Tramadol Workshop Dr' Sol Stern Family Physician Chairman of Palliative Care Halton Healthcare Servi

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Tramadol WorkshopDr. Sol SternFamily
PhysicianChairman of Palliative CareHalton
Healthcare ServicesOakville, Ontario
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Conflict of Interest Disclosure

• Dr. Sol Stern
• Company-Supported Lectures/Conflict of Interest
• AstraZeneca
• Boehringer Ingelheim
• GlaxoSmithKline
• Janssen Ortho
• Merck Frosst
• Pfizer
• Purdue Pharma
• Sanofi Aventis
• Wyeth
• Novartis
• Abbott
• Paladin
• Servier

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Goals and Objectives

• Review the role of family physician in acute and
  chronic pain management
• Discuss some of the barriers to optimal treatment
  of pain in family practice
• Review clinical experience with Tramadol and
  compare it to other available analgesics

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Prevalence of Acute and Chronic Pain

• Family physician sees on average 40 -50 patients
  /day and spend an average of 6 minutes/patient
• Pain and emotional issues are the most common
  presenting complaints
• The far majority of analgesics prescribed for
  patients with pain are prescribed by family
  physicians

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Gaps/Barriers to Managing Pain by Family
Physicians

• Safety of Analgesics including NSAIDs and Coxibs
• Abuse and misuse of opioid analgesics
• Fear of regulatory authorities (CPSO)
• Complexity and time involved treating patients
  with chronic pain
• Lack of education/information re the abuse
  potential of opioids and the safety of NSAIDs

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Chronic Pain WHO Analgesic Ladderfor Patients
with Cancer
WHO ANALGESIC LADDER
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STRONG OPIOIDS For moderate to severe pain
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WEAK OPIOIDS For mild to moderate pain
1
. morphine methadone hydromorphone oxycodone
fentanyl
NON-OPIOIDANALGESICS
tramadol codeine oxycodone
AcetaminophenASA, NSAIDs, COX2s
Adapted from Jacox A, et al. Clinical Practice
Guideline No. 9, 1994 Twycross R. Eur J Pain
19993 (Suppl. A)23-9 NOTE all steps to be
non-opioids and adjuvant .
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Mortality Due To NSAID-Induced Ulcers Canada
An estimated 1,900 Canadians die from
NSAID-induced ulcers each year
Courtesy of Dr. Paul Harris
Anthroscope 1998 - The Arthritis Society (Canada)
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Codeine metabolism

• Codeine works by being converted to Morphine!
• Conversion is via Cytochrome P450, 2D6
• Anything that blocks this enzyme will stop the
  conversion and prevent the formation of Morphine,
  thus preventing the analgesic effect. Eg. Paxil,
  Prozac
• The most constipating of all opioids
• As abusable as other opioids because it is
  essentially morphine.

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Clinical Experience with Tramadol

• Atypical opioid
• Not toxic to organs
• Efficacy at least as good as NSAIDs, Coxibs,
  Tylenol 3, Percocet
• Less opioid related side-effects than other
  opioids (sedation, GI)

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Cautions with Tramadol

• Reduce dosage in renal failure
• Avoid Use with MAO inhibitors
• Advise patients of potential drug interactions
  with SSRI/SNRIs
• Advise patients of potential of lowering seizure
  threshold
• Nausea is the most common side-effect (usually
  transient)

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Observed Benefits

• Sample programs
• Ability to phone in medications and write repeat
  prescriptions
• 30 year Safety Data from Europe
• Constipation very infrequent
• Patient acceptance
• Effective in patients who lack Cytochrome P450
  2D6 enzyme

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Consequences of Scheduling Tramadol

• Patients reluctance to use
• Physician reluctance to prescribe
• Turn back to Tylenol 3 and Tylenol 1
• Why schedule a drug with proven data of low abuse
  potential and still allow the sale of Tylenol 1
  OTC and allow phone in prescriptions of Tylenol
  3 (drugs that have documented evidence of abuse)

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Key Messages

• Tramadol is an effective option for the
  management of both acute and chronic pain and has
  a reasonable safety profile
• Scheduling Tramadol without changing how
  Tylenol 3, 2, and 1are dispensed in Canada
  makes no sense and will deliver a message to
  consumers and physicians that tramadol is
  abusable and codeine is NOT!!!!