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Tramadol has long been considered a 'safer' opioid painkiller, but new research suggests it may be just as addictive as oxycodone - if not more so.
Oxycodone, the generic version of Purdue Pharma's blockbuster Oxycontin, has been widely blamed for the getting millions of Americans hooked on opioids.
Animal studies of tramadol suggested that the drug had a less powerful draw, so it was given a lower schedule classification by the Drug Enforcement Agency (DEA).
But according to a new Mayo Clinic study, people who get tramadol are no less likely to keep filling prescriptions for painkillers long after their surgical sites have healed than are those prescribed other drugs.
The scientists warn that no opioid is totally safe to prescribe, as even the 'least addictive' form can still become a habit, according to their results.
Tramadol was long considered less addictive than other opioids, but a new study suggests people are just as likely to get hooked on it as they are on hydrocodone or oxycodone
Three quarters of all opioid addictions are thought to begin with prescription drugs.
Namely, they're thought to begin primarily with oxycodone (generic for OxyContin) or other faster-acting opioid painkillers.
But in recent years, as the opioid epidemic has left millions addicted to prescription drugs, heroin and fentanyl, doctors have increasingly prescribed tramadol, as it is long-acting and supposed to produce less of a high.
While other these fast-acting drugs take effect within 20 to 30 minutes and last about four hours, tramadol takes longer to hit, but continues to treat pain for over six hours.
Steering away from the most dangerous and habit-forming drugs certainly seems like a good preventive measure, but tramadol may not be as safe as it was once believed.
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Overall, tramadol became the second most prescribed opioid after hydrocodone in the US in 2012, and between 2008 and 2014, prescription rates doubled.
In the specific context of post-operative prescriptions, rates vary somewhat.
Among patients who underwent any of the 20 most common surgical procedures between January 2009 and June 2018, only four percent received tramadol, compared to the 51 percent that got hydrocodone and the 38 percent that went home with oxycodone, according to the new study.
Still, that represents a marked increase in tramadol prescriptions over the past decade, and other research has estimated that anywhere from eight to 25 percent of surgical patients might leave with the drug.
Tramadol does not have the depressive effects on breathing that oxycodone does, which makes it safer, and because it's been considered less addictive, tramadol was initially not scheduled by the DEA when it came on the market in 1995.
Finally, in 2014, the DEA started regulating the drug, adding it to the list of schedule II drugs, alongside hydrocodone and oxycodone.
Schedule II drugs cannot be automatically be refilled, but doctors can call in additional orders for the drug.
According to the new study, 357,884 out of 444,746 patients that underwent a common surgery in the course of its nine yeas go a prescription for some kind of opioid to manage their pain while recovering.
Tramadol prescriptions (pink dashes) have gained popularity for patients who are being discharged after surgery, as short-acting opioid drugs (solid purple) have fallen from favor
About seven percent asked for a refill within the first six months.
Another one percent continued to ask for refills of any of the painkillers for nine months, and 0.5 percent got 10 or more refills, qualifying as long-term use.
No matter how many refills they got, patients who were taking tramadol were the most likely to continue taking the drug.
'We found that people who got tramadol were just as likely as people who got hydrocodone or oxycodone to continue using opioids past the point where their surgery pain would have been expected to be resolved,' said senior author Dr Molly Jeffery.
'This doesn't tie to the idea that tramadol is less habit forming than other opioids.'
And now that we know more about tramadol's pharmacology, we know that, even though it is not as depressive to respiration, the drug can cause overdoses, but naloxone, the overdose reversal drug, does not work very well against tramadol's effects - an added danger.
Although tramadol now shares a DEA scheduling with oxycodone and hydrocodone, the new study authors say the enforcement agency doesn't pay as close attention to it.
'Given that tramadol is not as tightly regulated as other short-acting opioids, these findings warrant attention,' said Dr Cornelius Thiels, lead study author.
The DEA's prescription drug monitoring program has been ramped up to keep a closer eye on patients that might be misusing hydrocodone and oxycodone - and on the doctors who might be enabling these addictions.
But the new study suggests the agency ought to do the same for tramadol, and that doctors, too, need to take pause before prescribing the drug.
'This data will force us to reevaluate our post-surgical prescribing guidelines,' said Dr Thiels.
'And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids.'
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