To the Editor: We would like to raise some issues regarding the Research Letter on tramadol abuse and dependence among physicians by Dr Skipper and colleagues.1 First, the authors refer to hundreds of spontaneous tramadol-related reports to MEDWATCH, and Brinker et al2 note that reports of tramadol abuse continue after one would expect a decline in reporting. However, the independent steering committee (ISC) monitoring tramadol is involved in active case finding, without which the reports would have declined. In the most recent period (2002-2004), data from the ISC master database, which is composed of all abuse- or dependence-related reports to the company plus those obtained through case finding, indicate a total of 216 reported cases of abuse or dependence. Of these, 146 (67%) were generated by the ISC. In 2004, only 5 of 28 cases were spontaneous reports.
Second, the authors report that tramadol ranks second to oxycodone in number of exposures reported to the Toxic Exposure Surveillance System (TESS). Exposures reported to TESS are categorized as unintentional or intentional. An examination of TESS data from 2001 through 2003 indicates that for intentional exposures, tramadol ranked fifth for the years 2001 and 2002 and sixth in 2003, well below the 2000 level.3 - 4
Finally, the authors question the methods of a prospective study designed to determine the incidence of tramadol use or abuse in a high-risk, high-access population.5 They state that “the total number of physicians admitting abuse of tramadol was divided by the total number of physicians being monitored, without measuring the percent of these physicians actually taking the drug.” On the contrary, this study tested every urine specimen for tramadol for all study participants (n = 1601), in addition to capturing all “mentions” of tramadol. In addition to reporting the number of participants found to be abusing tramadol (n = 15 [6.9 per thousand persons per year]), it was also reported that 140 participants (69.1 per thousand persons per year) tested positive for tramadol. Most of these physicians (n = 116), however, quickly stopped taking the drug or had a verified prescription. These data (15/1601 [0.94%] found to abuse tramadol) are not significantly different from what the authors report for primary tramadol abuse from Alabama and Michigan (8/595 [1.34%] found to abuse tramadol) (P = .40). We do recommend that when prescribing any medication with even modest abuse potential, prescribers should be aware of potential abuse and monitor their patients appropriately.
Financial Disclosures: Dr Adams is a consultant to Ortho McNeil and is a member of the independent steering committee that monitors tramadol. Dr Dart consults with the pharmaceutical industry on behalf of his institution. Dr Schnoll was previously a member of the independent steering committee.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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