Canada Considers Reclassifying Tramadol: Not a Safer Option

Millions of North Americans are physically dependent on drugs prescribed for pain, anxiety and depression. When the drugs are tapered too quickly, withdrawal symptoms ensue. Many doctors begin offering tramadol as a safer option but the truth is, it is not safer at all. There’s a good chance that a decade-old misstep by Health Canada helped influence his thinking. To appreciate the misstep, it's necessary to first understand the drug.

Tramadol is a synthetic painkiller developed in the 1960s. In the body, it increases serotonin levels in much the same way antidepressants do. This contributes to its analgesic effect. In the liver, tramadol is converted to a different compound called M1, an opioid that relieves pain the same way morphine does. In a sense, tramadol is two drugs in one, and this "dual mechanism of action" has helped companies promote it to doctors wanting to help patients in pain.

But there's a catch: The conversion of tramadol (the antidepressant) to M1 (the opioid) varies tremendously from person to person. About 6 per cent to 7 per cent of Caucasians lack the enzyme completely, deriving none of the opioid effects, while in other patients the conversion is highly efficient. Roughly a third of people of East African or Middle Eastern descent, for example, convert tramadol to M1 readily.

The practical implication of this variability is that when a doctor prescribes tramadol, he or she rolls the dice, not knowing whether the patient will get a bit of opioid, a lot of opioid or none at all. In the patient-level experiment that is pain management, a key goal is to find a medication that works and is well-tolerated. Tramadol adds needless uncertainty to this experiment.

Fully aware of tramadol's pharmacology, in 2007 Health Canada announced it was considering "scheduling" tramadol as a controlled drug, like codeine, morphine and every other opioid in clinical use. It then sought input from stakeholders and, in doing so, was quickly lobbied by tramadol manufacturers and at least one patient advocacy group supported financially by these same companies. The lobbying seems to have worked: Ten years later, tramadol is nowhere to be found in the Controlled Drugs and Substances Act; in Canada, it enjoys more or less the same legal status as drugs for hypertension. It's not hard to see why tramadol's preferential classification might lead a doctor to perceive it as safer than, say, Percocet.

Health Canada is now revisiting its 2007 decision. Placing tramadol where it belongs – in Schedule 1 of the Controlled Drugs and Substances Act. Classifying tramadol as its pharmacology demands will help dispel the perception that it's somehow safer than other opioids. This is Health Canada's opportunity to correct an old mistake and put the health of Canadians ahead of commercial interests.

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  • This was one of the drugs my brother was prescribed after his cancer surgery so I guess maybe he lacks the enzyme because he said it was even less affective than taking Tylenol. Yet the surgeon prescribed it and then they switched to another one that was similar in that it didn’t help with his pain. :( crazy it affects others sooo differently
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