Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

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RxCowboy

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#1
We shouldn't be treating chronic pain with opioids. From JAMA:

March 12, 2019
Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis
Chao Zeng, MD, PhD; Maureen Dubreuil, MD, MSc; Marc R. LaRochelle, MD, MPH; et al

JAMA. 2019;321(10):969-982. doi:10.1001/jama.2019.1347

Key Points
Question Is tramadol prescription associated with a higher risk of all-cause mortality than other pain relief medications among patients with osteoarthritis?

Findings In this cohort study that included 88?902 patients with osteoarthritis, initial prescription of tramadol was associated with a significantly increased risk of mortality over 1 year compared with initial prescription of naproxen (hazard ratio [HR], 1.71), diclofenac (HR, 1.88), celecoxib (HR, 1.70), and etoricoxib (HR, 2.04), but not compared with codeine (HR, 0.94).

Meaning Tramadol prescription may be associated with increased all-cause mortality compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but further research is needed to determine if this relationship is causal.

Abstract
Importance An American Academy of Orthopaedic Surgeons guideline recommends tramadol for patients with knee osteoarthritis, and an American College of Rheumatology guideline conditionally recommends tramadol as first-line therapy for patients with knee osteoarthritis, along with nonsteroidal anti-inflammatory drugs.

Objective To examine the association of tramadol prescription with all-cause mortality among patients with osteoarthritis.

Design, Setting, and Participants Sequential, propensity score–matched cohort study at a general practice in the United Kingdom. Individuals aged at least 50 years with a diagnosis of osteoarthritis in the Health Improvement Network database from January 2000 to December 2015, with follow-up to December 2016.

Exposures Initial prescription of tramadol (n = 44 451), naproxen (n = 12 397), diclofenac (n = 6512), celecoxib (n = 5674), etoricoxib (n = 2946), or codeine (n = 16 922).

Main Outcomes and Measures All-cause mortality within 1 year after initial tramadol prescription, compared with 5 other pain relief medications.

Results After propensity score matching, 88 902 patients were included (mean [SD] age, 70.1 [9.5] years; 61.2% were women). During the 1-year follow-up, 278 deaths (23.5/1000 person-years) occurred in the tramadol cohort and 164 (13.8/1000 person-years) occurred in the naproxen cohort (rate difference, 9.7 deaths/1000 person-years [95% CI, 6.3-13.2]; hazard ratio [HR], 1.71 [95% CI, 1.41-2.07]), and mortality was higher for tramadol compared with diclofenac (36.2/1000 vs 19.2/1000 person-years; HR, 1.88 [95% CI, 1.51-2.35]). Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 vs 18.4/1000 person-years; HR, 1.70 [95% CI, 1.33-2.17]) and etoricoxib (25.7/1000 vs 12.8/1000 person-years; HR, 2.04 [95% CI, 1.37-3.03]). No statistically significant difference in all-cause mortality was observed between tramadol and codeine (32.2/1000 vs 34.6/1000 person-years; HR, 0.94 [95% CI, 0.83-1.05]).

Conclusions and Relevance Among patients aged 50 years and older with osteoarthritis, initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine. However, these findings may be susceptible to confounding by indication, and further research is needed to determine if this association is causal.
 
Nov 23, 2010
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#3
I don't know what all this medical mumbo jumbo means. All I know is tramadol works wonders when I aggravate my herniated disc. All the others have really sucky side effects for me.
I was on it following surgery last year and one of the few movies I watched during that time that I hadn't seen before was Justice League. Reading comments about the movie afterwards, Tramadol definitely prevented me from remembering large parts of that. Although the comments lead me to believe that was a positive side effect.
 

Duke Silver

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#4
I was on it following surgery last year and one of the few movies I watched during that time that I hadn't seen before was Justice League. Reading comments about the movie afterwards, Tramadol definitely prevented me from remembering large parts of that. Although the comments lead me to believe that was a positive side effect.
You are kind of a jack of all trades, no?
 

RxCowboy

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#5
I don't know what all this medical mumbo jumbo means. All I know is tramadol works wonders when I aggravate my herniated disc. All the others have really sucky side effects for me.
That's acute pain, and different than what this article is talking about.
I was on it following surgery last year and one of the few movies I watched during that time that I hadn't seen before was Justice League. Reading comments about the movie afterwards, Tramadol definitely prevented me from remembering large parts of that. Although the comments lead me to believe that was a positive side effect.
Amnestic effects aren't typical. Maybe you were taking too much. But, again, taking it post-op, we're talking about acute pain and that isn't what the article is talking about.
 
Nov 23, 2010
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#6
That's acute pain, and different than what this article is talking about.

Amnestic effects aren't typical. Maybe you were taking too much. But, again, taking it post-op, we're talking about acute pain and that isn't what the article is talking about.
I think it was mostly knocking me out much more than I thought. It did make me wonder how there was such a thing as "functioning" opioid addicts though, which I'd assume is essentially the goal of giving them to someone with chronic pain.
 
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#7
I took tramadol for several years, following multiple surgeries (2 spinal fusions, 1 sacral cyst, 2 shoulder surgeries). I did not realize it was an opioid. Seemed to work better for me as a "pain preventative" rather than a "pain reliever". Also ate ibuprofen and naproxen sodium like candy for years, until recently. Bloodwork showed "significant kidney function decline", so I was told that the only things I can take are aspirin and acetaminophen. I can't take them though, due to frequent and gushing nose bleeds. So, I am left with nothing, other than an occasional dram of Scotch or tequila, for pain management. :(
 

RxCowboy

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#8
I took tramadol for several years, following multiple surgeries (2 spinal fusions, 1 sacral cyst, 2 shoulder surgeries). I did not realize it was an opioid. Seemed to work better for me as a "pain preventative" rather than a "pain reliever". Also ate ibuprofen and naproxen sodium like candy for years, until recently. Bloodwork showed "significant kidney function decline", so I was told that the only things I can take are aspirin and acetaminophen. I can't take them though, due to frequent and gushing nose bleeds. So, I am left with nothing, other than an occasional dram of Scotch or tequila, for pain management. :(
Acetaminophen causes nosebleeds?

Aspirin would have pretty much the same effects on your kidneys as NSAIDs. It's all about inhibiting prostaglandin synthesis, which is what aspirin and NSAIDs do.
 

RxCowboy

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#9
I think it was mostly knocking me out much more than I thought. It did make me wonder how there was such a thing as "functioning" opioid addicts though, which I'd assume is essentially the goal of giving them to someone with chronic pain.
Eventually, they don't function. That's a big part of the problem. They stop functioning. It is a mess.
 

steross

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#11
I took tramadol for several years, following multiple surgeries (2 spinal fusions, 1 sacral cyst, 2 shoulder surgeries). I did not realize it was an opioid. Seemed to work better for me as a "pain preventative" rather than a "pain reliever". Also ate ibuprofen and naproxen sodium like candy for years, until recently. Bloodwork showed "significant kidney function decline", so I was told that the only things I can take are aspirin and acetaminophen. I can't take them though, due to frequent and gushing nose bleeds. So, I am left with nothing, other than an occasional dram of Scotch or tequila, for pain management. :(
There is another option if you are in Oklahoma.
 

RxCowboy

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#15
I think tramadol has taught us that anything that acts at opioid receptors is going to cause all of the problems of opioids, regardless of the chemical structure. You'd think we might've already learned that lesson with meperidine and fentanyl, but evidently not. That includes kratom, which acts at mu and delta opioid receptors. If it acts at mu receptors its going to cause dependence.
 
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llcoolw

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#16
I think tramadol has taught us that anything that acts at opioid receptors is going to cause all of the problems of opioids, regardless of the chemical structure. You'd think we might've already learned that lesson with meperidine and fentanyl, but evidently not. That includes kratom, which acts at mu and kappa opioid receptors. If it acts at mu receptors its going to cause dependence.
I've posted this many times here and will again. Do not let the vet give this to your pets. It's very vile on the side effects. It hurts to know you're hurting your loved ones even more when you see their reaction to these meds. I received a script when they first came out and took them as directed. After taking the second one, my stool was a bloody mess. Maybe it's just me. Then my cat got them and went cross eyed and kept walking into the wall. Moms dog got them and kept falling like Bambi. The comments above are the first I've read that it actually worked.
 
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#19
And what exactly do you think that means?
Exactly, I'm not quite sure, but I think it means that the findings are susceptible to confounding by indication".

the question is not what I think it means, the question is what does the author think it means....

seems the term is used inconsistently .... here is one abstract about it from 1999 and another in 2014

https://www.ncbi.nlm.nih.gov/pubmed/10355372
However, in the literature, the term confounding by indication is not always used consistently.

https://link.springer.com/article/10.1007/s40471-013-0004-y
We argue for greater conceptual and semantic clarity with regard to the different forms of confounding by indication and conclude that non-experimental methods do not adequately address this bias in studies of intended effects when the indication defies quantification.
 

RxCowboy

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#20
Exactly, I'm not quite sure, but I think it means that the findings are susceptible to confounding by indication".

the question is not what I think it means, the question is what does the author think it means....

seems the term is used inconsistently .... here is one abstract about it from 1999 and another in 2014

https://www.ncbi.nlm.nih.gov/pubmed/10355372
However, in the literature, the term confounding by indication is not always used consistently.

https://link.springer.com/article/10.1007/s40471-013-0004-y
We argue for greater conceptual and semantic clarity with regard to the different forms of confounding by indication and conclude that non-experimental methods do not adequately address this bias in studies of intended effects when the indication defies quantification.
What it means is, that from the database they drew the data from they cannot tell precisely the indication for which the tramadol was prescribed, only that it was prescribed. It would be better if we knew that the tramadol were prescribed for arthritis than for a different indication which they didn't control for. However, the mortality being higher than diclofenac, which is probably the worst of the NSAIDs from a cardiovascular standpoint, is pretty damning.