Opioid use by patients in an orthopedics spine clinic.Mahowald ML, Singh JA, Majeski P.Minneapolis VAMC, and the University of Minnesota, Minneapolis.OBJECTIVE: Concerns regarding the efficacy, toxicity, tolerance, dependence, and abuse of opioids have limited their use for patients with chronic spine pain. In our previous study of rheumatology clinic patients, opioid analgesics were found to be highly effective, produced only mild side effects, and had few instances of opioid abuse. The purpose of this study was to replicate our previous study in another large cohort of patients with nonmalignant pain due to well-defined spinal diseases. METHODS: Opioid use was studied in 230 orthopedics spine clinic patients by retrospective analysis of prescriptions for 3 years and cross-sectional analysis of efficacy and toxicity by patient interviews. Opioid use and stability of the daily dose over 3 years were derived from computerized pharmacy records. Medical records, operative reports, and radiographic studies were reviewed to determine the reason for dosage escalations and to detect instances of abuse or addiction behaviors. Patients were interviewed to determine the efficacy, frequency, and types of side effects and instances of obtaining opioids from sources outside the Veterans Affairs system. RESULTS: Opioids were prescribed for 152 of the 230 patients, for <3 months (short-term [STO]) in 94, >/=3 months (long-term [LTO]) in 58, and none in 72 (no opioid [NTO]). Medications prescribed were codeine, oxycodone, propoxyphene, Tramadol ( Generic Ultram ), morphine, meperidine, fentanyl, or hydroxycodone, either alone or in combination. Interviews were completed in 72 STO, 50 LTO, and 45 NTO patients. Pain severity (0-10 scale) was not different in patients with different spinal pathologies. Opioids significantly reduced the back pain severity score from 8.3 +/- 1.5 to 4.5 +/- 2.2 (mean +/- SD). Mild side effects (most commonly, constipation and sedation) were reported by 58% of the opioid-treated patients but rarely caused them to stop taking the medication. There was no significant increase from the mean +/- SD initial opioid dosage of 5.0 +/- 12.2 30-mg codeine equivalents per day (30 mg oral codeine = 5 mg oral morphine) to the mean peak dosage of 7.9 +/- 12.5 and the mean recent dosage of 4.3 +/- 6.3, suggesting that tolerance to opioid analgesia did not appear to occur in these patients. Dosage escalations of >2 30-mg codeine equivalents occurred 19 times in 17 LTO patients and was due to worsening of the underlying painful condition, complications of spine surgery, or unrelated surgical or medical problems in all but 3 of them (5%). These 3 patients also displayed other abuse behaviors. Abuse behaviors were not more frequent in those with or without a history of abuse/addiction. CONCLUSION: This study provides data on the efficacy, toxicity, tolerance, and abuse or addiction behaviors with opioid therapy in a large cohort of patients in an orthopedics spine clinic. The results provide objective data from patients with well-defined spine diagnoses to challenge the position that opioid treatment is inappropriate for chronic nonmalignant pain. This study provides clinical evidence to support and protect physicians treating patients with chronic musculoskeletal diseases, who may be reluctant to prescribe opioids because of possible sanctions from regulatory agencies. More important, it will benefit patients by permitting them to receive these effective, safe medications.

Determination of common drugs of abuse in body fluids using one isolation procedure and liquid chromatography--atmospheric-pressure chemical-ionization mass spectromery.

A method for determining opiate agonists (morphine, morphine-3-glucuronide, morphine-6-glucuronide, 6-monoacetylmorphine, codeine, codeine-6-glucuronide, dihydrocodeine, dihydromorphine, buprenorphine, methadone, Tramadol ( Generic Ultram ), and ibogaine), cocaine and its metabolites (benzoylecgonine and ecgonine methyl ester) and lysergic acid diethylamide in serum, blood, urine and other biological matrices is presented. Aliquots (0.5-1.5 mL) of biological fluids were spiked with appropriate deuterated internal standards and extracted using a common solid-phase extraction method (C18 cartridges). The extracts were subjected to liquid chromatographic-atmospheric-pressure chemical-ionization mass spectrometric examination using selected ion monitoring procedures. These procedures were developed after analysis of full-scan mass spectra of examined compounds. The extraction method appeared very universal; the recoveries were high for almost all drugs and the extracts were very clean. The procedure was applied for routine forensic casework.
Eur J Clin Pharmacol. 2005 Jan 21Tramadol ( Generic Ultram ) concentrations in blood and in cerebrospinal fluid in a neonate.Allegaert K, de Hoon J, Verbesselt R, Devlieger H, Tibboel D.Department of Paediatrics, University Hospital, Gasthuisberg, Leuven, Belgium.Based on blood and cerebrospinal fluid samples collected in a full-term neonate, the penetration of Tramadol ( Generic Ultram ) in the central nervous system is described. Following intravenous administration of Tramadol ( Generic Ultram ), a lag time of about 4 h was observed until full blood-brain equilibration was achieved. This pharmacokinetic observation is in line with a recent pharmacodynamic evaluation of the central opioid effects of Tramadol ( Generic Ultram ) in adults.

Laparoscopic donor nephrectomy (LD) is rapidly gaining popularity, however, this may not be affordable by donors in many developing countries because of its high cost. We describe our mini flank incision (MD) donor nephrectomy technique and its outcome. METHODS: A 7-10-cm subcostal rib sparing transverse incision was given 2 cm lateral to the tip of the 12th rib, towards the lateral border of rectus muscle. All dissections were performed with help of long retractors and instruments, vessels were transfixed and cut. In last 45 cases, vessels were clipped with Liga or Weck clips. Donors and recipients outcome was analysed. RESULT: From January 2000 to December 2002 a total of 148 patients underwent donor nephrectomy by mini incision technique. Mean patient age was 44.8 +/- 7.3 yr (range 20-70 yr). Nephrectomies were performed in 115 patients on the left side and in 33 cases on the right side. The mean incision length was 9.1 +/- 1.8 cm (range 7-10 cm). Mean operative time was 105 +/- 10.5 min (70-130 min). Mean analgesic (Tramadol ( Generic Ultram )) requirement was 205 +/- 52 mg; postoperative hospital stay was 2.2 +/- 0.5 d. Twelve per cent patients developed fever and 4% had superficial wound infection in postoperative period. Three patients required blood transfusion. Mean convalescence period was 22 +/- 2.8 d. CONCLUSION: Extrapleural, extraperitoneal, subcostal mini incisions live donor nephrectomy is a relatively safe procedure with low morbidity. This technique has a shorter hospital stay, early convalescence and better cosmesis. It is cost-effective and is an ideal substitute for the developing country.

Electromagnetically generated extracorporeal shockwaves for fragmentation of extra-and intrahepatic bile duct stones: indications, success and problems during a 15 months clinical experience.

Electromagnetically generated extracorporeal shock waves (without waterbath) were applied after intravenous premedication with 10-15 mg diazepam and 100 mg Tramadol ( Generic Ultram ) in the treatment of 33 patients (aged 32 to 91 years) with multiple intrahepatic stones (n = 4) or huge common bile duct stones (n = 29, 18-30 mm in diameter), which could not be removed by conventional endoscopy. Stone disintegration was achieved in 70% of common bile duct stones and in all intrahepatic concrements after 800-7500 discharges, which were applied during one (n = 21), two (n = 6) or three sessions (n = 6). Apart from mild fleabite-like petechiae at the side of shock wave transmission no other side effects were observed for a total of 51 procedures. We believe electromagnetically generated shock waves are safe, easy to apply, and relatively effective in the therapy of common bile duct and intrahepatic stones.

Role of epidural Tramadol ( Generic Ultram ) hydrochloride on postoperative pain relief in caesarean section delivery.

Two groups comprising 25 patients in each went for caesarean section delivery under epidural anaesthesia. Group I patients received 50 mg (1 ml) of Tramadol ( Generic Ultram ) hydrochloride with 14 ml of 2% lignocaine with adrenaline (1:200,000) and group II cases received 15 ml of 2% lignocaine with adrenaline (1:200,000). Both the groups of patients were comparable in age and body weight. In both the groups, there were good operative conditions, insignificant changes in pulse and blood pressure. The neonatal status was also similar in both the groups. The patients belonging to group I showed longer duration (15.39 +/- 0.45 hours) of analgesia in comparison to group II patients (2.46 +/- 0.54 hours).

Direct determination of Tramadol ( Generic Ultram ) glucuronides in human urine by high-performance liquid chromatography with fluorescence detection.

A sensitive and selective reversed-phase high-performance liquid chromatography method has been developed for the direct determination of three glucuronides of the centrally acting analgesic Tramadol ( Generic Ultram ) (1). Separation of these glucuronides into their diastereomers was achieved by HPLC using ion pair chromatography with nonanesulfonic acid sodium salt and LiChrospher 100 RP 18 as stationary phase. Quantification of O-demethylTramadol ( Generic Ultram ) glucuronide and N,O-didemethylTramadol ( Generic Ultram ) glucuronide in human urine was performed by fluorescence detection. The urine samples were purified by a two-step solid-phase extraction. The glucuronides were found to be highly enriched in the 1S,2S-diastereomers. The results of a study with three healthy volunteers are presented.