Treating postoperative pain? Avoid tramadol, long-acting opioid analgesics and long-term use

A recent cohort study investigated ‘the risk of transitioning from acute to prolonged use’ of opioid analgesics in patients undergoing elective surgery. Patients given tramadol or long-acting opioids after discharge were at greater risk of prolonged opioid use than those who were given other short-acting opioids. EBM Verdict on: Chronic use of tramadol after acute pain episode: cohort study. BMJ 2019 May 14. doi: 10.1136/bmj.l1849. Long-acting opioids and tramadol should be avoided when discharging patients from hospital after elective surgery. Alternative short-acting opioids at low doses and for short durations are preferable. Strong pain-relieving medicines called opioids are commonly prescribed when patients are discharged from hospitals. However, pain after elective surgery is usually short-lived. This cohort study1 addresses an important question regarding the prolonged use of opioid analgesics after elective surgery in light of the opioid crisis in the USA and Canada and increased prescribing of opioids in high-income countries.2 Tramadol is both a weak mu-opioid receptor agonist and a serotonin and norepinephrine reuptake inhibitor. Its active metabolite, O-desmethyltramadol, is longer acting than tramadol itself and is a more potent mu-opioid receptor agonist. Responses to tramadol, therefore, vary according to the genotype of the main metabolising enzyme, CYP2D6.3 Tramadol has been available for over 30 years in the UK and for 24 years in the USA (see box 1). It is considered by many to be safer than other opioids. However, deaths from tramadol are increasing.4 Evidence is also emerging that tramadol’s adverse effects are similar to stronger opioids such as fentanyl, which receive stricter regulations by scheduling authorities than tramadol.