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Treating postoperative pain? Avoid tramadol, long-acting opioid analgesics and long-term use
  1. Georgia C Richards
  1. Center for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Georgia C Richards, Center for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; georgia.richards{at}

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A recent cohort study investigated ‘the risk of transitioning from acute to prolonged use’ of opioid analgesics in patients undergoing elective surgery. Patients given tramadol or long-acting opioids after discharge were at greater risk of prolonged opioid use than those who were given other short-acting opioids.

EBM verdict

EBM Verdict on: Chronic use of tramadol after acute pain episode: cohort study. BMJ 2019 May 14. doi: 10.1136/bmj.l1849.

  • Long-acting opioids and tramadol should be avoided when discharging patients from hospital after elective surgery. Alternative short-acting opioids at low doses and for short durations are preferable.

Strong pain-relieving medicines called opioids are commonly prescribed when patients are discharged from hospitals. However, pain after elective surgery is usually short-lived. This cohort study1 addresses an important question regarding the prolonged use of opioid analgesics after elective surgery in light of the opioid crisis in the USA and Canada and increased prescribing of opioids in high-income countries.2

Tramadol is both a weak mu-opioid receptor agonist and a serotonin and norepinephrine reuptake inhibitor. Its active metabolite, O-desmethyltramadol, is longer acting than tramadol itself and is a more potent mu-opioid receptor agonist. Responses to tramadol, therefore, vary according to the genotype of the main metabolising enzyme, CYP2D6.3

Tramadol has been …

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  • Contributors GCR wrote and edited the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests GCR is reading for the degree of Doctor of Philosophy on the prescribing of opioid analgesics in primary care, funded by the National Institute for Health Research School for Primary Care Research Doctoral Studentship, the Naji Foundation and the Rotary Foundation.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.