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EMEDPA

Tramadol, don't do this....

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so I just spent the morning try to get a pt out of status seizures likely brought on by tramadol. Ativan 2 mg x 3, phosFenytoin 1000 mg, and keppra 1500 mg.

folks, if a pt has a hx of seizures, is an alcoholic, and takes 2 psych meds PLEASE do not put them on tramadol ever!

here's a little checklist. this should be on md calc:

 

does your pt have a hx of any seizures other than childhood febrile seizures?

is your pt an alcoholic?

does your pt take any psychiatric medication?

 

if the answer to ANY of the above is yes, DO NOT prescribe tramadol. if you are a pcp with a pt meeting any of the above criteria, please seriously consider transitioning these pts to other medications less likely to induce seizures.

 

rant over. thanks.

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update: I admitted said pt a few hrs ago. she is STILL having breakthrough seizures on keppra + Fosphenytoin. not my problem any more...

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Don't forget serotonin syndrome since Tramadol is a partial mu agonist with 5HTP activity like SSRIs and SNRIs.

 

I see too many folks who are on Cymbalta for pain at max dose AND tramadol at 200 mg per day AND benzos AND long acting narcs with the tramadol for "breakthrough" or some similar combination.

 

In Washington State the Seattle Pain Clinics just got shut down and their lead doc, Dr Li and a few others lost their licenses for deadly narcotic issues.

 

They have over 11,000 patients in the state and now the WSMA and MQAC are asking us all to take these patients on and not leave them abandoned. 

 

Most are over the 120 mg MED level and on frankly stupid combos of medication or suboxone (which most of us don't have cert for). 

 

We have an immense number of people in society who are heavily medicated without a clue.

 

I am not dissing pain or migraines or whatever but we, as a medical society, have allowed for some messed up recipes with deadly results.

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And ----

 

Don't forget the 6-12 pack per day, one ppd cigarettes and some "medicinal" Mary Jane to go with all this crap.

 

Sometimes better living through chemistry can kill you.

 

I'll just stick with cookies - they are bad enough for me.

 

Deep Sigh

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In Washington State the Seattle Pain Clinics just got shut down and their lead doc, Dr Li and a few others lost their licenses for deadly narcotic issues.

 

They have over 11,000 patients in the state and now the WSMA and MQAC are asking us all to take these patients on and not leave them abandoned. 

 

Most are over the 120 mg MED level and on frankly stupid combos of medication or suboxone (which most of us don't have cert for). 

Number I heard was 20,000.  I've personally seen two as new pain management patients since this all blew up, both were under 120 MED/day, both >50yo, both with well-defined ostensibly real problems with a rock-solid consistent PMP report.

 

Of course, we're less likely to see problem patients because my clinic doesn't take new medicare or ANY medicaid, so insurance status already acts as a filter.

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The ONLY case of serotonin syndrome I've yet seen was a pain management pt on max cymbalta who was weaned to tramadol to try to get her off Norco. No kidding, this little lady went through #36 of 60 tramadol 50s in about 16 hr...came in loopy, febrile, tachycardic, hypertensive and not (yet) seizing. Fun times. I've had a healthy respect for the stuff since and can't remember the last time I wrote more than a few tramadol.

 

Sent from my SAMSUNG-SM-N910A using Tapatalk

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Thank you for this post....I work in Rheumatology and often go to Tramadol....I sometimes have patients that come to me on SSRIs and Tramadol and tell them to stop their Tramadol.  Really appreciate this reminder....thread.  Esp the seizure disorder reminder.....

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Number I heard was 20,000.  I've personally seen two as new pain management patients since this all blew up, both were under 120 MED/day, both >50yo, both with well-defined ostensibly real problems with a rock-solid consistent PMP report.

 

Of course, we're less likely to see problem patients because my clinic doesn't take new medicare or ANY medicaid, so insurance status already acts as a filter.

 

 

 

The email and hard copy lit MQAC sent us said 11,200 or so. That is statewide. 

We don't take new Medicare and have a practice of over 10.000 patients with just 3 providers. We really aren't equipped to take on a slew of controlled patients. The need to monitor controlled patients takes basically an entire extra staff member and the reimbursement doesn't really equate it. 

 

We are trying hard to not see any that weren't our existing patients in the first place. We NEVER referred to them but one of their clinics is literally our next door clinic neighbor. Cannot count how many times the police have been there for violence and threats and folks yelling at the door etc etc. 

 

I know pain is real but pain management is not a field I have any desire at this point in my career to endeavor upon.

 

EMED - DANG! One sick lady. Folks just have no idea what they ingest and what it can do to you as well as all the "legal" habits like alcohol and weed (at least in WA). 

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I've seen more people get into trouble with tramadol than many other meds....  although I work in neuro so I'm probably seeing a bigger percentage of folks with suboptimally controlled epilepsy than most

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Thanks for the reminder.  I usually ask the pertinent questions but realize that at times of stress and "seeing as many patients as possible" dictates, I have probably missed a few important questions.  I have seriously changed my prescribing habits over the years to include less and less controlled medications of any class, screen for drug/alcohol/psych disorders and carefully pick meds (or refer out to appropriate providers). Initially when tramadol came out it was touted as the drug that would treat pain and was not addictive and side effects were minimal.  Then......we started hearing that the information was not really true.......

 

At this point of my career I have learned so much more about drug-drug interactions and learned the underlying issues of why people want what they want.  Just the other day my CP and I were talking about "too many cooks in the kitchen" for patients.  Each specialty adds another med, and then they come back to us in FP and I feel I need to stop and possibly undo stuff that has been prescribed.  It's not easy.

 

My other issue is renewing medications when I am on day call for our group.  Invariably, the refills are for controlled substances and I take time to review charts, check our state pharmacy drug monitoring site (for most patients) and then renew if indicated.  But, often I will not put my name on the 120 or 180 # of tablets and reduce the dose to a 5 day supply until they can actually have this renewed by their PCP.  I just had one the other day who was on valium 5mg 4 x a day, hydrocodone 5/325 TID, and temazepam qhs, plus was way past age 65.  Yuck, made me feel sick just thinking about it. 

 

I don't make friends with my group when I only give a short supply, but....carry on.  

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I get a lot of drug seking in the ER I work in, so tramacet/tramadol is ofen an option.  On of our docs is really hesitant to prescribe it for the above reasons - had two cases of serotonin syndrome in elderly folks awhile back.  I still use it as a go to, but am quite wary of the interactions and pick and choose my patients more these days.

 

SK

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I don't make friends with my group when I only give a short supply, but....carry on.  

 

Last I heard we aren't at work to make friends :-)...I tend to tell people that part of my job is to tell them things they don't want to hear.  I took over a family practice where I'd say about 65% of the patients were over 60 and about 65% of those were on temazepam for greater than 5 years and "couldn't do without it".  A lot of upset folks when I told them it was time to move on with life and I'd be weaning them off (most were on it due to losing long term spouses...and someone not really realizing that older folks' sleep patterns change from when they were younger).  Just shake my head some days.

 

SK

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Question - I always thought tramadol was a crappy medication and hard to justify using due to the above reasons. In my ER, however, everyone loves it for these two groups - 1) drug seekers (because it's not really an opiate) and 2) old people (because it's not really an opiate so maybe they think they will have less of a risk of falling). What do you guys think of this? Is tramadol better for old people than hydro or oxy?

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RC2- she did ok after metablozing all her tramadol and getting therapeutic on 3 anticonvulsants.

ERCat- Tramadol has a lot of drug interactions, specifically with things drug addicts and old folks are taking(psych meds, alcohol...)...not a great drug really for anyone...

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Question - I always thought tramadol was a crappy medication and hard to justify using due to the above reasons. In my ER, however, everyone loves it for these two groups - 1) drug seekers (because it's not really an opiate) and 2) old people (because it's not really an opiate so maybe they think they will have less of a risk of falling). What do you guys think of this? Is tramadol better for old people than hydro or oxy?

 

 

1) WRONG - it is Mu receptor active - I think one of the greatest marketing ploys of a drug company was getting Tramadol as unscheduled drug.....  now it is scheduled

2) horrid idea - BEERS list actually lists Ultram, and Start/Stop list opiates (see above) 

 

Ultram is a nasty little drug - think of it like vicodin with side effects - ie seizure threshold, but my favorite (and which is common) is uncontrolled vertigo as a side effect - talk about unenjoyable...

 

I do write it occasionally, as at times it is okay, but not a lot.....  Writing more T3

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Tramadol hasn't really been shown to reduce pain (http://www.ncbi.nlm.nih.gov/pubmed/9701294), and anyone you're prescribing it to who has any tolerance or experience with opiates will not find a benefit from it. I've had a few patients when I was in the Army who I had taking 600mg motrin, 650mg tylenol, 50mg tramadol TID as a cocktail that worked pretty well.

 

With all of the side effects and not really a good benefit, I just don't use it anymore unless a patient is already on it and requests it as an alternative to true narcotics. I'd much rather write someone for 6 hydrocodones to give them 24 hours of relief until they see a PCP (or are at least out of my ED). I'm not making or breaking anyone's drug habit with that, and I don't see the drug seekers and drama queens slowing down anytime soon.

 

There was a good RCT in 2014 (http://www.ncbi.nlm.nih.gov/pubmed/24628747) showing equivalent pain relief from hydrocodone/apap and T3. I've started writing for a lot more T3 since then. Much less abuse goes on, and the people who are actually looking for pain relief should still get it.

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Tramadol is used so much for 'drug seekers', yet, I've seen plenty of patients abuse it and admit they've abused it. Given the awful side effect profile, the drug-drug interactions and known lowered seizure threshold, I'd rather write for Percocet or Vicodin. On the elderly that truly need something besides Tylenol or Ibuprofen, but I'm worried about the narcotic side effects, I'll do a low dose or half tab of Vicodin (2.5mg). Or I dose them in the ED to see how they respond.

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