Opioids, Tramadol and Tapentadol in Chronic Pain

Alison opens with why community practitioners are well placed to spot drug interactions, inappropriate medications and self-prescribing. Opioids are first line for severe acute nociceptive pain, but they lack evidence for chronic non-cancer pain, and opioid deaths now exceed road traffic deaths in countries including Australia and the US. She lists common and less common side effects and runs through morphine, oxycodone (including controlled-release forms and the naloxone combination Targin) and codeine, whose liver conversion varies so much between individuals that some people risk overdose and others get little effect. She also covers buprenorphine, methadone and hydromorphone, which give a slower, steadier state. Tramadol acts weakly on the mu opioid receptor and also inhibits serotonin and noradrenaline reuptake, so overdose or combination with an SSRI can cause serotonin syndrome, an interaction a clinician may pick up in a full history. Tapentadol has a lower side effect profile but is expensive.