Abstract
The objective of this cohort study was to determine the association between the use of tramadol in emergency departments and the later consumption of opioids at the outpatient level in a group of patients from Colombia. Based on a medication dispensation database, patients over 18 years of age treated in different clinics in Colombia who for the first time received tramadol, dipyrone, or a nonsteroidal anti-inflammatory drug (NSAID) in the emergency room between January and December 2018 were identified. Three mutually exclusive cohorts were created, and each patient was followed up for 12 months after the administration of the analgesic to identify new formulations of any opioid. A Cox proportional-hazards regression model was constructed to identify variables associated with receiving a new opioid. A total of 12,783 patients were identified: 6020 treated with dipyrone, 5309 treated with NSAIDs, and 1454 treated with tramadol. The mean age was 47.1 ± 20.4 years, and 61.6% were women. A total of 17.3% (n = 2207) of all patients received an opioid during follow-up. Those treated with tramadol received a new opioid with a higher frequency (n = 346, 23.8%) than the other cohorts (14.7% NSAIDs and 17.9% dipyrone, both p < 0.001). In the tramadol group, using more than 10 mg of morphine equivalents was associated with a greater use of new opioids (HR:1.47, 95%CI:1.12–1.93). Patients treated with tramadol in emergency departments have a higher risk of opioid use at the one-year follow-up than those treated with NSAIDs or dipyrone.
Highlights
Opioids are a group of drugs used mainly in the treatment of acute pain of moderate to severe intensity, as well as for the management of chronic pain, especially in cancer patients; they are not a first-line option in chronic noncancer pain [1, 2]. e continuous use of these medications generates tolerance, which can lead to abuse and physical and mental dependence, in addition to an increased risk of adverse drug reactions [3, 4]
A cohort study was conducted with patients seen at five clinics in Colombia between January 1 and December 31, 2018, of either sex, older than 18 years, who received tramadol, nonsteroidal anti-inflammatory drugs (NSAIDs), or dipyrone during their stay. e patients were identified from the drug dispensing database of Audifarma SA, which delivers drugs to different clinics and hospitals in the country as well as to outpatients
Discussion e present study found an association between the use of tramadol in emergency departments and the risk of receiving an opioid again in the 12 months after its prescription compared to the use of NSAIDs, acetaminophen, or dipyrone in a group of patients aged over 18 years, affiliated with the Colombian health system. e mean age (53.1 years) of the cohort of patients who received opioids in this study was higher than that found in other studies (21.8–39.7 years) [18, 19], and the proportion of women (56.9%) was higher than that of men, which is consistent with what has been reported in other studies (52.5–72.3%) [5, 13, 18,19,20]
Summary
Opioids are a group of drugs used mainly in the treatment of acute pain of moderate to severe intensity, as well as for the management of chronic pain, especially in cancer patients; they are not a first-line option in chronic noncancer pain [1, 2]. e continuous use of these medications generates tolerance, which can lead to abuse and physical and mental dependence, in addition to an increased risk of adverse drug reactions [3, 4]. Tramadol has been considered a moderately narcotic opioid analgesic since it is a partial agonist of μ (mu) receptors, and it has been found that it has a lower risk of dependence and other adverse reactions compared to other opioid analgesics, such as morphine, methadone, and fentanyl [4, 14, 15]. In studies conducted in Colombia, codeine (57.7%) and tramadol (30.9%) were the most prescribed opioid analgesics in outpatients [16], whereas in patients with postoperative pain in eight clinics in the country, tramadol was the most commonly used (25.8%) [17]. Given the high frequency of the use of tramadol along with the little information about the real risk of increasing the probability of using opioids again, we sought to determine the association between the administration of tramadol or other nonopioid analgesics in emergency departments and the risk of later opioid consumption at an outpatient level in Colombian patients
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