Towards Safer Use of Tramadol in the Emergency Department

Greater Southern Area Health Service

This project was entered in the 2006 Baxter NSW Health Awards, Safety of Health Care category.

Contact: Jessica Ryder

Abstract

Because of concerns about the safety and cost-effectiveness of tramadol use, our pharmacy department conducted a campaign to reduce the potential for adverse outcomes associated with tramadol use in the ED.   Patients receiving tramadol over 3 months in 2003 and over 6 months of 2004/2005 after interventions were identified and the medical records evaluated. The first evaluation found that 3% were on interacting medication, 3% were at risk of seizures but that 42% did not have documentation of concomitant medications. Subsequent interventions included prescriber education and campaigns encouraging documentation of concomitant medications. Re-evaluation found an improvement in the documentation of concomitant medications to 27%. Perhaps because of improved records we found 13% were on interacting medications and 2% were at risk of seizures.  Average usage of tramadol fell from 5.6g to 1.8g per month.  Careful recording of concomitant medications and co-morbidities is vital in the safe use of tramadol.   

Aim

To decrease the potential for adverse outcomes in the prescribing of tramadol in the emergency department within 12 months.

Background

There were concerns that the campaign to decrease the use of pethidine would lead to increased tramadol usage. In addition, there were concerns about the safety of the use of tramadol because tramadol has an adverse drug reaction profile similar to other opioids (2005b). In addition, tramadol is to be used with caution in patients with epilepsy, head trauma or increased intracranial pressure (Kaye & Theaker, 2001). The use of tramadol has also been associated with serotonin syndrome when administered as a single serotonergic agent and in combination with other serotonergic drugs (ADRAC, 2004). There were also concerns about the cost-effectiveness of tramadol (Kaye & Theaker, 2001).

Method

Patients receiving tramadol in the emergency department were identified using drug register recorded over 3 months (mid-August 2003 to mid-November 2003). The medical records of the individuals were then evaluated by pharmacists focusing on the medication history, relevant co-morbidities, allergies, adverse drug reactions and the time of last dose of analgesia if applicable.

Planning and Implementation

The evaluation was carried out in 110 patients found that the use of tramadol could not be supported in 3% of the patients that were on medications with potential interactions and in 3% of the patients that had a history of epilepsy or presented with head injuries. It was also found that 42% of the patients did not have documentation of concomitant medications and 25% of the patients did not have documentation of adverse drugs reactions and/or allergies.  Subsequently, the department undertook interventions focusing on the documentation of medication histories and promotion of the safe and efficacious use of tramadol over December 2003 to April 2004. These included prescriber and nursing staff educations via in-services and a grand round session. Information on tramadol and the findings of the study was published in the drug bulletin that was distributed in the hospital and to the local general practitioners. A reminder to check the medication history when using tramadol was attached to the drug register and a decision was made to continue using the drug register. Patients were also provided with written information regarding tramadol.

Outcomes and evaluation

The second evaluation was conducted from September 2004 to February 2005 where 95 records were examined by a pharmacist based on the same parameters. During this phase, it was found that 13% of the patients were on medications with potential interaction, 2% of the patients had a history of epilepsy or presented with head trauma and 2% of the patients had recorded adverse drug reactions to tramadol. There was an improvement in the documentation of concomitant medications, with 27% lacking documentation during this evaluation. In addition, there was an improvement in the documentation of adverse drug reaction documentation with 18% of the patients lacking documentation. Overall, the use of tramadol in the emergency department decreased from 3.4g per month of the parenteral formulation and 1.2g per month of the oral formulation to 1.4g per month of the parenteral formulation and 0.35g per month of the oral formulation.

Graph 1: The amount of tramadol supplied to the emergency department for both parenteral and oral formulation from Jul 2003 to February 2005

Future Scope

It was found that careful consideration and documentation of concomitant medications and relevant co-morbidities is vital in promoting the safe use of tramadol.

References

Adverse Drug Reactions Advisory Committee. Serotonin syndrome. Aust Adv Drug Reactions Bull 23(1), Feb 2004
K. Kaye, N. Theaker. Tramadol: a position statement of the NSW Therapeutic assessment Group Inc. September 2001. Available from: http://www.nswtag.org.au

MIMS Online. 2005a. Sydney: CMPMedica Australia. Available from: http://mims.hcn.net.au/

Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2005