A study in the British Medical Journal found that patients who receive tramadol after surgery have a higher risk of longer-term use of the drug. Tramadol is classified as a Schedule IV controlled substance, and drugs like oxycodone are Schedule II because of their addiction risk.

The researchers looked at whether patients who received tramadol alone after surgery went on to use opioids long-term. They found that people who received tramadol had similar to somewhat higher risks of prolonged opioid use when compared with those who received other short acting opioids. They cautioned the use of tramadol as a substitute for other opioids.

Since the opioid addiction crisis, some prescribers have focused on limiting the number of pills prescribed or utilizing multimodal and non-opioid based pain control. Tramadol has seen an increase in use because physicians may consider it safer and less addictive. It is now one of the most commonly prescribed opioids in the country and it used for postoperative acute pain.

Tramadol is different from short acting opioids and its side effect profile includes lower rates of constipation, respiratory depression, overdose and addiction. The FDA classifies it at a lower level than drugs like morphine and oxycodone, so many studies on the impacts of opioids exclude tramadol.

The study looked at claims data from the OptumLabs Data Warehouse between January 1, 2009 through June 30, 2018. They looked at 20 commonly performed procedures and grouped patients by those receiving just tramadol, tramadol with another short acting opioid, no opioid, long acting opioid or one or more short acting opioid other than tramadol. They then grouped patients into categories of opioid use after surgery. Additional opioid use after surgery (at least one opioid fill 90-180 days after surgery), persistent opioid use after surgery (starting 180 days after surgery and lasting at least 90 days) and long-term opioid therapy (180 days after surgery that spans at least 90 days and includes 10 or more opioid fills or 120 more days’ supply of opioids).

Most of the participants received one or more short acting opioids (75%) and 3% received tramadol alone. Of the patients who filled a prescription for opioids after surgery, 7% had one refill 90-180 days after surgery, 1% refilled a prescription 180-270 days after surgery (persistent users), and 0.5% had 10 or more prescription fills (long-term users). Patients in all three of these categories were more likely to have received a prescription for tramadol. Tramadol use increased over the study period and was the third most prescribed opioid in the study at 4%. Hydrocodone was prescribed 51% of the time followed by oxycodone at 38%.

Researchers concluded that tramadol carries a similar or somewhat greater risk of transitioning from acute to prolonged use compared with other short acting opioids and physicians should use a caution level similar to that around prescribing other short acting opioids.

Read more from the BMJ here.