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TO THE EDITOR: Kudos to Dr. Sachs for her attempt to develop an evidence-based approach to the use of oral analgesics for acute pain.1 However, her recommendation against the use of tramadol (Ultram) seems to be the result of selective reporting of the research literature, based on a randomized trial2 comparing tramadol with hydrocodone (Vicodin) and a randomized trial3 comparing tramadol with placebo or acetaminophen and codeine. Dr. Sachs does not cite a double-blind randomized trial4 of 200 adults that showed that tramadol (75 mg) plus acetaminophen was as effective as hydrocodone (10 mg) plus acetaminophen in relieving pain caused by extraction of impacted molars, and was less likely to cause adverse drug events. She also did not cite a meta-analysis5 of individual patient data that showed that, compared with placebo, tramadol (75 mg) plus acetaminophen had a number needed to treat (NNT) of 2.6 to reduce pain by 50 percent, which was comparable to the NNT of 2.4 for 5 mg of oxycodone (Oxycontin) plus acetaminophen in a separate meta-analysis.6 However, the meta-analysis5 of tramadol should be viewed cautiously because it is based on unpublished pharmaceutical company data.
Using a MEDLINE search strategy (tramadol and postoperative pain/drug therapy) limited to randomized controlled trials, I identified 104 separate trials comparing tramadol with a variety of other medications for the treatment or prevention of postoperative pain. The evidence from those trials is mixed, with some trials showing substantial benefit and others showing little benefit for tramadol.
I believe the evidence on tramadol for acute pain is mixed. It would be useful to have a trial comparing multiple doses of tramadol plus acetaminophen with multiple doses of hydrocodone plus acetaminophen. Until that time, it is prudent to keep...