VOLUME 33, ISSUE 2

Perhaps no other topic in medicine evokes as much controversy as the prescription of opioids. Following heavy lobbying by pharmaceutical companies and the inclusion of pain as the “5th vital sign” in the early 2000s, the prescription rate of opioids skyrocketed hitting a peak of 81.3% of all prescriptions in 2012 1,2. Widespread availability has created a breeding ground for opioid misuse, addiction, and overdose. As of 2017, opioid overdose has surpassed motor vehicle collisions as the leading cause of injury-related death in the United States3. The incidence of opioid-related deaths continues to climb with no signs of slowing. In 2019, there were 49,860 opioid related deaths reported4. In addition, the fiscal cost of opioid addiction and opioid related disability was upwards of $63.5 billion per year as of 2011 and has likely only increased5. Justifiably, physicians and governing agencies have reacted to these alarming statistics with stringent regulations on opioid administration and prescribing practices6. What is concerning, however, is the increasing trend of surgeon over-utilization of tramadol and codeine under the pretense that these are safer alternatives. We will discuss the abuse potential associated with tramadol and codeine, in addition to other problems with their indiscriminate use.

Despite our best intentions as physicians, our collective responsibility and contributions to the opioid pandemic can’t be denied. There have been no discernable improvements made with regards to the opioid problem in recent years, especially throughout the recent pandemic. Problems include overprescribing, inadequate medication knowledge, resistance to following opioid-sparing protocols, reluctance to use regional anesthesia for fear of complications, underuse of potential behavioral-modification techniques, and inadequate research on the pain management needs of infants, children, and adolescents7,8. It is our duty as anesthesiologists to recognize, assess, and appropriately treat our patients’ pain. Satisfactory treatment of pain improves post-operative recovery and surgical outcomes.

Unfortunately, surgical exposure to opioids is a known cause of opioid use disorder in previously opioid naïve adolescents and adults, with 3-10% continuing to use opioids 6-12 months after their procedures. What is noteworthy is that this continuous use is independent of the type of surgery, whether it is minor or major. This information does not mean we should eliminate opioids from our toolbox, but it does suggest that we should use opioid-sparing protocols whenever possible9,10.

Fortunately, with the advancement and increased variety of pain management modalities, an opioid-sparing approach is quite feasible. The alternatives include peripheral nerve blocks, neuraxial techniques, and use of non-narcotic analgesics like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS). Utilization of these alternative methods for pain control provides excellent pain relief and is devoid of the side effects associated with opioids1,6,7. A multimodal, multidisciplinary approach to pain management is key in minimizing opioid use and its consequences of abuse, misuse, addiction, diversion, and overdose related deaths. This multimodal approach to pain management is now central to most Enhanced Recovery After Surgery protocols (ERAS). The goal is to minimize opioids and their multiple immediate side effects. As an example, most colleagues in our pediatric anesthesia division have eliminated the use of opioids for tonsillectomy/adenoidectomy (T&A) procedures. Instead, they use a multimodal regimen with ketamine, dexmedetomidine, acetaminophen, and ibuprofen. Likewise, our pediatric otolaryngologists no longer provide take-home opioid prescriptions for post-op pain for these procedures. It is a well-known phenomenon that most patients use only a small part of the prescribed opioids, leaving a significant portion of the prescription available for possible misuse by others. Regional anesthetic techniques can be a useful adjunct for pain control and are slowly becoming incorporated into many ERAS protocols. However, even though regional anesthesia has been shown to significantly reduce opioid use, it is unfortunately underused. There is a lack of knowledge, skills, availability of ultrasound devices, and misunderstanding of related risks and benefits11.

Some surgeons have resorted to either significantly minimizing the number of narcotic pills they prescribe or totally avoiding opioid use in response to the opioid crisis6. Thus, strict opioid regulations have sometimes led to under management of pain in patients6. Unfortunately, this has included patients undergoing major surgeries and/or severe cancer-related pain12. Some physicians have tried to achieve a middle ground by prescribing codeine containing medications or tramadol in lieu of traditional, stronger opioids. Tramadol has now become one of the most prescribed opioids in the United States despite it not being a safer alternative to pure opioids6,12. Tramadol was first approved for use in the United States in 1995 as a non-controlled analgesic. Because tramadol had fewer prescribing-related restrictions, it is likely that physicians viewed the drug as having less potential for addiction. It was not until 2014 that tramadol was classified as a controlled substance. As a controlled substance schedule IV medication, it is less tightly regulated than other opioids classified as schedule II medications, such as hydrocodone and oxycodone.

There have been fewer studies involving tramadol due to its perceived lower risk profile. Importantly, a study from the Centers of Disease Control found that 13.7% of patients prescribed tramadol were still taking the medication after one year13. A study conducted at the Mayo Clinic found that patients who take tramadol are more likely to require pain medications long after surgery completion. The study included 444,764 patients who had surgery across the United States between 2009-2018. Tramadol was the third most prescribed medication, following hydrocodone at 51% and oxycodone at 38%. However, the patients who received tramadol were just as likely, if not more likely, to exhibit prolonged opioid use. Thus, substituting tramadol for post-operative pain control is not a reasonable solution for the opioid crisis. With regards to pain management in children, the Food and Drug Administration has issued separate warnings against the use of codeine and tramadol. Both drugs have been implicated in the deaths of children. Despite this, these drugs are still being given to children and adolescents likely secondary to the ease of prescribing.

Lastly, under treatment of pain secondary to either heavy reliance on tramadol and/or underutilization of opioids, where appropriate, may lead to increased drug related complications if patients attempt to self-medicate in order to control their pain. There have been reports of patients combining post-operative prescription medications with leftover pain medications they have at home or those acquired from friends or loved ones. This heightens the risk of overdose, respiratory depression, and other unwanted side effects.

In conclusion, we, the authors, advocate for individualized, goal-directed pain management in lieu of a blanket ban of opioids. For physicians, the objective is clear: to balance the need for pain management with the long-term possibility of addiction and misuse.