Current evidence indicates that opioids should not be used as first line therapy, but only when all other treatment options have been tried and failed [12]. The National Institute for Health and Care Excellence’s (NICE) found no evidence of long-term effectiveness in chronic non-cancer pain treatment, despite its analgesic effect in the short-term. [13] Furthermore, prescribing of opioids for acute indications such as surgical pain in opioid-naïve patients can also lead to a transition to chronic opioid therapy. [5]
A higher percentage of women with active prescription and an average age of 54.7 years were expected data since the prevalence of pain for more than three months is more common in women and in people over 65 years old in Spain.
Exploring the origin of the prescriptions, most of them came from the general practitioner, when a prescription by a specialist would be advisable [14]. The influence of general practitioner on the dissemination of opioids is substantial to promote an appropriated use. Insufficient training and information about opioid management protocols, time pressure to assess patients properly and system-level constraints such as limited access to specialized and integrative care are some of the reasons that could explain the off-label prescription of opioids [14].
About the duration of treatment, 36.7% of patients had a prescription with durations between 9.5 and 12 months. According to the SmPC of tramadol/dexketoprofen [10], it is intended only for short-term use and treatment should be limited strictly to the symptomatic period (5 days). Although in our study, only three patients had post-surgical pain treatment and for 10 days, several studies of chronic postsurgical pain [14] showed that if postoperative pain is not managed properly, it could evolve in chronic pain, becoming a serious problem. In addition, in the absence of evidence on the efficacy and safety of long-term opioid use, it is recommended to re-evaluate at three months the opioid treatment [12].
In relation to the diagnoses found, tramadol/dexketoprofen was hardly used in cancer pain management or in the context of palliative care what is a cause of concern considering the long-term treatment observed (more than 300 days) in 43% of patients. In reference to the most common diagnoses (primary osteoarthritis, low back pain, fibromyalgia and lumbago with sciatica), nociceptive pain was highly prevalent and should be treated with analgesics and anti-inflammatory drugs. Although long-term opioid treatment has not yet been widely studied on a population basis, many patients may tolerate and respond to this treatment, and it should not be denied to them, with a close follow-up in terms of effectiveness and safety. [15]
It was also found that 26.6% of patients with tramadol/dexketoprofen prescription had been treated concomitantly with one of the two components of this drug, which was unable to account for.
Interventions to improve prescribing should be carried out since there are numerous contraindications and precautions related to tramadol/dexketoprofen, as well as risk of tolerance and addiction [10]. In this sense, some interventions could be that patients had an assessment of their pain and their perspectives regarding the use of this drug (and opioids in general), and physician considered them to promote their correct use, specially preventing their misuse [12]. Another possibility could be to make a reminder to physicians about the indications of tramadol/dexketoprofen and provide information about the inadequate diagnoses and/or prolonged use in chronic noncancer pain, and alternatives in such cases according to evidence [5].