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October 20, 2004

Tramadol Abuse and Dependence Among Physicians

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2004;292(15):1815-1819. doi:10.1001/jama.292.15.1818-b

To the Editor: Historically, new opioid pain medications have been introduced as having low abuse liability and then later found to have significant risk. Tramadol achieves its analgesic activity from an M1 metabolite with potent opioid properties and through inhibition of reuptake of monoamines.1 Following release of this product, reports of tramadol abuse began to occur and package insert warnings regarding abuse have been heightened 3 times. The US Food and Drug Administration’s (FDA’s) MEDWATCH system has received hundreds of spontaneous reports of tramadol-associated abuse, dependence, and withdrawal.2 Among individual opioids listed in the 2001 and 2002 annual reports of the American Association of Poison Control Centers Toxic Exposure Surveillance System, tramadol ranked second to oxycodone in number of exposure cases.3 Other reports, sponsored by the manufacturer, have suggested low abuse liability; however, their conclusions are problematic due to methodologic issues. For example, in 1 report4 the total number of physicians admitting abuse of tramadol was divided by the total number of physicians being monitored, without measuring the percent of these physicians actually taking the drug. In April 1998 the FDA cited the lack of comparative data as a major reason for the committee’s decision to not recommend scheduling tramadol.5 The present study reports relative frequency of tramadol abuse compared with other drugs.

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