet to have a patient walk in in my office begging me to write them tramadol. They need to make benzos schedule II if anything.
 
Tramadol was an OTC drug around 6 years ago...


People will always find something to abuse.
 
Splenda88 said:
Tramadol was an OTC drug around 6 years ago...


People will always find something to abuse.
Click to expand...

I will beat that: 10-15 years ago there were bottles of Ultram ER available as free pharm-rep samples.

This would be more proof of my fundamental rule that outside of the PMP databases, everything done in the "war on opioids" has backfired. As a recently retired EM doc, it seems that the moving of hydrocodone products to schedule II has actually increased the prescribing of oxycodone by PCPs. The P meaning primarily "providers" as opposed to physicians. "They are both C-II, so we might as well go with percocet." Tramadol has its problems, but I would rather it be prescribed than lortab or percocet.
 
lobelsteve said:
Relative to other opioids, tramadol has been reported as a weak agonist of the µ-opioid receptor, binding to the human µ-opioid receptor with an affinity constant (Ki) of 2.4 micromolar (µM) in vitro. 11,12 However, the (+)-enantiomer of its M1 metabolite shows a nearly 700-fold higher affinity (Ki=3.4 µM) for the human µ-opioid receptor in vitro than the parent compound.13

Other studies report d-tram is 200x more affinity than tram. So where is codeine? Trezix? Butrans? Belbuca? Suboxone?

This does not add up.

It is the person and not the drug. Especially not this drug.
Click to expand...
I read a paper last year that concluded that although the M1 of Tramadol has a high affinity for µ-opioid receptor in vitro, it has a very difficult time crossing the BB barrier. I'm sorry I am too lazy to look it up.

One of the inherent things I like about Tramadol is its max dose. I've personally never seen it abused, never had a pt run out early. Never had a pt admit to taking more than prescribed.

I'm sure it's abused by some but I continue to think it's a good choice for some pts.
 
hyperalgesia said:
I read a paper last year that concluded that although the M1 of Tramadol has a high affinity for µ-opioid receptor in vitro, it has a very difficult time crossing the BB barrier. I'm sorry I am too lazy to look it up.

One of the inherent things I like about Tramadol is its max dose. I've personally never seen it abused, never had a pt run out early. Never had a pt admit to taking more than prescribed.

I'm sure it's abused by some but I continue to think it's a good choice for some pts.
Click to expand...

I'd go other way and make it OTC. Will see overdose ER visits go up for 1-2 years, but all cause mortality should drop due to safety awareness campaign at same time for NSAIDs.
 
I have seen a few cases of tramadol addiction and also several of tramadol dependence, and I agree, that wean off completely seems less tolerated than with pure mu opioids. the problem is that one believes that it is less addictive and less abused, and it essentially is a self fulfilling condition.

suspect addiction has to do with variable expression of CYP2D6, in a mechanism similar to how codeine can lead to overdose in some and minimal clinical effects in others.


yes it is less addictive than these pure mu agonists... but is that the bar we are setting: "its less addictive, so make it available to everyone"? that's almost touching the ground...
 
Codeine is OTC in Canada, so is methocarbamol. I know plenty of people who buy them there because "it works better than tylenol" and are floored when I tell them they are taking opiates and sedatives without a prescription. :shrug:
 
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