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Wednesday, January 5, 2011

Open Letter To The FDA

I have noticed over the past several years that there is an increasing frequency of patients wanting refills for Ultram (tramadol) pain pills early. I am concerned that it is the new drug of choice for addiction because it relieves pain, makes you feel good, and is readily obtainable from practically any prescriber.

An extreme case I had was a lady who goes to a different emergency room every 3 or four days to get a prescription for Ultram. It is usually written with a muscle relaxer and naproxen. She always only fills the Ultram. On this particular evening her newest emergency prescription was one day too early for insurance to cover it. It is out policy to never fill pain pills early if the insurance company denies the claim. Our computer systems do not process next day insurance claims until after 3am. She sat in the pharmacy with 3 young children, one in diapers for 3 hours before the youngest kept screaming and fussing because it was way past bedtime for young children. She finally left the pharmacy at 12am with her children when she had planned to stay until she could get her pills as soon as possible because she was getting fidgety and cranky.

Please re-evaluate Ultram for its potential for abuse and addiction. At the least give it a Schedule V so we can try to prevent some of this personal and child abuse.

Thank you for your attention to this matter.

Big N Tasty RPh


Fries With That, tech said...

It's scheduled inmy state!

(nanny nanny boo boo! ;))

Shalom said...

Argh. Tramadol. The only opiate that's not a controlled substance.

Had a patient once whose tramadol came up too early to refill. I went back through his profile, and found he was averaging about 15-16 tablets per day, on a script that allowed for 8 maximum; he'd kept calling for refills, and paying cash for the ones that were too early, and nobody in the store seemed to have noticed this. I was a floater just visiting that store, and didn't feel like putting up with him; told him it was too soon to fill (like 3 months too soon) and he'd better call his doctor. He heard that and suddenly he didn't speak English, although he'd been doing fine up to that point in the conversation.

Later that day I get a call from his doctor, who says "Patient says he's out of refills on his Tramadol, we want to renew it.". I told them, the problem wasn't that he was out of refills, it was that he'd been going through them twice as fast as they were prescribed; that he'd used 3600+ tablets over the past 8 months.

They were shocked. They said "How in the world did that happen!" I said "Don't ask me. You're the only doctor in his RX profile; you're the one who's been calling in these refills every couple of weeks. Why didn't you notice it until we called you?"

Dunno what happened after that, I was at a different store the next day. I would hope the doctor did something about it, though.

(All right, for all you nitpickers out there, there is one other non-scheduled opiate, which is nalbuphine. It's non-scheduled because it's a κ-agonist but a μ-antagonist, so if you're dependent on traditional opiates it'll trigger withdrawal.)

hannah said...

Shit, ultram makes you feel good? I'm allergic to vicodin and percocet (third degree grease burns to my foot --) horrible itchy full-body rash after taking them.) I always thought that put me out of the league of pain killer abusers. But now I could totally rock that with my NSAID rx!

Texas Pharmacy Chica said...

Arizona, right? Tramadol is scheduled there? Carisprodol got scheduled in TX in 2009....big mess.

Don't get me started on FDA taking propoxyphene off the market with little to no warning. It was on the market for 60 years - could we at least phase it out over, say, 3 months? I mean, aerosal driving agents were phased out over 15 YEARS......

Anonymous said...

Big and Tasty - I have worked with so many tramadol addicts it's astonishing when I am rxing Suboxone. They buy online as well as multisourcing locally (including through their VETERINARIAN), and are usually coming in on the 400mg+/day doses. Extra-whiny, "but, see, it's not MY fault, no one told me it was addictive." Bullshit. They've been going to epic lengths to lie and feed the addiction. It's one more rationalization. They are extra-difficult to detox, because they can slither around and buy online, etc., and the tox screens are a special order.

Still, I agree, it damn well should be scheduled (and the benzos should be moved up from a IV to a II or III, in my book. But I'm a crankypants.)

I have special respect for the seizure-inducing potential of higher-dose tramadol, as I've seen it drop thresholds now in multiple high-dose abusers who were inpatients, and so I am sure to share that little piece of joy with patients.
Sometimes it gets their attention. Usually not.

It's a shame, because in the lower doses, it is a decent analgesic. My spouse has been on a 50mg nighttime dose as an adjunct to chronic Tylenol and DMARDs when there are occasional RA flares, says it works perfectly well and is much more tolerable than hydrocodone for a 2 week run.

Anyway, good post, and reminds me to go agitate again with my state to get the stuff (and Soma) scheduled.

Anonymous said...

Arkansas we've scheduled soma AND ultram. Cuts down on a lot of headaches.

Anonymous said...

I was prescribed Tramadol for back pain earlier this year; my doc specifically told me it was not addictive when I asked. Go figure!

Big 'N Tasty RPH said...

I don't even want to get into the online pill market. I hate getting calls about "Will this show up on a drug test?" because of something purchased from an internet operation.