Scheduling of Tramadol: Rheumatology Perspective

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Scheduling of TramadolRheumatology Perspective

• Philip A. Baer MDCM, FRCPC, FACR

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• Practicing rheumatologist
• VP, ORA
• Member, CRA
• Medical Director, Transamerica Life Canada

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Disclosure Dr. Baer

• Speaker, Advisory Boards, Investigator
• Purdue Pharma, Janssen-Ortho
• Novartis, Pfizer, Merck
• Procter Gamble, Sanofi-Aventis, Lilly
• Solvay, Astra Zeneca
• Abbott, Amgen, Wyeth, Schering
• Roche, Bristol Myers Squibb

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Overview

• Most patients in a rheumatology practice have
  pain.
• Many rheumatologists are uncomfortable with pain
  management, especially use of stronger
  opioids/narcotics.
• Pain is under-treated in rheumatology practice.
• The NSAID treatment model is not the answer for
  many patients.
• Codeine is not the answer for everyone.
• Tramadol provides another option, and the lack of
  scheduling increases the comfort that
  rheumatologists have with using it.

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• Most patients in a rheumatology practice are in
  pain
• Canadian Pain Survey 25 have moderate to severe
  daily pain (Leading cause-arthritis)
• ORA 2007 Member survey 50 of patients seen
  complain of moderate to severe pain (Dr. E.
  Weinberg)
• My view Everyone I see, except patients with
  osteoporosis, complains of pain

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• Many rheumatologists are uncomfortable with pain
  management, especially use of stronger
  opioids/narcotics
• Lack of training
• Lack of time for follow-up of patients in pain
• Dont want to attract pain patients
• Regulatory concerns
• ORA Survey younger rheumatologists were least
  comfortable

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• Pain is under-treated in rheumatology practice
• Treat inflammation and hope the pain will
  improve
• Problems
• Advanced OA waiting for surgery
• Spinal OA/DDD not suitable for surgery
• Damaged joints in RA/sero-negative arthritis
• Non-inflammatory regional pain and FM

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• The NSAID treatment model is not the answer for
  many patients
• Comorbidities
• Cardiovascular concerns
• Failure to respond
• Intolerance

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Management of Hip/Knee Osteoarthritis (ACR)
Diagnosis
Physical Measures Patient Education
Medications
Anti-inflammatory
Intra-articular
Analgesic
Steroids Hyaluronate
NSAID PGE2/PPI COX-2 inhibitors Topical NSAIDs
Acetaminophen
Tramadol Topicals Opioids
Antidepressants Glucosamine Chondroitin
Surgery
American College of Rheumatology. Arthritis
Rheum. 2000431905-15.
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• Codeine is not the answer for everyone
• Non-metabolizers
• Rapid metabolizers
• Intolerance
• Inadequate effect

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• Tramadol provides another option, and the lack of
  scheduling increases the comfort that
  rheumatologists have with using it
• Effective in nociceptive and neuropathic pain
• Low abuse potential based on data
• Can be sampled
• Can be repeated verbally/in writing
• Handoff to primary care is easier

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