The addition of tramadol as a second opioid may improve pain relief in severe osteoarthritis: a prospective study.
BACKGROUND
Opioid combination has been shown to reduce the need for escalating doses for the treatment of cancer pain. A prospective study was planned to evaluate the addition of tramadol to a stronger opioid for the treatment of severe pain as a result of osteoarthritis, previously uncontrolled by non-opioid analgesics or weak opioids.


METHODS
All subjects received tramadol 200 mg and tizanidine 2 mg. At 2 weeks, tramadol was discontinued for patients still reporting poor pain relief (effectiveness ≤50%), and a stronger opioid was titrated to a morphine equivalent amount (MEA) of 40-60 mg orally. After two additional weeks, patients were then divided into two groups: the Strong Opioid Group (SO) and the Tramadol plus the Strong Opioid Group (TSO). The SO group was allowed to escalate opioid dose for lack of effectiveness; the TSO group received tramadol 150 mg daily, thereafter additional strong opioid titration was allowed.


RESULTS
A total of 74 patients were studied: SO (n = 40) and TSOG (n = 34). All patients eventually achieved pain relief quality, with both groups reporting similar Karnofsky Performance Scale effectiveness. The SO group achieved satisfactory pain relief (>50%) at an average daily oral MEA of 120 mg. TSO subjects achieved satisfactory pain relief (>50%) at an average daily oral MEA of 95 mg.


CONCLUSIONS
The addition of tramadol provided a synergistic effect resulting in a 30-mg decrease in necessary morphine equivalents with fewer opioid-related adverse effects.
Doctorate Program in Advanced Technology in Rehabilitation Medicine, University of Rome, Tor Vergata, Italy. luigidilorenzo2005@libero.it
Luigi
L
Di Lorenzo
Calogero
C
Foti
Alfonso Maria
AM
Forte
Enzo
E
Palmieri
Rita
R
Formisano
Abraham
A
Vatakencherry
Marco
M
Pappagallo
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000627:therapeutic use*; D003000:Clonidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D017567:Karnofsky Performance Status; D008297:Male; D008875:Middle Aged; D010003:Osteoarthritis / Q000150:complications; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D010147:Pain Measurement / Q000379:methods; D011446:Prospective Studies; D013997:Time Factors; D014147:Tramadol / Q000627:therapeutic use*
D000700:Analgesics; D014147:Tramadol; C023754:tizanidine; D003000:Clonidine