The analgesic efficacy of oblique subcostal transversus abdominis plane block after laparoscopic hysterectomy: A randomized, controlled, observer-blinded study.

BACKGROUND: We aimed to assess whether an ultrasound (US)-guided oblique subcostal transversus abdominis plane (OSTAP) block would improve the postoperative pain scores and decrease the tramadol consumption after a laparoscopic hysterectomy. METHODS: Sixty-six female patients with American Society of Anesthesiologists I, II, or III, aged 18 to 65 years who were scheduled for laparoscopic hysterectomy for benign gynecologic pathologies were recruited in this randomized, controlled, observer-blinded trial. Sixty patients completed the study. Patients were randomized into 2 groups. In the OSTAP group, the patients received a bilateral OSTAP block with 40 mL of 0.375% bupivacaine and in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. All patients received tramadol patient-controlled analgesia for the first 24th hour. Patients in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. The primary outcome was the 24th hour tramadol consumption. The secondary outcomes included visual analog scale (VAS) scores during movement, the tramadol consumption at the 1st, 4th, and 12th postoperative hours, and nausea scores at the 24th hour postoperatively. RESULTS: At all time points, tramadol consumption of the OSTAP group remained significantly lower when compared with Sham group. The OSTAP group showed a statistically significant reduction at the postoperative 24th hour tramadol consumption (mean difference 22 mg, 95% confidence interval -38.4 to -5.6 mL; P = .009). Compared with the Sham group, OSTAP block reduced the VAS scores at all time points during movement. Nausea scores at the 24th postoperative hour were significantly lower in the OSTAP group compared with the Sham group CONCLUSION:: We concluded that bilateral US-guided OSTAP blocks reduced 24th hour tramadol requirements and VAS scores after laparoscopic hysterectomy. The OSTAP block is a promising technique for producing effective and prolonged postoperative analgesia in patients undergoing laparoscopic hysterectomy surgeries.

Tramadol dispensing patterns and trends in Canada, 2007-2016.

PURPOSE: Opioid use and associated mortality and morbidity have substantially increased in Canada, which recent interventions have aimed to reduce. Tramadol is an atypical prescription-only (but unscheduled under Canada's narcotics law) opioid analgesic and not subject to controls for other (eg, strong) opioids. Given experiences in different jurisdictions, tramadol may have been increasingly dispensed as a "substitute" drug during a period with increasingly restrictive controls for other (scheduled) opioids. METHODS: We examined the annual population-level retail dispensing (as a proxy for use) of tramadol and (scheduled) "strong opioids" in Canadian provinces for 2007-2016 based on data from a representative national sample of community pharmacies, covering the majority of episodes of opioid dispensing. Data for both aforementioned formulation categories were converted into defined daily doses (DDD)/1000 population/day and examined descriptively and by segmented regression analyses (to identify significant breakpoints in trends). RESULTS: Tramadol use strongly increased in all provinces until 2009. After 2009, tramadol dispensing levels either decelerated their increase or plateaued; "strong opioid" dispensing levels, in comparison, increased strongly until 2011 and decelerated or decreased for the remaining period. Tramadol was consistently dispensed at lower levels than "strong opioids." CONCLUSIONS: Tramadol and "strong opioids" showed similar (bifurcated) use trends, with initial increases and subsequent inflections, yet reductions in dispensing occurred earlier for tramadol than for "strong opioids" (the latter occurring following with recent interventions). Distinct from experiences with differential opioid control regimes elsewhere, there is no evidence that tramadol figured as a "substitution" drug for increasingly restricted "strong opioids" in Canada.

A claims analysis of the utilization of tramadol for acute pain in patients prescribed buprenorphine/naloxone for opioid use disorder.

OBJECTIVE: To determine the prevalence of tramadol prescribing among commercially insured adults receiving medication-assisted therapy (MAT) with buprenorphine/naloxone. DESIGN: The authors conducted a cross-sectional descriptive study to evaluate the use of tramadol among patients prescribed buprenorphine/suboxone for MAT. SETTING: This study utilized data from 2010 to 2013 Optum® Clinformatics® Data Mart. This cohort is an administrative health claims database from a large national insurer. These data included pharmacy and medical care utilization and information describing patient enrollment. PATIENTS/PARTICIPANTS: Patients were 12-64 years of age and had complete and available medical, pharmacy, and administrative records in the Optum Clinformatics Data Mart during the study period. MAIN OUTCOME MEASURES: Patients who received at least one paid claim for buprenorphine/naloxone from 2010 to 2013 and also received at least one overlapping pharmacy dispensing for tramadol were identified for analysis. The authors determined if the concurrent buprenorphine/naloxone and tramadol dispensings were from the same or a different prescriber. RESULTS: In this analysis of 18,734 US commercially insured patients receiving MAT with buprenorphine/naloxone, the authors identified 1,198 (6.4 percent) patients who received at least one overlapping dispensing for tramadol during a 4-year period spanning 2010-2013. Among these patients, 266 (1.42 percent) were co-prescribed buprenorphine/naloxone and tramadol from the same provider. CONCLUSIONS: These results suggest that the use of tramadol among patients receiving buprenorphine/naloxone is not uncommon. Further study is warranted to further determine the benefits and risks associated with the use of tramadol for pain management among patients prescribed buprenorphine/naloxone.

Opioid purchases and expenditure in nine western European countries: 'are we killing off morphine?'.

BACKGROUND: In clinical practice the major role of opioid drugs is the management of malignant and nonmalignant pain. The primary aim of this study is to evaluate the trend in sales of four opioid analgesic drugs (codeine, tramadol, morphine, fentanyl), from wholesalers to community pharmacies, as an indicator of opioid consumption in nine European countries in 2001, 2002 and 2003. Secondary aims are to compare: (a) the amount of each drug purchased by different countries in 2003; (b) the average price for each drug in the different countries in 2003; and (c) the total expenditure for each opioid from 2001 to 2003. METHODS: Data from the Statistical Report on drugs purchased by pharmacies was supplied by IMS Health, an internationally accepted information provider for the pharmaceutical and health care industries. FINDING: In the period 2001 2003, while the percentage increase of purchases of fentanyl and tramadol was considerable, that of morphine was the lowest in most of the nine countries. The largest consumer of codeine was the UK and of tramadol was Belgium. The consumption of morphine was the lowest reported in all the countries together and was three times lower than that of transdermal fentanyl. There was a high variability in the costs of the opioids among the different countries. In 2003, the total expenditure for fentanyl reached the highest total expenditure [corrected] followed by codeine. Morphine presents the lowest expenditure in all nine countries and over all three years. INTERPRETATION: These results open up many questions. What factors influence opioid purchasing and costs in these European countries? It would be interesting to have the answers from those people who know the actual situation in the individual countries.

Pain relief in Thailand.

Pain is a complex problem, for both those who are enduring it and those trying to relieve it. Most people in the developed world have access to adequate treatment and management of pain, the availability of trained and educated doctors and nurses, feasible opioid prescribing policies, as well as ready access to appropriate medication. Often, this is not the case in developing countries such as Thailand. This paper is based on recent experience in the southeast of Thailand providing pain relief for persons with HIV and AIDS in Rayong Province at the Camillian Social Centre. The severity and frequency of pain endured by this group of individuals presented a daily challenge. Problems encountered in providing pain relief for these patients and some potential solutions are described. There is a lack of literature on pain relief in Thailand.