Doctors beware: this opioid is not listed

Eyeview
By David Charbonneau
December 7, 2017 - 5:00am

KAMLOOPS — Doctors rely on Canada’s Controlled Drugs and Substances Act as a guide in prescribing drugs. Tramadol is not listed there but that could change soon.

Tramadol is a sneaky drug, as Dr. David Juurlink discovered when a patient with a shoulder injury was prescribed tramadol. On the positive side, tramadol relieved the shoulder pain. Then problems starting showing up, says Dr. Juurlink:

The first sign of trouble arose three months later. His shoulder pain gone, the patient assumed he no longer needed tramadol. He was wrong. Shortly after stopping it, he developed debilitating insomnia, shakes and back pain – something he'd never experienced before. Irritable, exhausted and functioning poorly at work, he soon found the solution: All he needed to do was keep taking tramadol, and these problems went away." (Globe and Mail, November 27, 2017)

There are two outcomes of being hooked on drugs. One is a physical dependence, such as exhibited by the above patient. The other is addiction in which a patient’s health deteriorates and their behaviour is transformed – what we usually think of as addiction. This patient needed the drug for no other reason than to avoid the debilitating effects of not taking the drug.

The reasons why tramadol is not listed are complex. First, the way that it affects patients depends on their genetics. Tramadol acts as if it were two drugs. It relieves pain using the same mechanism as aspirin does but for some with a particular enzyme, it converts to an opioid. Only six per cent of Caucasians have the enzyme, whereas 30 per cent of those of East African or Middle Eastern decent will experience opioid conversion.

Tailor-made drugs, specific to a patient’s genetics, hold future promise. That would allow doctors would know in advance whether a patient has the enzyme or not. For now, doctors roll the dice in prescribing tramadol.

Second, when Health Canada last reviewed tramadol in 2007, during the era of the Harper government, a libertarian regime affected policy. Manufacturers of tramadol lobbied Health Canada directly and indirectly to keep the drug off the list. Manufacturers peddled the “dual mechanism of action” of tramadol without disclosing just what that meant. Indirect lobbying came in form of financial support to at least one patient advocacy group who wanted to keep the drug freely available.

The Holy Grail of painkillers would be one as effective as opioids without the side effect of addiction. Researchers have been looking for more than a century. The German drug company, Bayer, marketed a cough suppressant derived from morphine under the trademark Heroin in 1895. It was marketed as being non-addictive.

More recently, OxyContin was marketed as a pain-relief drug “without unacceptable side effects.” Doctors believed that they were prescribing a safe drug but OxyContin proved otherwise. Patients who took it for pain relief got hooked and when prescriptions ran out, they went to the streets in search of substitutes.

Under the Trudeau government, Health Canada is considering placement of tramadol under the Controlled Drugs and Substances Act – where it belongs. Whether it is listed or not will be a test of a government’s resolve to put the health of Canadians above commercial interests.

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