The questions about prescribing

How these drugs are managed in Northern Ireland. /

THE rise in the number of Tramadol Hydrochloride prescriptions issued raises new questions about how opioid drugs are managed within our health service.

Figures held by the Northern Ireland Prescription Database reveal prescriptions for tramadol hydrochloride painkillers have more than tripled over the last ten years; from 123,955 prescriptions in 2000 to 395,119 in 2010.

These figures are compiled by the Health and Social Care Board who operate alongside the prescribing information system, COMPASS, to monitor prescribing practice across Northern Ireland.

The UK agency responsible for medicines shows nine cases of adverse reactions to tramadol hydrochloride came from Northern Ireland between 2006 and 2010. But reporting of adverse incidents is voluntary; The experience of “Helen”, who is interviewed in The Detail, has not been reported as far as she is aware.

Helen says she decided to go public about her experience because she was so concerned about the handling of her case by her GP; the practice, she says, failed to inform her about the side effects of the tramadol hydrochloride-based drug, Zamadol, or recognise her withdrawal symptoms, which led her to have suicidal thoughts.

When asked how the use of tramadol hydrochloride is evaluated, the Health and Social Care Board referred us to the COMPASS system which monitors prescribing data and which also distributes a circular to health professionals three to four times a year containing updated advice about drugs across all spectrums.The HSCB says:

“The COMPASS report highlights trends in prescribing (increases or decreases) and identifies outliers within comparator groups. This information is used by practices and medicine management advisers to target appropriate action”

According to the HSCB, any individual incidents of high prescribing levels are discussed with the practice concerned.

A BROADER UPWARD TREND?

However HSCB did not appear concerned with the current level of prescribing of tramadol hydrochloride in Northern Ireland and said in a statement:

“It should be noted that on average there has been a year on year increase of 6% in overall prescription growth and the rate of increase of prescribing of tramadol is in line with this annual increase.”

Following further questions from The Detail the HSCB confirmed this has not always been the case, between 2001 and 2006 the rate of increase of tramadol hydrochloride prescriptions ranged from 17%-20%, far outweighing overall prescription increases of 4%. This period of high prescribing pushed annual tramadol hydrochloride prescriptions over the 300,000 mark, a figure which continues to rise today albeit at a reduced rate.

NHS report shows increase in tramadol prescriptions

NHS report shows increase in tramadol prescriptions

This increase in tramadol hydrochloride prescriptions has been reflected in other parts of the UK and has been causing alarm.

Two recent reports published by the NHS in England, investigating prescription drugs and addiction to medicine, reveal a surge in the prescription of opiate painkillers from 3 million prescriptions in 1991 to just under 16 million in 2009.

Tramadol hydrochloride has emerged as the most commonly prescribed opiate painkiller in England.

The Council for Information on Tranquillisers, Antidepressants and Painkillers (CITAP), a charity for patients based in England, promotes the use of alternative methods of pain relief, especially in the treatment of long-term chronic pain. Paul Entwhistle, Medication Counsellor and Scientific Advisor to CITAP says:

“GPs will often administer drugs like tramadol to treat long term chronic pain rather than search for the underlying problem”.

“Pain is subjective and a constant problem, GPs need to explore other means of pain management," he says.

Tramadol is the most commonly prescribed opiate painkiller in England.

Tramadol is the most commonly prescribed opiate painkiller in England.

SOURCES OF GUIDANCE ON TRAMADOL

As well as the COMPASS reports, information about the pros and cons of using tramadol hydrochloride is available to GPs through other professional sources.

Numerous articles in the British Medical Journal have flagged hazards which can accompany use of tramadol hydrochloride, including its addictive nature. A number of articles have also argued that the drug is overused across primary care.

Ultimate responsibility for the safety of medicines lies with the Medicine and Health Regulatory agency (MHRA), a UK governmental body. The MHRA clearly states:

“All medicines have side effects – no effective medicine is without risk”.

The organisation monitors suspected adverse reactions (ADRs) to all medicines via the Yellow Card Scheme, which allows health professionals and patients to report suspected ADRs – but this is on a voluntary basis.

From 2006 to 2010 the MHRA received 545 individual reports of ADRs to tramadol hydrochloride, nine of them in Northern Ireland. These suspected effects include tremors, insomnia, depression, heart palpitations and suicidal thoughts – all symptoms experienced by Helen, whose case has not been reported to MHRA to her knowledge.

The most recent warnings regarding tramadol hydrochloride came in January this year in COMPASS notes about the dangers of long-term prescribing of all opioid drugs. A short section on tramadol hydrochloride advised:

“Prescribers should anticipate, identify and treat common opioid-associated adverse effects and patients should be advised about side-effects and the likelihood of their occurrence before starting opioid therapy.”

And fundamentally, it questions the value of tramadol hydrochloride as a means of treating pain:

“Tramadol is considered to be no more effective than other weak opioid analgesics and its safety profile is problematic."

“Tramadol has been promoted as a drug to be used between the WHO Step 2 analgesics for moderate pain (such as codeine) and the WHO Step 3 analgesics (strong opioids such as morphine) for severe pain.

“However, evidence from clinically useful trials (particularly in primary care, chronic pain, and cancer pain) is sparse.”