hydrocodone combination pills now to be Schedule II medications.

[Denali]

Ironically, I see the opposite problem. People come to me as their PCM, after their surgeon gives them a minimal amount of meds after a major surgery (ortho cases, ex laps, etc) then pull the "discharged from service" routine. I rarely write more than 30 norco (our pharmacy moved away from vicoden due to acetominophen concerns) at a time, rarer to use oxycodone. I like that Tramadol went to Schedule IV... But if the patient comes to me more than two or three visits for the same pain complaint, I send them to pain management.

I agree though, lots of PCMs out there doing 90 + refills of norco or percocet vice actually putting them on a 12 hour release opiate and using the other meds for break throug. Kind of like diabetes, you have your lantus, then your meal coverage dosing...

I'm curious, why the issue with tramadol?

[Sensei]

Sensei, you come across Tripp Winslow yet??

PM sent.

I'm curious, why the issue with tramadol?

I'm not a big fan of tramadol due to the fact that it is a weak analgesic with some nasty side-effects, namely seizures. The seizures associated with tramadol can occur even in therapeutic doses. Most of the dogma in emergency medicine is that tramadol combined with Tylenol (Ultracet) is little better than Tylenol alone at real doses (1 gram TID).

Codeine and Demerol are other drugs that I do not use due to the side-effect profile. Codeine is weaker than hydrocodone and has a very high rate of GI upset which causes many people to claim an allergy. Demerol has a toxic metabolite, normeperidine, which accumulates in renal failure to cause seizures and is associated with serotonin syndrome in patients taking SSRI's.

I almost never prescribe oral Dilaudid or Fentanyl patches due to the overdose potential and those drugs are not in the purview of emergency medicine.

Thus, I stick with hydrocodone or oxycodone for the out-patient treatment of most painful conditions that need more than a NSAID or Tylenol. I never prescribe more than 20 tabs from the ED and I very rarely (maybe twice per year) prescribe opiates for acute back pain, migraines, or dental pain.

[Caduceus]

What Sensei said... No real issues with tramadol, I just think its too easy to over prescribe since it doesn't have a similar reputation for dependency. This may open some eyes (mine included)? I usually use tramadol more than hydrocodone, never dilaudid or fentanyl (our pharmacy doesn't carry fentanyl nor demerol, maybe dilaudulid), and I only use codeine sporadically. Which by default leaves tramadol as a step above NSAIDs for pain.

[Hmac]

I used to use Tylenol #3 routinely, now haven't prescribed it in almost a decade. For me, oral pain meds are mostly hydrocodone or oxycodone but it reminds me that I'll have to check and see what my Fellow is ordering - he just started August 1 and I'm not sure what his personal biases are. I think he's using Tramadol occasionally. We have a post-op acute pain management protocol that involves Toradol and/or IV acetominiphen at the close of the operation, as well as a lot of wound injections with Exparel. That has been a pretty extraordinary drug relative to acute post-op pain management. In our total joint program, our length of stay is 1.4 days, even for bilaterals, and use of narcotics is minimal. No more nerve blocks or infusion catheters.

[Denali]

What Sensei said... No real issues with tramadol, I just think its too easy to over prescribe since it doesn't have a similar reputation for dependency. This may open some eyes (mine included)? I usually use tramadol more than hydrocodone, never dilaudid or fentanyl (our pharmacy doesn't carry fentanyl nor demerol, maybe dilaudulid), and I only use codeine sporadically. Which by default leaves tramadol as a step above NSAIDs for pain.

I was under the impression that it was the "safe" alternative to narcotic analgesics, that its action was mildly narcotic like, while not really being a narcotic...On another note I had major surgery this summer, and the doctors treated my pain with a marvelous nsaid, completely foregoing all narcotic pain management altogether! My surgeon explained that they now feel that narcotic pain killers contribute to a longer convalescence as opposed to not. The stuff they treated me with was called "Toradol" and it was amazing how effectively it neutralized pain....

[Caduceus]

toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)

[montanadave]

toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)

When I had a kidney stone, a shot of Toradol in the ass was greatly appreciated.

[Hmac]

toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)

It's hard on the liver. 6 or 8 doses max if given IV. Oral form isn't very effective. Interestingly, we've found that IV acetominiphen is a little more effective than IV Toradol in the immediate postop period. Our postop pathways include giving both. Some high-risk patients, however, get higher doses of Lovenox, in which case we hold the Toradol and go just with the IV acetominophen.

[Sensei]

Toradol is a great drug for colicky pain in patients who are vomiting because it can be given IV or IM. It is an NSAID in the same family as ibuprofen and enjoys all the same renal and GI side-effects of other drugs in its class. The oral form of Toradol is expensive and has a higher side-effect profile than ibuprofen. Thus, it is rarely prescribed because the juice is not worth the squeeze.