Robert Fowler comes in to ask about pain killers for his wife Elizabeth, who has just had a hysterectomy.
"The operation went well," he tells you. "But she's in quite a bit of pain, which we knew would happen. When she came out of hospital, she was on tramadol but she's running low and the GP has given us a prescription for this."
He shows you a prescription for naproxen 500mg tablets.
"I'm a bit worried, to be honest," he continues. "These are 500mg and the old tablets were only 50mg, so these ones are much stronger. Dr Patel even said that Elizabeth could take paracetamol at the same time if these weren't strong enough.
"But why would she need to do that? I think the doctor's made a mistake. And can't she carry on with the tramadol anyway? She seems very happy on it, I haven't seen her this relaxed for years! I did say that when I phoned to request the prescription but either the receptionist hasn't passed on the message or Dr Patel has done what she wants regardless."
Can you tell me?
1 Is naproxen 500mg stronger than tramadol 50mg?
2 What are the possible reasons for Dr Patel not giving another prescription for tramadol?
What OTC says…
1 Robert is focusing on the strength of the tablets rather than the medication itself. This has led him to the incorrect conclusion that the naproxen 500mg his wife has been prescribed by the GP is stronger than the tramadol 50mg she was given by the hospital. The truth is that tramadol, an opioid-type drug used to relieve moderate to severe pain, is considered to have a stronger analgesic effect than naproxen, which is a non-steroidal anti-inflammatory drug (NSAID, the same family as ibuprofen).
This may seem obvious to someone working in a pharmacy, but can need careful explanation to other people.
In such situations, it is important to be non-judgemental and sensitive so as to not make the other person feel foolish or patronised.
2 Although a synthetic drug, tramadol is very similar in structure and action to the opioids, a family of medicines known for their painkilling properties. Common opioids include morphine, diamorphine (heroin), oxycodone and codeine. This means that – like opioids – tramadol works by altering levels of chemicals in the brain that influence how pain is felt, and patients can become tolerant or even dependent on tramadol.
To reduce the chance of this, tramadol is prescribed at the lowest dose needed to control the pain. Moving on to a non-opioid, such as an NSAID plus paracetamol if needed, is a sensible plan on the part of the GP.
The trick is to find the balance between controlling pain and minimising the risk of side effects and tolerance developing. The remaining tramadol Elizabeth has at home are best reserved for the times when the pain tends to be worse (for example, at night) and the naproxen should be used the rest of the time. As Elizabeth's surgery heals further, the tramadol at night can be replaced with the NSAID and paracetamol used instead of, rather than in addition to, the NSAID during the day.
There may be times when the pain appears worse, for example upon exertion, but any increase in pain that persists should be taken seriously and medical advice should be sought.