Doc: Long-term Tramadol use shouldn’t be taken lightly
Dear Dr. Roach: I just read your column regarding concerns about taking tramadol long term for arthritis pain. I am a 74-year-old female, and I take one or two 50-mg tablets a day, depending on my pain level. Most days, my pain is controlled on that dose. I also take 1,300-mg acetaminophen twice daily. I have chronic atrial fibrillation, and take Coumadin daily. I have been taking tramadol for over a year. I have been on other pain medications in the past, but my doctor didn’t want me to stay on them long term. What are my options?
Dear N.P.: Opiates like tramadol are useful pain medications for acute pain, but they are not appropriate for many people with chronic pain. They have side effects and can be misused, and people tend to develop a tolerance for them, which means that they really don’t work very well; people report the same amount of pain despite long-term use, compared with when they weren’t taking them. Given the large amount of overdose with these drugs, deliberate and accidental, it is entirely appropriate to limit opiate use to a few days in those with acute pain and to consider whether any patient needs them long term. So, I understand why you are asking about options.
There is another side to the story, however. Some people do well on opiates, taking reasonable doses that remain stable, and they get good relief from the medication. There also are people for whom there are no other good medication options, such as people with extremely painful facial nerve pain syndromes. Policies that are intended to reduce harm from opiates need to consider the group of people for whom they are appropriate, and who may be harmed by restrictive policies.
In your situation, given the low dose of tramadol you have been taking for a year, and the (what sounds like) adequate control on this dose, I would not feel strongly that you needed to change.
Dear Dr. Roach: I have been diagnosed with atrial fibrillation. I am on Xarelto, which my doctor prescribed, and I seem to be doing well. However, the cost of this medicine has been rising, and I’m struggling to keep paying for it. Any chance it will be going generic soon?
Dear C.C.: Medication costs are a significant source of distress for many Americans, and for a few people who are unable to pay for life-sustaining medication, a contributor to disability and death. While I don’t have a solution to the problem overall, there are some sources for help.
The first is the pharmaceutical manufacturer. In the case of rivaroxaban (Xarelto), the manufacturer, Janssen, has a savings program so that people with commercial prescription coverage pay only $10.00 in copays (Xarelto.com or 888-XARELTO). Another resource is the Johnson & Johnson Patient Assistance Foundation at 1-800-652-6227 or JJPAF.org.
Finally, Goodrx.com is a free service where users can print coupons for their local pharmacies. The prices are sometimes below the insurance copays for my patients. Unfortunately, when I checked, Xarelto was $425 for a month’s supply through Goodrx.
Rivaroxaban will become available as a generic in 2021.
Email questions to ToYourGoodHealth@med.cornell.edu.