Download Tramadolophobia among Egyptian patients with cancer

The fear of using tramadol for pain control
(tramadolophobia) among Egyptian patients with cancer
Samy A. Alsirafy 1
Radfan N. Saleh 2, 3
Radwa Fawzi 2
Ahmad A. Elnaggar 4
Ahmed M. Hammad 1
Wessam El-Sherief 1, 2
Dina E. Farag 1
Riham H. Radwan 2
1
Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology & Nuclear
Medicine, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
2
Department of Clinical Oncology, Kasr Al-Ainy Center of Clinical Oncology &
Nuclear Medicine, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
3
Aden Refinery Company Hospital, Aden, Yemen
4
Department of Medical Oncology, Faculty of Medicine, Zagazig University,
Sharkia, Egypt
Corresponding author:
Samy A. Alsirafy
Palliative Medicine Unit
Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK)
Kasr Al-Ainy School of Medicine, Cairo University
PO Box 99, Manial El-Roda; Cairo, 11553; Egypt
Tel: (+20) 111 80 35647
e-mail: [email protected]
1
Abstract
Background: Tramadol is the only available World Health Organization (WHO)
step-II analgesic in Egypt. However, it is becoming a stigmatized drug because of its
abuse/misuse. The fear of using tramadol for pain control (tramadolophobia) by
Egyptian patients with cancer is a frequent problem in our practice.
Aim: This study was conducted to explore the prevalence of and the reasons behind
tramadolophobia among Egyptian patients with cancer.
Design: A structured interview including open-ended and closed questions.
Setting/participants: The study included 178 adult patients with cancer from two
cancer centers in Cairo and Sharkia, Egypt.
Results: The source of information about tramadol was a non-healthcare-related
source in 168 (94%) patients, mainly the media (50%). The believed uses of tramadol
were addiction-related in 94 (53%) patients, tonic (physical, sexual, and to boost
alertness) in 59 (33%) and analgesic in 55 (31%). Twenty-six (15%) patients gave
history of tramadol use, largely (69%) as a tonic. In case tramadol was prescribed for
pain control, 90 (51%) patients refused to take it, 59 (33%) patients agreed to take it
with concern about addiction and only 29 (16%) patients agreed without concerns.
Among those who refused taking tramadol for pain, the mentioned reason of refusal
was addiction-related fears in 57%.
Conclusion: The stigmatization and misconceptions about tramadol may have
resulted in tramadolophobia among the majority of Egyptian patients with cancer.
This further complicates the barriers to cancer pain control in Egypt. Being the only
available WHO step-II analgesic in Egypt, interventions to overcome
tramadolophobia should be taken.
Keywords: Cancer, pain, tramadol, abuse, phobia, Egypt
2
What is already known about the topic?

Fear of prescribing/using opioids for pain represents a major barrier to cancer
pain control.
What this paper adds?

Tramadol is becoming a stigmatized drug among patients with cancer in
Egypt.

The fear of using tramadol for pain (tramadolophobia) further adds to the
barriers to cancer pain control.
Implications for practice, theory or policy?

Before commencing tramadol for cancer pain, discussions about it with
patients should be routinely initiated to correct misconceptions.

Interventions to correct misconceptions about tramadol at a public level are
needed.
Introduction
Tramadol is a synthetic weak opioid agonist that is used as a step-II analgesic for mild
to moderate cancer pain according to the World Health Organization (WHO)
analgesic ladder (WHO 1996).
In Egypt, tramadol is very important for cancer pain management. It is the only opioid
available for use as a WHO step-II analgesic for mild to moderate cancer pain.
Codeine and other weak opioids are not available in preparations suitable for cancer
pain management. In addition, the currently available registered strong opioids’
formulations in Egypt do not come in small doses suitable for replacing weak opioids
as a WHO step-II analgesic. Furthermore, tramadol is the only opioid registered in an
oral immediate release form.
Tramadol abuse/misuse is a rising problem in a number of countries. In an
International Narcotics Control Board (INCB) survey, 33 countries (42% of those
responding) reported “non-medical use and/or abuse of tramadol”. According to that
survey, tramadol is under national control in 33 countries. However, few countries
reported that tramadol abuse was a “significant risk” (INCB 2014). Egypt is among
the countries with such “significant risk” where there is a rising tramadol
abuse/misuse epidemic over the last years (Fawzi 2011, Bassiony 2015). The
abused/misused tramadol is mainly a smuggled one. The Egyptian authorities reported
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seizures of 650 million tramadol tablets in the year 2012 alone (INCB report 2015).
The accumulating evidence of tramadol abuse/misuse in Egypt resulted in placing
tramadol under national control in 2013 (INCB report 2015).
In our practice, it is not uncommon to encounter patients who are afraid to use
tramadol for pain because of its defamed reputation. The prevalent abuse/misuse of
tramadol in Egypt has resulted in its stigmatization. This stigmatization may have led
to the fear of using tramadol for pain control (tramadolophobia).
This study was conducted to preliminary estimate the prevalence of tramadolophobia
among Egyptian patients with cancer and to explore the reasons behind it.
Methods
The study included adult (>18 years) patients with confirmed cancer diagnosis who
gave a verbal informed consent to participate in the study. Patients who already
received/were receiving tramadol for cancer pain management were excluded because
discussions about their concerns about tramadol may have been initiated by health
care professionals.
Patients were recruited from two cancer centers in Cairo (Kasr Al-Ainy Center of
Clinical Oncology and Nuclear Medicine [NEMROCK], Kasr Al-Ainy School of
Medicine, Cairo University) and Sharkia (Department of Medical Oncology, Faculty
of Medicine, Zagazig University, Sharkia) governorates.
A structured interview that included closed and open-ended questions was developed
for the purpose of this study (Figure 1). The questionnaire of the interview was
translated into the Arabic Egyptian slang and revised by the investigators.
The study was approved by the research ethics committee of NEMROCK, Kasr AlAiny School of Medicine, Cairo University.
4
Figure 1. The structured interview used to investigate tramadolophobia among
patients with cancer
Results
The interviewers approached 293 patients with cancer among whom 281 (95.5%)
agreed to participate in the study. From these 281 patients, 42 patients were excluded.
The causes of exclusion were: already received/receiving tramadol for cancer pain in
22 (7.8%), missing data in 14 (5%), and age below 18 years in 6 (2%). Sixty-one
(21.7%) patients said that they do not know tramadol in response to the first question
and the interview was discontinued.
The characteristics of 178 patients who said that they know tramadol are shown in
Table 1.
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Table 1. Patients’ characteristics
n.
%
95
83
53.4
46.6
Sex
Female
Male
Age
Median (range)
Marital status
Married
Single
Widow
Divorced
Unknown
Education level
Illiterate
Less than high school
High school
University
Unknown
Primary cancer
Breast
Hematological
Gastrointestinal
Gynecological
Head and neck
Sarcomas
Others
49 (20-80)
153
9
7
4
5
86
5.1
3.9
2.2
2.8
39
31
60
23
3
21.9
17.4
33.7
12.9
1.7
62
55
16
11
9
7
18
34.8
30.9
9
6.2
5.1
3.9
10.1
When they were asked about the source of information about tramadol, 168 patients
(94.4%) mentioned a non-healthcare-related source, mainly the media (television) and
unspecified people. Only 16 (9%) patients mentioned a healthcare-related source.
Eight (4.5%) patients did not specify a source by saying phrases like “very famous”
and “all people take it”. The details of the source of knowledge about tramadol as
described by patients are shown in Table 2.
6
Table 2. Sources of knowledge about tramadol as described by interviewed
patients *
Source
N
%
Non-healthcare-related
Media (television)
89
50
People
Unspecified
57
32
Street
20
11.2
Youth
15
8.2
Work
11
6.2
Abusers/dealers
9
5.1
Friend
7
3.9
Relative
7
3.9
Coffee shops
1
0.6
Wedding parties
1
0.6
Healthcare-related
Pharmacy
6
3.4
Hospital
4
2.2
Patient
4
2.2
Physician
3
1.7
8
4.5
Unspecified
* Patients may have enumerated more than one source
When they were asked about the uses of tramadol, the answer of 94 (52.8%) patients
was an abuse-related one, while 59 (33.1%) mentioned that it is used as a tonic and 55
(30.9%) as an analgesic/treatment.
The uses of tramadol as described by patients are detailed in Table 3.
Table 3. The uses of tramadol as described by interviewed patients *
Use
N
%
Abuse-related
Narcotic/drug
58
32.6
To get a high
27
15.2
Addiction
17
9.6
Tonic
Unspecified
35
19.7
Sexual
16
9
Physical
14
7.9
Alertness
10
5.6
Analgesic/treatment
Analgesic
52
29.2
Treatment
3
1.7
6
3.4
Other
13
7.3
Do not know
* Patients may have enumerated more than one use
All patients who said that tramadol is used as a sexual tonic were males and all of
them were interviewed by males.
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When asked about the uses of tramadol, some patients specified groups using
tramadol. Eight (4.5%) patients said it is used by youth, 4 (2.2%) by addicts, 4 (2.2%)
by working people, 3 (1.7%) by drivers and 2 (1.1%) by losers.
Twenty-six (14.6%) patients said that they used tramadol before. Tramadol was used
as a tonic in 69% of these patients, following the advice of non-healthcare persons in
65%, and brought from a non-healthcare source in 50%. In 77%, the tramadol used
was a smuggled one. The details of tramadol use are illustrated in table 4.
Table 4. Details of previous tramadol use by 26 patients
Reason to use
Tonic
Physical (for work)
Sexual
Alertness
Unspecified
During exams
Analgesic/treatment
Analgesic
Flu
Curiosity
To get a high
Who advised to use
Non-healthcare
Friend/colleague
People (unspecified)
Relative
Healthcare
Physician
Pharmacist
Unknown
Type of tramadol
Smuggled
Legal
Unknown
Source
Non-healthcare
Friend
Drug dealer
Coffee shop
Healthcare
Pharmacy
Hospital
Unknown
Duration of use (months)
Median (range)
N
%
5
5
4
3
1
19.2
19.2
15.4
11.5
3.8
12
1
2
2
46.2
3.8
7.7
7.7
12
3
2
46.2
11.5
7.7
6
2
1
23.1
7.7
3.8
20
3
3
76.9
11.5
11.5
8
3
2
30.8
11.5
7.7
10
2
1
38.5
7.7
3.8
1 (0.03 – 120)
In case tramadol was prescribed as an analgesic, 90 (50.6%) patients refused to take
it, 59 (33.1%) patients agreed to take it with concern about addiction and only 29
(16.3%) patients agreed to take it without concerns about addiction.
8
Among the 90 patients who said they would refuse taking tramadol as an analgesic,
the main cause of refusal was fears related to addiction in 51 (56.7%) patients. The
causes of refusal are detailed in table 5.
Table 5. Causes of refusal to use tramadol for pain among 90 patients
Cause
Addiction-related
Addiction
Narcotic
Dependence
Believed harmful effects
Harmful/dangerous (unspecified)
Central nervous system
Unspecified
Disorientation
Agitation
Depression
Nervousness
Kidney
Liver
Causes death
Other
Bad reputation
Afraid (unspecified)
Haraam (forbidden religiously)
Fear of legal sanctions
Ineffective
Expensive
Unspecified
N
%
29
16
9
32.2
17.8
10
16
17.8
4
3
1
1
1
2
2
1
4.4
3.3
1.1
1.1
1.1
2.2
2.2
1.1
10
5
5
3
1
1
4
11.1
5.6
5.6
3.3
1.1
1.1
4.4
These 88 patients who agreed to receive tramadol as an analgesic rated their concern
about addiction as no concern in 29 (33%), mild concern in 15 (17%), moderate
concern in 18 (20.5%) and severe concern in 26 (29.5%).
Discussion
In Egypt, cancer pain control remains largely inadequate. The most recent opioid
consumption data reported by the INCB in 2015 show that there is some increase in
the level of opioid consumption in Egypt (INCB narcotics 2015). However, the
current figures still indicate that cancer pain is largely uncontrolled in Egypt.
According to the level of consumption of narcotic drugs, Egypt is ranked 117 among
countries with 75 defined daily doses for statistical purposes per million inhabitants
per day (INCB narcotics 2015). The inadequate cancer pain control in Egypt is
attributed to many barriers including the limited availability of opioids recommended
by the WHO and the restrictive regulations that limit the accessibility of patients with
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cancer to the available opioids (Alsirafy 2010 EJPC, Alsirafy 2010 JPSM, Alsirafy
2011).
Tramadol is the only opioid available and suitable for use as a WHO step-II analgesic
in Egypt. Currently, there are no other registered weak opioids or strong opioids in
doses suitable for replacing tramadol. The only registered oral morphine is the 30 mg
slow-release morphine tablets, which is already unavailable in Egypt for several
months now. In addition to its value as a WHO step-II analgesic, immediate-release
oral tramadol is the only registered opioid that can be used as a breakthrough
analgesic for some patients with cancer pain in Egypt.
Taking into consideration the importance of tramadol for cancer pain management, its
stigmatization and the resulting tramadolophobia is expected to have a significant
negative impact on cancer pain control in Egypt which is already faced by many
obstacles.
In the current study, tramadolophobia was highly prevalent in the studied population.
In case they have pain and tramadol was prescribed for them as analgesic, the
majority (84%) said they won’t take it or will take it with concern about addiction.
Only 16% said they would take it without being concerned about addiction. In the
absence of alternatives to tramadol, this prevalent tramadolophobia may result in
significant suffering among patients with cancer pain.
Patient-related barriers, especially fear-of-addiction, are among the recognized
barriers to cancer pain management (Paice 1998, Paice 2014). Fear of addiction was
the main reason behind tramadolophobia among the studied population. In 57% of
patients, the mentioned reason of refusing to take tramadol as an analgesic was
addiction-related. The percentage is expected to be higher than that because some
patients may have expressed indirectly their fear of addiction by saying “it is
harmful/dangerous” (18% of patients) or “it has a bad reputation” (11%).
In addition to the fear of addiction, other reasons may be relevant. Some patients
expressed their concerns about legal sanctions and others believed that tramadol is
“haraam” (forbidden religiously). Few other patients mentioned unfounded adverse
effects like hepatic and renal toxicities. It was surprising that only 31% of interviewed
patients reported that tramadol is used as an analgesic while 53% and 33% reported
abuse-related and tonic uses, respectively. With these high levels of
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misconceptualization and stigmatization of tramadol, it is not at all surprising that the
majority of patients with cancer would experience tramadolophobia.
While tramadol abuse/misuse is a fact in Egypt, it is very much likely that the media
has contributed significantly to its misconceptualization and stigmatization. The
source of information about tramadol was the media (television) in half of the
interviewed patients. This concurs with Fawzi (2011) who suggested that the media is
a major reason for tramadol abuse in Egypt.
To overcome tramadolophobia, interventions at many levels should be taken. At the
level of cancer pain practice, discussions with cancer pain patients for whom tramadol
will be prescribed are necessary to understand how they feel about tramadol and to
correct misconceptions. In addition, there should be continuous monitoring to ensure
adherence to the treatment. At the public level, evidence-based interventions to defeat
the myths surrounding tramadol are needed, especially through the media which
played a crucial role in misconceptualizing and stigmatizing tramadol. For example,
although no exact estimations exist, tramadol is widely used to boost the sexual
performance of men in Egypt (Elhadidy 2014). There is evidence to support the use of
tramadol for premature ejaculation (Kirby 2015). However, the long-term use of
tramadol may impair the sexual function of men. In a recent study from Egypt,
tramadol-dependent (daily intake for at least one year) married men experienced a
significant improvement in the sexual functions 6 months after stopping tramadol
(Elhadidy 2014).
Actions should be taken at a national level to combat the abuse/misuse of tramadol,
which resulted in the emergence of tramadolophobia. However, there should be a
balance between the regulations that limit the abuse of opioids and its availability for
cancer pain management (WHO 2011). In response to the misuse/abuse of tramadol in
Egypt, tramadol was put under national control in 2013 (INCB report 2015).
Currently, tramadol is available only in cancer care facilities and few governmental
pharmacies and only for patients with cancer. While it important to prevent the
diversion of tramadol, all efforts should be made to make it available for medical use.
The current study has a number of limitations. The structured interview included
open-ended questions. This was necessary because of the lack of knowledge about the
topic of the study. Furthermore we did not use standardized tools to assess patient11
related barriers to cancer pain management, like the Barriers Questionnaire II (Gunnar
2002). Future studies using standardized assessment tools with focus on tramadol are
needed. Another limitation is that we did not include patients with cancer in “pain”.
This was an exploratory study that guides future research including patients with
cancer pain.
Conclusions
In conclusion, the results of the current study suggest that the abuse/misuse of
tramadol in Egypt has resulted in tramadolophobia among patients with cancer.
Interventions to overcome tramadolophobia as a barrier to cancer pain control are
necessary.
References

Alsirafy SA. Dealing with barriers to cancer pain control in Egypt. Eur J
Palliat Care 2010; 17(1): 10-11.

Alsirafy SA. Regulations governing morphine prescription in Egypt: an urgent
need for modification. J Pain Symptom Manage. 2010;39(1):e4-6.

Alsirafy SA, El-Mesidi SM, El-Sherief WA, et al. Opioid needs of patients
with advanced cancer and the morphine dose-limiting law in Egypt. J Palliat
Med 2011; 14(1): 51-54.

Bassiony MM, Salah El-Deen GM, Yousef U, Raya Y, Abdel-Ghani MM, ElGohari H, Atwa SA. Adolescent tramadol use and abuse in Egypt. Am J Drug
Alcohol Abuse. 2015;41(3):206-11.

El-Hadidy M.A, El-Gilany AH. Physical and sexual well-being during and
after tramadol dependence. Middle East Current Psychiatry, 2014; 21(3), 148151.

Fawzi MM. "Some medicolegal aspects concerning tramadol abuse: The new
Middle East youth plague 2010. An Egyptian overview." Egyptian Journal of
Forensic Sciences. 2011;1(2): 99-102.

Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S. Patient-related
barriers to pain management: the Barriers Questionnaire II (BQ-II). Pain.
2002; 99(3):385-96.
12

International Narcotics Control Board. Narcotic drugs: estimated world
requirements for 2015, statistics for 2013. New York: United Nations; 2015.

International Narcotics Control Board. Report of the International Narcotics
Control Board for 2014. New York: United Nations; 2015.

International Narcotics Control Board. Report of the International Narcotics
Control Board for 2013. New York: United Nations; 2014.

International Narcotics Control Board. Report of the International Narcotics
Control Board for 2014. New York: United Nations; 2015.

Kirby EW, Carson CC, Coward RM. Tramadol for the management of
premature ejaculation: a timely systematic review. Int J Impot Res. 2015 May
14. doi: 10.1038/ijir.2015.7. [Epub ahead of print]

Paice JA, Toy C, Shott S. Barriers to cancer pain relief: fear of tolerance and
addiction. J Pain Symptom Manage. 1998;16(1):1-9.

Paice JA, Von Roenn JH. Under- or overtreatment of pain in the patient with
cancer: how to achieve proper balance. J Clin Oncol. 2014;32(16):1721-6.

World Health Organization: Cancer pain relief with a guide to opioid
availability. Geneva: World Health Organization, 1996.

World Health Organization. Ensuring balance in national policies on
controlled substances: guidance for availability and accessibility of controlled
medicines. Geneva: World Health Organization, 2011.
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