Clinical twisters: Addressing escalation of pain

July 23, 2007

Patient takes tramadol 100 mg every six hours for chronic back pain; other medications include two lithium carbonate, extended release tablets, ziprasidone, temazepam, and trazodone.

I must first answer the NP's question with a question. Does the patient have any other diagnoses, conditions, or medications that are not listed? Assuming D.F. does not, I would answer: The reason this patient is having pain now is that the current tramadol dose is enough to cover his back pain but not the increased pain caused by today's procedure. In other words, he now has controlled chronic pain and new, uncontrolled acute pain.

For the purpose of controlling pain, the NP should consider the current tramadol dose as a baseline. The maximum daily dose of tramadol is 400 mg per day, however, so an increase in dose is not warranted. Instead, the NP should choose another analgesic such as hydrocodone/acetaminophen or oxycodone/acetaminophen at starting doses, titrate the patient to pain relief, and then taper the dose over an appropriate time period based on the procedure performed and the patient's level of pain.

Pain escalation should be expected in chronic pain patients after surgery. Tramadol treats baseline pain, but it does nothing for additional pain secondary to surgery. This case is complex; it must address the underlying chronic pain condition, comorbid psychiatric condition(s), and current medications.

D.F. is currently on the maximal dose of tramadol. Increasing the dose will likely increase the side effects without providing additional pain relief. These are an extension of the therapeutic effects, and include nausea, vomiting, constipation, lethargy, seizures, tachycardia, hypertension, and serotonin syndrome. Respiratory depression is rare, even in overdose situations.

Acetaminophen might augment tramadol but may be inadequate. Ketorolac is contraindicated secondary to his concomitant lithium therapy. The combination results in dramatic increases in lithium serum concentrations and possible toxicity. Other NSAIDs have unpredictable and highly interindividual effects on lithium levels. The combination of lithium and NSAIDs should be avoided, and lithium levels should be evaluated every four to five days if they are used.

A combination of tramadol and a stronger opioid is possible. Certain opioids can be successfully combined in a "balanced analgesia." This minimizes doses of each analgesic drug and minimizes side effects. This effect doesn't appear to exist for tramadol/opioid combinations. While the risk of adverse effects doesn't appear to increase, tramadol adds nothing to the analgesic effects. At worst, opioid (e.g., morphine) requirements increase in some patients.

It is reasonable to temporarily switch this patient to a stronger opioid, such as morphine or an opioid/acetaminophen combination. The patient should be monitored for nonopioid tramadol withdrawal effects, which will present similar to those of SSRI or tricyclic antidepressant withdrawal and may include worsening depression and/or anxiety.

This treatment plan should include adequate psychiatric support. Chronic pain itself has a high incidence of comorbid anxiety and depression. Inadequate pain relief could lead to long-term suboptimal control of the underlying chronic pain condition. The patient should be frequently reassessed with the four "As": analgesia, activity, adverse effects, and aberrant behavior. Cognitive behavioral therapy can help the patient readjust to tramadol once the acute surgical pain has resolved.

Jacintha Cauffield, Pharm.D., BCPS Family Medicine of Southwest WashingtonVancouver, Wash.