Does tramadol make you tired: Tramadol: strong painkiller to treat severe pain

24.11.197707.11.2021 by alexxlab

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Tramadol: strong painkiller to treat severe pain

Follow your doctor’s instructions about how to use this medicine. This is particularly important because tramadol can be addictive.

The dose can vary but you should not normally take more than 400mg a day.

Tramadol does not usually upset your stomach, so you can take it with or without food.

Different types of tramadol

Tramadol comes as:

fast-acting tablets – these contain 50mg of tramadol
slow-acting tablets – these contain 50mg, 75mg, 100mg, 150mg, 200mg, 300mg or 400mg of tramadol
fast-acting capsules – these contain 50mg of tramadol
slow-acting capsules – these contain 50mg, 100mg, 150mg or 200mg of tramadol
drops that you swallow – these contain 100mg of tramadol in 1ml of liquid
an injection (usually given in hospital)
soluble tablets – these contain 50mg of tramadol
tablets that dissolve in the mouth – these contain 50mg of tramadol
an injection (usually given in hospital)

Tramadol drops, injections and some tablets and capsules are fast-acting. They start to work within 30 to 60 minutes. They’re used for pain that is expected to last for only a short time. You may be told to take fast-acting tramadol only when you need it for pain or on a regular basis. Always follow the instructions given to you by your doctor.

Some tramadol tablets and capsules are slow-release. This means the tramadol is gradually released into your body over either 12 or 24 hours. This type of tramadol takes longer to start working but lasts longer. It’s used for long-term pain.

Your doctor will decide the right dose for you, depending on how sensitive you are to pain and how bad your pain is. Your dose may need to be changed several times to find what works best for you. In general, you will be prescribed the lowest dose that relieves your pain.

How much to take

Dosages vary from person to person. Your dose will depend on how bad your pain is, how you’ve responded to previous painkillers and if you get any side effects.

How to take it

Fast-acting tramadol comes as capsules, drops and 2 different tablets – soluble and dissolve-in-the-mouth tablets:

capsules: swallow each capsule whole with plenty of water
drops: mix the drops into a glass of water then drink the whole contents of the glass
soluble tablets: dissolve each tablet in 50ml (1/2 cup) of water and drink
dissolve-in-the-mouth tablets: make sure your hands are dry before handling the tablet. Take the tablet out of the blister pack and put it on your tongue. Suck the tablet, do not chew it. After it has melted, swallow or have a drink of water. You can also dissolve the tablet in a glass of water if you prefer.

Slow-release tramadol comes as tablets and capsules. It’s important to swallow slow-release tramadol tablets and capsules whole with a drink of water.

When to take it

When to take it depends on the type of tramadol that you have been prescribed:

fast-acting tablets and capsules – usually 3 to 4 times a day
drops – usually 3 to 4 times a day
slow-release tablets and capsules – usually 1 or 2 times a day

If you’re 65 and over, or you have liver or kidney problems, you may be asked by your doctor to take tramadol less often.

You can take your tramadol at any time of day but try to take it at the same time every day and space your doses evenly. For example, if you take tramadol twice a day and have your first dose at 8am, take your second dose at 8pm.

What if I forget to take it?

This will vary depending on which type of tramadol you are taking.

If you forget to take a dose, check the information on the patient information leaflet inside the packaging or ask your pharmacist or doctor for advice on what to do.

Never take 2 doses at the same time to make up for a forgotten one.

If you forget doses often, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What will happen if I stop taking it?

If you need to take tramadol for a long time your body can become tolerant to it.

This is not usually a problem but you could get unpleasant withdrawal symptoms if you stop taking it suddenly.

If you want to stop taking tramadol, talk to your doctor first. Your dose will usually be reduced gradually so you do not get unpleasant withdrawal effects.

Tramadol can cause unpleasant withdrawal symptoms if you come off it suddenly, such as:

feeling agitated
feeling anxious
shaking
sweating

What if I take too much?

It’s important not to take more than your prescribed dose, even if you think it’s not enough to relieve your pain. Speak to your doctor first, if you think you need a different dose.

Taking too much tramadol can be dangerous.

If you’ve taken an accidental overdose you may feel very sleepy, sick or dizzy. You may also find it difficult to breathe. In serious cases you can become unconscious and may need emergency treatment in hospital.

The amount of tramadol that can lead to an overdose varies from person to person.

If you’ve taken 1 extra dose by mistake, check the information that comes with the medicine packaging or ask your pharmacist or doctor for advice. Generally, you are unlikely to get any symptoms and you can take your next dose as usual.

If you need to go to A&E do not drive yourself. Get someone else to drive you or call for an ambulance.

Take the tramadol box or leaflet inside the packet plus any remaining medicine with you.

Tramadol Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing

Tramadol (Oral Route) Precautions – Mayo Clinic

Precautions

Drug information provided by: IBM Micromedex

It is very important that your doctor check your or your child’s progress at regular visits, especially within the first 24 to 72 hours of treatment to make sure the medicine is working properly. Blood and urine tests may be needed to check for unwanted effects.

Do not use this medicine if you are using or have used an MAO inhibitor (MAOI) such as isocarboxazid [Marplan®], linezolid [Zyvox®], phenelzine [Nardil®], selegiline [Eldepryl®], tranylcypromine [Parnate®]) within the past 14 days.

You should not take other medicines that also contain tramadol. This includes Conzip®, Qdolo, Rybix™, Ryzolt™, Ultram®, Ultram® ER, or Ultracet®. Using these medicines together may increase your chance for more serious side effects.

Check with your doctor before using this medicine with alcohol or other medicines that affect the central nervous system (CNS). The use of alcohol or other medicines that affect the CNS with tramadol may worsen the side effects of this medicine, such as dizziness, poor concentration, drowsiness, unusual dreams, and trouble with sleeping. Some examples of medicines that affect the CNS are antihistamines or medicine for allergies or colds, sedatives, tranquilizers, or sleeping medicines, medicine for depression, medicine for anxiety, prescription pain medicine or narcotics, medicine for attention deficit and hyperactivity disorder, medicine for seizures or barbiturates, muscle relaxants, or anesthetics, including some dental anesthetics.

This medicine may cause sleep-related breathing problems (eg, sleep apnea, sleep-related hypoxemia). Your doctor may decrease your dose if you have sleep apnea (stop breathing for short periods during sleep) while using this medicine.

Using this medicine while you are pregnant may cause neonatal withdrawal syndrome in your newborn baby. Check with your doctor right away if your baby has an abnormal sleep pattern, diarrhea, a high-pitched cry, irritability, shakiness or tremors, weight loss, vomiting, or fails to gain weight. Tell your doctor right away if you think you are pregnant or if you plan to become pregnant while using this medicine.

Tramadol is highly metabolized in the body. Some people change tramadol to a stronger product (O-desmethyltramadol) more quickly than others. These individuals are called “ultra-rapid metabolizers of tramadol”. Contact your doctor immediately if you experience extreme sleepiness, confusion, or shallow breathing. These symptoms may indicate that you are an “ultra-rapid metabolizer of tramadol. ” As a result, there is too much O-desmethyltramadol in the body and more side effects of O-desmethyltramadol than usual. Children may be especially sensitive to this effect (eg, serious breathing problems, death). Do not give this medicine to:

Children younger than 12 years of age.

Children younger than 18 years of age who have had surgery removal of tonsils or adenoids.

Children 12 to 18 years of age who have a high risk for breathing problems (eg, obstructive sleep apnea, obesity, lung disease).

If a nursing mother is an ultra-rapid metabolizer of tramadol, it could lead to an overdose in the nursing baby and cause very serious side effects.

For nursing mothers using this medicine:

Talk to your doctor if you have any questions about taking tramadol or about how this medicine may affect your baby.

Call your doctor if you become extremely tired and have difficulty caring for your baby.

Your baby should generally nurse every 2 to 3 hours and should not sleep more than 4 hours at a time.

Check with your doctor, hospital emergency room, or local emergency services (eg, “call 9-1-1”) immediately if your baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, difficulty breathing, or limpness. These may be symptoms of an overdose and need immediate medical attention.

Check with your doctor right away if you or your child have anxiety, restlessness, a fast heartbeat, fever, sweating, muscle spasms, twitching, nausea, vomiting, diarrhea, or see or hear things that are not there. These may be symptoms of a serious condition called serotonin syndrome. Your risk may be higher if you also take certain other medicines that affect serotonin levels in your body.

This medicine may cause some people to be agitated, irritable, or display other abnormal behaviors. It may also cause some people to have suicidal thoughts and tendencies or to become more depressed. Make sure your doctor knows if you have trouble sleeping, get upset easily, have a big increase in energy, or start to act reckless. Also tell your doctor if you have any sudden or strong feelings, such as feeling nervous, angry, restless, violent, or scared. Let your doctor know if you or anyone in your family has bipolar disorder (manic-depressive disorder) or has tried to commit suicide.

This medicine may cause serious allergic reactions, including anaphylaxis, angioedema, or certain skin conditions (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis). These reactions can be life-threatening and require immediate medical attention. Call your doctor right away if you or your child have a rash, itching, blistering, peeling, or loosening of the skin, fever or chills, cough, red irritated eyes, red skin lesions, often with a purple center, sore throat, sores, ulcers, or white spots in the mouth or on the lips, trouble breathing or swallowing, unusual tiredness or weakness, or any swelling of your hands, face, mouth, or throat while you are using this medicine.

This medicine may cause some people to become drowsy, dizzy, or lightheaded. Do not drive or do anything else that could be dangerous until you know how this medicine affects you.

This medicine may cause adrenal gland problems. Check with your doctor right away if you have darkening of the skin, diarrhea, dizziness, fainting, loss of appetite, mental depression, nausea, skin rash, unusual tiredness or weakness, or vomiting.

Dizziness, lightheadedness, or fainting may occur, especially when you get up suddenly from a lying or sitting position. Getting up slowly may help. Also, lying down for a while may relieve dizziness or lightheadedness. If this problem continues or gets worse, check with your doctor right away.

This medicine may cause hyponatremia (low sodium levels in the blood). Check with your doctor right away if you have coma, confusion, decreased urine output, dizziness, fast or irregular heartbeat, headache, increased thirst, muscle pain or cramps, nausea or vomiting, swelling of the face, ankles, or hands, trouble breathing, or unusual tiredness or weakness.

Check with your doctor right away if you have anxiety, blurred vision, chills, cold sweats, coma, confusion, cool, pale skin, depression, dizziness, fast heartbeat, headache, increased hunger, nausea, nervousness, nightmares, seizures, shakiness, slurred speech, or unusual tiredness or weakness. These may be symptoms of hypoglycemia (low blood sugar level).

Before having any kind of surgery (including dental surgery) or emergency treatment, tell the doctor or dentist in charge that you are taking this medicine. Serious side effects can occur if your doctor or dentist gives you certain medicines without knowing that you have been taking tramadol.

If you think you or someone else may have taken an overdose of this medicine, get emergency help at once. Your doctor may also give naloxone and other medicines to treat an overdose. Signs of an overdose include: seizures, difficult or trouble breathing, irregular, fast or slow, or shallow breathing, pale or blue lips, fingernails, or skin, pinpoint pupils of the eyes, or trouble breathing.

Do not change your dose or suddenly stop using this medicine without first checking with your doctor. Your doctor may want you to gradually reduce the amount you are using before stopping it completely. This may help prevent worsening of your condition and reduce the possibility of withdrawal symptoms, including stomach cramps, anxiety, fever, nausea, runny nose, sweating, tremors, or trouble with sleeping.

Using too much of this medicine may cause infertility (unable to have children). Talk with your doctor before using this medicine if you plan to have children.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.

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Portions of this document last updated: Oct. 01, 2021

“With tramadol, I ride like a Jaguar”: a qualitative study of motivations for non-medical purpose tramadol use among commercial vehicle operators in Kumasi, Ghana | Substance Abuse Treatment, Prevention, and Policy

The details of the participants’ background information are shown in Table 1. The study included a total of 23 in-depth interviews in the final analysis. The respondents’ age range was 18–43 years, indicating the youthful nature of the study participants. Most of the participants were males (20), with three (3) of the assistants being females. Again, length of tramadol misuse among the participants ranged between 1 and 7 years (see Table 1).

Table 1 Background characteristics of the study participants

Friends, relatives and the community as sources of tramadol information

As tramadol is not prescribed to participants in this study, information on the drug mostly became known to them through recommendations and interactions with friends, relatives and members of the community within which they live. It became known from the interviews that participants follow recommendations and testimonies from friends and others who had used or are using the drug for other purposes aside from its medical functions. The following explanations were provided by some of the participants:

I have known tramadol for about six years now, and it was a friend who mentioned it to me (30 years old, male, driver)

Another participant also pointed out:

One of my relatives who is a carpenter told me that tramadol is very good for those of us who do manual work because it gives you energy … … so I tried it (41 years old, male, driver)

An assistant also remarked:

I did not know about tramadol till a friend told me about it last year, and since then I have been using (28 years old, female, assistant).

Initiating factors of tramadol misuse

Curiosity, peer coercion and enticement were repeatedly cited by the participants as the factors that initiated them into their first tramadol use. Participants particularly explained that friends either coerced or lured them into tramadol misuse especially in cases where they reported bodily pains and perceived sexual issues to them. Other participants highlighted that friends convinced them to take tramadol because they believed the drug is a mood-stabilizing agent that could help light up their mood. One assistant had to say:

I was introduced into tramadol use through my master that I was working with three years ago. He forced me to take the drug because I was too dull for this work, and the drug will make me very active. In the first instance, I declined to take it, but he constantly threatened of sacking me if I decide not to take the drug. I gave up and took it, and from there I have been enjoying it (25 years old, male, assistant)

One driver also recounted his experience:

I started using tramadol when I was an assistant to one Cargo driver in 2016. He told me the drug is very good for stabilizing mood, relieving bodily pains and sexual performance. In fact, I didn’t believe him on the first day he said it but as he continued to convince me, I accepted to try it and I have continued to take it till now. Even as we are talking, I have one on me (33 years old, male, driver)

Adding more evidence to this was a female assistant:

My master sacked me from work one day because I was not using tramadol. I remember when I started working with him in my first week, he told me the work is very tedious and requires some aggression. So, he asked me if I take tramadol which I responded No. From there, he consistently and persistently forced me to take the tramadol and I couldn’t resist the pressure, I decided to take it (31 years old, female, assistant)

Aside from the pressure, few of the participants reported curiosity as a factor that led them to tramadol use. These participants noted two sources of their curiosity: the continuous hyping of the drug by friends and other people who use the drug; and the constant public campaigns on radio and television. It emerged that the perceived good accounts that those who use the drug often give about the drug, as well as the public outcry of the misuse of the drug, have further given the drug much more popularity. Meanwhile, it was evident that the growing public misconceptions about the possible benefits of the drug also made the participants curious about the drug. As a result, these participants first took the drug with the objective of confirming or verifying the various conceptions and misconceptions they heard about the drug. One participant noted:

I think I started using tramadol all because of what I continued to hear about the drug from friends, radio and television. For instance, one day I was listening to the radio and heard them saying people who take tramadol hardly feel fatigued, do things aggressively and have a stabilized mood. Though they were talking against the misuse of the drug, I became curious and decided to try it, so I did (43 years old, male, driver)

And an assistant also confirmed:

I just wanted to kill my curiosity about the drug. I once saw a friend taking the drug, so I asked him to tell me more about it. With great joy, he, in fact, spoke very good things about the drug and before then I had heard a lot about it, so I was so curious. At last, I decided to try (29 years old, male, driver)

Motivations for using tramadol for non-medical purposes

The motivations for using tramadol for non-medical purposes were categorised into four main inter-linking identified categories: (1) sexual; (2) psychological; (3) physical; and (4) economic motivations (see Fig. 1).

Fig. 1

A self-developed framework for studying motivations for non-medical purpose Tramadol use

Sexual motivations

Participants had varied sexual reasons for using tramadol including prolong time of sexual intercourse and treating premature ejaculation and ejaculation-related personal distress.

Perceived improvement in sexual performance/prolong time of sexual intercourse

All the participants emphatically mentioned improving sexual performance as the main sexual reason for their continuous use of tramadol. Participants described their occupation as tedious that weakens their sexual functioning and as a result, they require certain drugs which have sexual enhancing or stimulating effect like tramadol. It was observed that the male participants believed taking tramadol between 15 and 30 min before sex improves sexual intercourse performance. They funnily expressed that sexual needs of today’s ladies are enormous, and one cannot meet them without practising what they termed as “hiring a lawyer”, which means taking aphrodisiacs. Thus, fear of losing their girlfriends or partners also explain their motivation for tramadol use.

You see, this work is very difficult and can weaken how you perform in bed in a few years. I will be sitting down from morning to evening and as I am sitting for that long period don’t forget that I am sitting on my manhood. Even medical doctors advised that sitting at a place for too long is not good as a man and can affect you sexually. So, to be able to perform in bed very well, I use tramadol (30 years old, male, driver)

Elaborating further was an assistant who said:

I take tramadol to perform well in bed. Let me give you one instance where I strongly believed tramadol is very effective for improving sexual performance. Before starting this work, my performance in bed was very good if not excellent. Few months in this work I witnessed I have decreased in performance sexually, so I complained to my master and he recommended the drug for me. Senior. … ..(referring to the interviewer) from there my performance is more than Usain Bolt (referring to an athlete Usain Bolt’s speed) (29 years old, male, assistant)

Another participant expressed his opinion with excitement:

My reason for taking tramadol is basically to perform well sexually. In fact, as a man, your main source of respect is how well you can perform in bed. Even your wedded wife will never respect you if you are not able to perform very well. Let me tell you this, ladies of today need guys who can really perform well in bed, in fact, their sexual demands are many whilst their standard is high. To be able to meet these needs and standards you will have to prepare to face them well. So, we do this by “hiring a lawyer” which is tramadol. When I take tramadol before sex, I ride like a Jaguar and never feel tired (36 years old, male, driver)

Interestingly, few of the male participants explained that their partners support their use of tramadol and some even buy for them. This was confirmed by two of the female participants who mentioned buying the drug for their partners on several occasions with the belief of meeting their sexual needs and standards.

My partner has bought tramadol for me on three occasions. I remember she told me that my performance has reduced and she has heard tramadol is very effective to improve sexual performance. So, she bought it for me, and I enjoyed very well that night (28 years old, male, assistant)

One female assistant confirmed:

I normally buy tramadol for my boyfriend, especially when I witness a reduction in his sexual performance (30 years old, female, assistant).

Premature ejaculation and ejaculation-related personal distress treatment

It was revealed that some of the participants were motivated to use tramadol because they believe the drug is effective for treating their perceived premature ejaculation and ejaculation-related issues. Few of the participants confirmed to have ejaculation issues that have been diagnosed and confirmed by a medical officer. These participants opined that though they have prescribed treatment drugs for their ejaculation issues of which tramadol is not one, they prefer using the drug as they consider it to be more effective in dealing with premature ejaculation and ejaculation related issues. However, the mechanisms through which tramadol treats premature ejaculation and other related ejaculation issues were not known to the participants. Some participants shared accounts on their perceived effectiveness of tramadol for premature ejaculation and ejaculation related issues:

Though I have not been diagnosed with premature ejaculation by a doctor, I still think I have ejaculation problems because I see symptoms of premature ejaculation that I mostly hear on Radio. I have tried several drugs, but they all seemed not effective. Just last year, someone recommended tramadol for me and I can bodily tell you that I have witnessed some significant improvement (23 years old, male, driver)

Another driver described his experience:

I was diagnosed with premature ejaculation last two years and was prescribed drugs by the doctor. I used the drugs for more than one and a half years with no significant improvement. I started treating it with tramadol from last six months coming and trust me that I have observed a significant difference … ..I feel much better now so I will continue to use the tramadol though it is not prescribed for me (35 years old, male, driver)

One assistant also noted with gratitude:

Thanks to tramadol for curing my premature ejaculation problems. The drug is good, and I will continue to use. The reason is that I was told that I have premature ejaculation four years ago and have been using different drugs prescribed by doctors over these years and nothing happened. I have been using tramadol which was recommended by a relative and now I am very fine. Even I went to the hospital last three days and the doctor was surprised to notice that the condition does not exist as it used to be. So, he asked of the drug that I am using and told him tramadol (31 years old, male, assistant)

Psychological motivations

Psychologically, two main factors were identified as motivations for non-medical purposes tramadol use among the study participants. These included perceived euphoria, mental alertness and attentiveness and sense of hope.

Euphoria

A perceived feeling or state of intense excitement and happiness attached to tramadol use among participants served as one motivation for their continued misuse of the drug. Almost all the participants maintained that tramadol brings them extreme happiness and excitements whenever they take it. Interestingly, because of the perceived euphoric effect of tramadol, it emerged that some of the participants were taking the drug, especially during sad moments.

Tramadol gives me excitement … … I can be happy the whole day when I take it (23 years old, male, driver)

Another participant supported this view with joy:

The feeling is deep and great when you take tramadol. It is all about excitement and happiness and nothing else. For me, I take the drug because of the happiness it brings me, and I’m told happiness is good for health and wellbeing (26 years old, male, assistant)

Another driver could not hide his happiness:

Tramadol is my source of excitement and happiness especially when I am very sad. I forget all my problems whenever I take it because of the happiness it brings (29 years old, male, driver)

Alertness and attentiveness

Few of the participants also mentioned of alertness and attentiveness as another motivation for their incessant tramadol use. They explained that the drug makes them focused and pay serious attention to their daily activities.

When I take tramadol, I don’t get distracted at all because I become highly focused and attentive (23 years old, male, driver)

Another participant also endorsed that:

I don’t care about others when I take tramadol because I am become focused and concentrated. I am always alert and attentive throughout the day (30 years old, male, driver)

Sense of hope and belonging

Another psychological motivation for tramadol use among the participants that the study revealed was a sense of hope and belonging. Some of the participants explained that the drug makes them hopeful of a better future. Others also highlighted that the drug makes them feel that they belong to a group or family that cares about them. Interestingly, one participant maintained that it is easy to get for instance financial support from a friend who takes tramadol than one who is a non-tramadol user.

Like I previously said, tramadol brings joy and happiness and for this reason, you will become hopeful of better things ahead even the current condition is not good. For me, the drug brings hope (29 years old, male driver)

Another female participant had this to add:

You will feel a sense of belonging to a family when you take tramadol. You will see others who take it showing you love and support even financially (30 years old, female, assistant)

Physical motivations

The physical motivations associated with tramadol misuse reported among participants included energy booster and tiredness or fatigue relieve.

Energy booster

Most of the participants reported that they use tramadol to boost their energy in order to carry out their daily activities. For them, tramadol is an effective energy booster which enhances their performances with no or limited stress. Most of the participants, therefore, saw the drug to be important in their economic life as to them it makes them work harder to earn income for a living on a daily basis.

Tramadol booster energy for work. I can work almost the whole day under the influence of the drug without feeling tired (33 years old, male, driver)

I can drive 24 hours all week because of tramadol because it serves as an energy booster for me (30 years old, male, driver)

Tramadol gives me special energy for this work (28 years old, female, assistant)

Tiredness or fatigue reliever

Most of the participants described tramadol as an effective drug for de-stressing themselves and relieving tiredness or fatigue.

Whenever I am stressed out, I take tramadol to de-stress myself. It works within a shortest possible time (30 years old, male, driver)

It is a special reliever of fatigue and I rely on it every day (28 years old, female, assistant)

It is a very good tiredness reliever drug. You can try it out one day (29 years old, male, driver)

Economic motivations

The economic motivations for tramadol use found in this study were affordability and accessibility/availability of the drug. The study found that tramadol is readily available and affordable.

Affordability

Participants were motivated to take tramadol because compared to other similar drugs, they believed tramadol is affordable and acquired with few Cedis (Ghana currency). They mentioned that even with 5 or 10 Cedis ($ 0.90–1.80), one can buy the drug.

Tramadol is not expensive so I can buy as many as I want. Even with 5 Cedis, I can get one (26 years old, male, assistant)

Also, explaining the economic motivation for tramadol use in terms of cost was a driver who commented:

I do not incur much cost to acquire tramadol because it is not expensive. Comparing with other drugs that perform similar functions, tramadol is the cheapest in terms of cost and that motivates me to use the drug (29 years old, male, driver).

An assistant also confirmed:

The last time I bought one the price was 5 Cedis, which to me is very affordable considering the functions it performs. So, I don’t spend much money on tramadol, and it is one of the reasons I like the drug (30 years old, male, assistant).

Availability/accessibility

Participants in this study opined that tramadol is readily available in most chemical shops. It was revealed that though tramadol is a prescription drug, participants obtained it without any prescription note. They specifically explained that no seller has ever requested a prescription note from them before selling the drug to them.

I can easily get tramadol to buy. I think nowadays almost all the chemical shops sell tramadol, so it is difficult to get (29 years old, male, driver).

Another driver agreed:

Getting tramadol to buy is not difficult at all. You can get one from any chemical shop in this area and no one asks for a prescription note or anything (42 years old, male, driver)

And an assistant gladly concluded:

I am glad that the drug is available everywhere nowadays so finding one is not hard. I am told a doctor must prescribe it to you before you can buy but since I started using no seller has ever asked of any prescription note from a doctor (25 years old, male, assistant)

Awareness and knowledge about possible tramadol side effects

Interestingly, all the participants were aware of some side effects associated with the misuse of tramadol. A myriad of possible adverse effects of tramadol misuse was reported by the participants, whereas some elaborated further their experiences on some of the adverse effects they encounter as a result of the misuse. The adverse effects that emerged from the interviews and analysis were categorised into three: physical, psychological and social effects.

Physical effects

Almost all the participants were aware of possible physical side effects of tramadol and recalled at least one adverse physical experience as a result of misusing the drug. Most reported and experienced adverse physical effects among the participants included, seizures, excessive vomiting, anorexia, loss of appetite, hallucination, severe nausea, agitation and confusion, drowsiness, dry mouth, headache, loss of strength, muscle aches, joint pains, severe redness, swelling, itching of the skin, sweating, swelling of the hands, ankles, feet, or lower legs, trembling and shaking of the hands or feet and weak or absent pulses in the legs. It was emerged that most of these effects were pronounced in the early stages of tramadol use among the participants. However, few of the participants explained that they continue to experience some of the highlighted adverse effects each time they use the drug. One of the participants noted:

Yes, I am aware that tramadol has some effects that can affect me physically. Some of my friends who misuse it have been reporting of several experiences such as vomiting, unnecessary confusion and agitation and body pains and weakness. I can also say what they say are true because I personally don’t feel like eating when I take the drug (30 years old, male, assistant.

Another participant also recounted his experience:

I believe the drug has some adverse effects that can be harmful. For instance, I feel very weak and sleepy whenever I take it. I also can’t eat either. I remember last two weeks I nearly collapsed as a result of the drug because I took three tablets without eating (29 years old, male, driver)

One participant also narrated his ordeal:

For me, everyone who takes tramadol including myself is aware of the possible side effects of the drug. In fact, we experience the effects regularly such as seizures, skin itching, loss of appetite, dry mouth, among others. Now, I can’t carry heavy load because I feel weak and my hands mostly shake (30 years old, male, assistant)

Another participant could not hide his story:

I aware of the side effects of tramadol because I listen to the radio, watch television and they talk about the harmful effects of tramadol misuse. Using myself for example, I always feel very weak, dizzy and confused each time I take the drug. I nearly had a seizure one time as a result of tramadol. Again, I do not really when I am on tramadol, whereas my mouth becomes dry (42 years old, male, driver)

Psychological effects

Some of the study participants also highlighted myriad of perceived psychological problems as additional adverse effects of tramadol. The participants repeatedly mentioned irritability, anger, overactive reflexes, loss of consciousness, discouragement, general feeling of discomfort and sad and loss of interest or pleasure. The participants recounted experiencing either one or a combination of these psychological problems associated with tramadol misuse.

I think I become too temperamental and do not feel like talking to anyone when I take tramadol. Sometimes, I feel discouraged to the extent that I get irritated and angry easily (27 years old, male, driver)

Another participant supported this view:

For me, I think the drug makes me unconscious most of the time. I sometimes act unreasonably, and I think it is that drug that influences me (26 years old, male, assistant)

Another participant also endorsed that:

Tramadol makes me think about strange things and frequently gets discouraged. Mostly I get angry and irritated over petty issues (31 years old, female, assistant)

Social effects

Social stigma and lack of respect were reported by all the participants as social effects of tramadol misuse. All the study participants verbalised that most community members disapprove tramadol misuse and as a result stigmatise them for their indulgence. They specifically mentioned that members of the society do not accord them the needed respect as a result of their tramadol misuse and this act constitute an adverse social effect of tramadol misuse.

Some people do not respect me for misusing tramadol, and even do not want to associate with me. In fact, some even regard me as worthy of disgrace to my family (31 years old, female, assistant)

Another participant had this to add:

My community members regard me as a useless being worthy of great disgrace. I remember on one occasion a certain girl that I am far older than her told me I have no respect and admiration because I take tramadol (24 years old, male, driver)

A pinnacle statement was made by one of the participants who said:

People talk to me anyhow because of the tramadol. No one regards me as a normal person in my community, but I don’t care. At times they point hands on me as a useless person and even tell others not to be like me. They regard people who use tramadol as non-humans and crazy people (28 years old, male, driver)

Praising tramadol use initiators

Interestingly, almost all the participants said a word of praises to those who initiated them into tramadol use. It was observed that these praises were linked to the perceived benefits associated with the use of the drug such as perceived improved physical and sexual activity performances. In all, these participants thanked their initiators for introducing them into tramadol use. One of these participants noted with appreciation:

In fact, I owe my master a lot of thanks and appreciations. I remember when he was introducing the drug to me, I was not really in support of it I now know he was doing me a lot of good. Oh, I am very grateful to him (27 years old, male, driver)

Interestingly, one assistant agreed with this:

I didn’t know the one who initiated me into tramadol use was helping me. In fact, the drug has helped me improved significantly in my daily activity performance. I must say huge thanks to my friend who introduced it to me (26 years old, male, assistant)

And a female assistant concluded:

You know this job is mostly for males as it is very hard. Since I started using tramadol, I don’t feel tired and can work all day. Big thanks to my friend who first gave me the drug (31 years old, female, assistant)

No sign for quitting the use of tramadol for non-medical purposes

Interestingly, almost the participants exhibited no sign of stopping the use of tramadol for non-medical purposes. In their own evaluations and assessments, the drug is effective for the purposes that they are using it for and as a result, do not have any reason for quitting it. For them, as far as they do not acquire the drug from what they described as “Fake or illegal sellers” but rather buy from licensed chemical shops they have no intention of quitting as they see the drug as safe.

Personally, I do not have any plans for stopping tramadol use for now. I don’t know what would happen in the future but for now, No (24 years old, male, driver)

Another driver endorsed this view:

I don’t know when I will stop using tramadol if am telling the truth. The drug is very effective, nice and feels great whenever I take. Maybe, when I am too old, I can consider stopping but now no intention to quit (28 years old, male, driver)

It was observed that few of the participants who were willing to stop using tramadol for non-medical purposes were looking for alternatives or substitutes for the drug. Some of the participants mentioned that until they find alternative drugs that work as tramadol, they are not going to stop its usage.

For me, I will stop using tramadol when I find a different drug that works like it. Till then, I have no plans of stopping (30 years old, female, assistant)

One driver also noted:

I am looking forward to finding another drug with the same effectiveness as tramadol before I stop using tramadol (26 years old, male, driver)

Willingness to support officials in eradicating fake tramadol and illegal peddlers

Though participants indicated no sign of stopping non-medical use of tramadol, they rather expressed strong support for the ongoing fake tramadol seizures and prosecution of illegal tramadol peddlers. They further expressed their willingness to collaborate with health officials and security agencies in finding fake and illegal tramadol peddlers. They claimed of knowing some of the illegal and fake tramadol peddlers and they could serve as whistle-blowers to health officials and security officers involved in the fight against tramadol proliferation in Ghana. For their interest, helping officials to eradicate fake tramadol and illegal sellers would help them acquire safe, quality and standard tramadol from certified sellers.

I think the officials are doing well by seizing fake tramadol and prosecuting illegal sellers. I and most of the people who use tramadol know can support the police in this regard because we know most of the illegal sellers in this city. We can give them information … … (35 years old, male, driver)

Another participant also offered his support:

I heard the police are seizing fake tramadol and punishing the illegal sellers. I know some of those sellers and can help the police. If those fake sellers are punished, we can good tramadol and not fake ones (33 years old, male, assistant)

A pinnacle statement was made by a driver who said:

For the sake of getting quality and standard tramadol from licensed shops, I am willing to support the police to arrest fake sellers. I know some of them and can help the police to arrest them (30 years old, male, driver)

Tramadol Overdose – Can You Overdose On Tramadol?

When tramadol is taken other than how it’s directed, or in larger doses than prescribed, this drug can cause an overdose. Often considered to be less habit-forming than other opioids, tramadol is still addictive and can lead to physical dependence.

Tramadol is an opioid analgesic, often sold under the brand name Ultram. Tramadol is a narcotic that impacts the central nervous system and binds to opioid receptors in the brain. These effects cause the functions of the body to slow down, especially breathing patterns. If a person takes too much Ultram, they can suffer a potentially lethal overdose. The main cause of overdose is slowed or stopped breathing.

People who struggle with taking too much tramadol may need help to stop taking the drug. Vertava Health provide medical detoxification and addiction treatment for people who suffer from opioid addiction, including tramadol.

Symptoms Of A Tramadol Overdose

Like other opioids, tramadol can result in a feeling of relaxation and well-being. This may lead some people to take too much of the drug. It is not common to overdose on tramadol when the drug is taken as prescribed. People who overdose on tramadol are often abusing the drug, or taking it more frequently than directed.

Tramadol comes in an extended-release tablet, which means the medication has a potent amount in each dose. If a person abuses tramadol by crushing and snorting the pill, they are at a heightened chance of overdose.

Symptoms of a tramadol overdose include:

extreme fatigue
falling in and out of consciousness (“nodding out”)
slowed heartbeat
weak muscles
decreased pupil size (“pinpoint” or “pinned out” pupils)
cold, clammy skin
gray or bluish tint to the skin
coma

Large amounts of opioids like tramadol can decrease the amount of oxygen available to the brain. This can result in coma, permanent brain damage, or death. Tramadol overdose is a medical emergency. If you suspect a person is suffering an overdose, call 911 immediately and try to keep the person awake until help arrives.

Tramadol Overdose Amount

People who take tramadol may wonder how much tramadol can lead to an overdose. The answer depends on a number of personal and behavioral factors, including how a person ingests the drug.

The typical therapeutic dose for extended-release is 100 milligrams, once a day. Oral tablets are usually 25 milligrams per day, taken in the morning. People with higher or lower body mass indexes may be prescribed a different dose. As a person’s body gets used to the medication (called a “tolerance”), the prescribed dosage may increase over time.

While tramadol can lead to feelings of euphoria, these are not typically as strong as the “high” from other opioids. People who use tramadol recreationally may chew, crush, snort, or inject the pill for a stronger effect. Others may mix tramadol with another drug, such as alcohol or benzodiazepines. These dangerous behaviors greatly raise a person’s risk of overdose.

Some people who take opioids keep naloxone (name brand Narcan) on hand. Naloxone is a drug that reverses the effects of opioids on the central nervous system. In the event of a tramadol overdose, the person suffering will not likely be able to give themselves naloxone. It is often up to another person present to administer the medication.

Risk Factors For Tramadol Overdose

Every day in the U.S., more than 130 people die from overdosing on opioids. If you or someone you love is suffering from pain that requires the use of opioid medications, it’s vital to know the risk factors for opioid overdose — and how best to prevent it.

Anyone who takes tramadol is at risk for potential dependence, addiction, and overdose. However, those who abuse this narcotic medication will be at an increased risk.

Additional factors can increase a person’s chance of overdose, including:

Large Or Frequent Doses

Tramadol is often prescribed due to its dual benefits of being able to treat pain while being less addictive. However, tramadol can still be habit-forming. People who take this drug over long periods can become physically dependent on the drug, which could cause a person to take large or frequent doses. Over time, the body becomes accustomed to having high amounts of the drug in order to function normally.

If a person suddenly stops or decreases their use, the body may display symptoms of opioid withdrawal. These symptoms can be extremely uncomfortable, including nausea, sweating, and muscle cramps. To avoid withdrawal symptoms, some people may take higher doses of tramadol than prescribed.

History Of Other Mental Health Conditions Or Substance Abuse

People who suffer from mental health conditions are at an increased risk for opioid abuse and overdose. When a person has symptoms of depression, bipolar disorder, or another mental health condition, they may take large amounts of tramadol to relieve the symptoms.

Additionally, people who struggle with polysubstance abuse may mix tramadol with other drugs. This raises the risk of overdose. Those who suffer from these conditions can benefit from learning safer coping mechanisms, such as mindfulness. Patients receive mental health and addiction treatment at Vertava Health’ rehab centers across the U.S.

Finding Treatment For Tramadol Abuse And Addiction

Although opioid overdose rates are climbing, tramadol abuse and overdose is a preventable and treatable condition. When people have access to effective addiction treatment, it reduces the chance of experiencing a tramadol overdose.

At Vertava Health, we provide inpatient treatment programs with services like on-site medical detox and dialectical behavioral therapy (DBT). People who suffer from substance abuse, as well as mental health conditions, can benefit from medication-assisted treatment and creative arts therapy.

To learn more about preventing tramadol abuse and overdose, or to find a rehab program near you, reach out to one of our treatment specialists today.

Tramadol Side Effects, Symptoms & Signs of Abuse

Article at a Glance:

Tramadol is an opioid painkiller and controlled substance that carries the risk of addiction.
Although tramadol is generally well-tolerated, side effects like nausea and vomiting are common.
Tramadol has been linked to serious side effects like seizures, serotonin syndrome and overdose.
Help is available if you or someone you love is struggling with tramadol addiction.

An Overview

Tramadol is an opioid painkiller used to relieve moderate-to-severe pain. Doctors typically prescribe the drug for short- or long-term management of acute or chronic pain. Marketed under the brand names ConZip, Qdolo and Ultram, tramadol is classified by the Drug Enforcement Administration (DEA) as a Schedule IV controlled substance.

As a narcotic, tramadol impacts your brain’s reward centers, which may prompt you to desire more of the drug. Even if you use tramadol as prescribed by your doctor, the drug can cause problems that include a range of side effects and even addiction. Whether you are concerned about your own tramadol use or the use of someone you love, it’s important to learn and watch for the signs of abuse and addiction.

Tramadol Side Effects

Prescription tramadol can help with pain relief, but as with any drug, side effects are possible. Though some side effects may be mild, others are quite dangerous.

Long-term tramadol side effects can include physical dependency that develops with or without addiction. As you continue taking tramadol, however, your risk of addiction to the drug increases. Even if you don’t develop an addiction, long-term use of tramadol will likely cause withdrawal symptoms when you stop using it, especially if you take a high dose of the drug. The following provides an overview of minor and major tramadol side effects.

Minor Tramadol Side Effects

Gastrointestinal symptoms are by far the most common types of side effects from tramadol. Other short-term, minor side effects usually require no medical attention, as they disappear on their own after the body adjusts to the medication. However, if any of these side effects continue or you simply have concerns about them, consult your health care provider.

The most common side effects include:

Constipation
Nausea
Dizziness/vertigo
Headache
Sleepiness
Vomiting
Central nervous system stimulation
Indigestion
Weakness
Itching
Dry mouth
Diarrhea
Sweating

Tramadol and Nausea and Vomiting

Like other opioids, tramadol can cause gastrointestinal side effects like nausea and vomiting. Although experts are not exactly sure why this occurs, they believe that factors may include:

A direct effect on the chemoreceptor trigger zone in the brain, which is responsible for creating a sensation of nausea
An effect on the vestibular system, which comprises the inner ear and parts of the brain that control balance and eye movements
An effect on the gastrointestinal tract, causing constipation that may worsen nausea

Major Tramadol Side Effects

Tramadol is generally well-tolerated with few serious side effects. However, serious side effects can still occur. If you suspect that you or someone you know is experiencing a serious tramadol side effect, seek emergency medical attention.

Severe side effects include:

Seizure
Serotonin syndrome
Respiratory depression (slowed breathing)

Tramadol and Seizures

Tramadol is known to cause seizures in people who abuse the drug and even people who use it as prescribed. However, experts are not sure what tramadol does to the brain that increases seizure risks.

A seizure occurs when the brain’s electrical system becomes overstimulated, causing brain cells to send abnormal signals. The severity of a seizure greatly depends on how much of the brain has been affected, ranging from a short-term state of confusion to uncontrollable muscle movements and convulsions.

Although the risk of seizures with tramadol is small, certain people may be at a higher risk for experiencing them based on their age, medical history, frequency of use and what other drugs they are taking at the same time.

Tramadol and Serotonin Syndrome Risk

Serotonin is a major neurotransmitter in the brain. Certain drugs, including tramadol, can increase the amount of serotonin available to the brain. However, increasing serotonin too much can be dangerous and lead to a condition called serotonin syndrome. Although serotonin syndrome can develop if you take any drug that increases serotonin, a person generally needs to take more than one serotonin-increasing drug for this condition to develop. Many such drugs exist, including most antidepressants, monoamine oxidase inhibitors (MAOIs), amphetamines, cocaine, St. John’s wort and tryptophan.

Symptoms of serotonin syndrome can include:

Muscle spasms
Sweating
Agitation
Tremor
Rigid muscles
Fever

Serotonin syndrome is a medical emergency and can be fatal. For this reason, it is important to seek emergency medical attention if you suspect this condition.

Tramadol and Respiratory Depression

Respiratory depression, or slowed breathing, is a serious and potentially deadly side effect of all opioids, including tramadol. When a person takes too much tramadol and overdoses, it can cause their breathing to slow down so much that they stop breathing entirely. The opioid reversal agent naloxone can temporarily reverse respiratory depression and should be administered if a person’s breathing appears to slow. After administering naloxone, seek emergency medical attention to make sure the person recovers and does not lapse back into respiratory depression.

Signs of Tramadol Abuse

Tramadol abuse is often among the earliest stages of addiction. If you cannot stop taking the medication — despite negative life consequences and efforts to quit — then you’re seeing the most telling sign that abuse has grown into a bigger problem. Taking a self-assessment quiz about your tramadol use may help give you insight into whether you are at risk for abuse and addiction. Further, you and your loved ones may notice behavioral, psychological and physical signs that commonly develop when someone begins to struggle with a substance like tramadol.

Behavioral Signs of Tramadol Abuse

Often, substance abuse is accompanied by some changes in behavior. Even if you do not notice behavioral symptoms, loved ones may notice symptoms like:

Nonmedical use of tramadol
Visiting multiple doctors to get more tramadol prescriptions
“Drug-seeking” behaviors, such as emergency doctor visits and lying about loss of prescriptions
Continued use of tramadol despite negative consequences

Psychological Signs of Tramadol Abuse

When you struggle with tramadol, you may notice that your own thought processes increasingly revolve around the drug. This can translate into a variety of psychological signs of tramadol abuse, including:

The belief that tramadol is necessary to get through the day
Craving tramadol
Lack of control over tramadol use

Physical Signs of Tramadol Abuse

Substance abuse is very stressful on your body. You may notice a variety of physical symptoms when you are between tramadol doses. These withdrawal symptoms can be unpleasant and may drive you to consume more of the drug.

Withdrawal symptoms include:

Anxiety
Sweating
Trouble sleeping
Rigors
Pain
Nausea
Tremors
Diarrhea
Upper respiratory symptoms
Goosebumps
Hallucinations

Tramadol Overdose

Taking too much tramadol can be deadly. This is especially true if you are using other central nervous system depressants, such as alcohol or other opioids, at the same time. For this reason, it’s important to be familiar with the symptoms of tramadol overdose and what to do if you observe them. Symptoms of tramadol overdose are similar to those of other opioids and include:

Unconsciousness or coma
Slowed or stopped breathing
Muscle flaccidity
Cold and clammy skin

Drug overdose can be fatal. If you suspect someone is experiencing an overdose, call 911 immediately. Do NOT be afraid to seek help. If you do not have access to a phone contact Web Poison Control Services for online assistance.

Staging an Intervention for Tramadol Abuse

It is often difficult for a person with addiction to recognize their problem and seek help on their own. As a result, if someone you love has an addiction, you may need to help them become aware of their problem and seek treatment.

Consider holding a tramadol addiction intervention. This event should be carefully planned to meet the following three goals:

Give specific examples to your loved one of how their addiction has hurt you.
Offer treatment options that you have already researched and vetted.
State what you will do if your loved one does not agree to get treatment.

Because interventions can be difficult and emotional, you may want to consult an intervention specialist or another addiction professional to help with the planning and executing processes. They may recommend you begin by writing an intervention letter to your loved one. Whether you opt to intervene alone or with outside help, remember that your primary objective is to bring your loved one back to health.

Find the Help You or Your Loved One Needs

Tramadol addiction can be frightening and overwhelming. Fortunately, help is available at The Recovery Village. Our tramadol experts have extensive experience in treating tramadol addiction and helping people begin the path to a drug-free life. Contact us today to learn more about treatment plans and programs that can work well for your needs.

Sources
Vestibular Disorder Association. “Causes of Dizziness.” Accessed December 20, 2020.
Drug Enforcement Administration. “Controlled Substances.” November 22, 2020. Accessed December 20, 2020.
Food and Drug Administration. “Ultram Prescribing Information.” 2009. Accessed December 20, 2020.
Fujimoto, Yohei; Funao, Tomoharu; Suehiro, Koichi; et al. “Brain Serotonin Content Regulates the Manifestation of Tramadol-induced Seizures in Rats: Disparity between Tramadol-induced Seizure and Serotonin Syndrome.” Pain Medicine, January 2015. Accessed December 20, 2020.
Drugs.com. “Tramadol.” August 17, 2020. Accessed December 20, 2020.
Sande, Tonje A.; Laird, Barry J.A.; Fallon, Marie T. “The Management of Opioid-Induced Nausea and Vomiting in Patients with Cancer: A Systematic Review.” Journal of Palliative Medicine, January 11, 2019. Accessed December 20, 2020.
Simon, Leslie V.; Keenaghan, Michael. “Serotonin Syndrome.” StatPearls, November 20, 2020. Accessed December 20, 2020.
Drug Enforcement Administration. “Tramadol.” March 2020. Accessed December 20, 2020.

Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

What Type of Withdrawal Symptoms from Tramadol Might a Patient Experience?

In this Ask the Expert Q&A, pharmacologists offer alternative treatment options for pain care.

Indicated for moderate to moderately severe pain, tramadol is a centrally acting analgesic that consists of two enantiomers that contribute to its analgesic activity.¹Tramadol is metabolized via CYP3A4, CYP2B6, and CYP2D6 to produce five metabolites: M1, M2, M3, M4, and M5. The medication undergoes CYP2D6 metabolism to its active metabolite (+)-O-desmethyl-tramadol (M1), which has higher affinity for the opioid receptor compared to the parent compound (see Figure 1, next page). ¹

While tramadol may be a viable agent for pain relief, there are several scenarios in which a provider may recommend discontinuation of the medication. These scenarios may include inadequate pain response, intolerable side effects, and drug-drug/drug-disease interactions, among others.

Pharmacologic Overview

Both the parent drug and M1 are partial agonists of the mu opioid receptor. Additionally, tramadol inhibits the reuptake of both norepinephrine and serotonin.¹ Norepinephrine reuptake inhibition is thought to play a significant role in relieving neuropathic pain from the descending nerve pathway.²Other opioids affect pain in the ascending pathway. Given its dual mechanism of action, tramadol acts upon both the ascending and descending pathway.

Although tramadol is classified as a partial mu opioid receptor agonist, its binding affinity is 6,000 times less than that of morphine which is similar to that of dextromethorphan. ³Tramadol’s analgesic effect is produced through the combined mechanism of both opioid and non-opioid mechanisms.³ In a study by Max et al, researchers compared amitriptyline to desipramine to fluoxetine to placebo in the treatment of diabetic peripheral neuropathy (DPN).⁴ Their findings elucidated the importance of norepinephrine reuptake blockade for the treatment of pain associated with the DPN model and ruled out any analgesic benefit from serotonin alone.

Symptom Comparison

According to the package insert, reported symptoms of tramadol withdrawal include anxiety, sweating, insomnia, rigors, pain, nausea, tremors, diarrhea, upper respiratory symptoms, piloerection, and, rarely, hallucinations.⁵ Other symptoms that have been reported less frequently include panic attacks, severe anxiety, and paresthesias.⁵ However, given that the binding affinity of tramadol is 1/6000 of that of morphine, one might expect withdrawal symptoms to be more consistent with that of serotonin withdrawal.

Serotonin withdrawal, which may be referred to as antidepressant discontinuation syndrome, generally occurs after abrupt discontinuation of an antidepressant taken for at least 6 weeks.⁶ Symptoms of serotonin withdrawal may include dizziness, vertigo, nausea, headaches, insomnia, anxiety, fatigue, and mood swings. Unlike opioid withdrawal, serotonin withdrawal does not include hypertension or diarrhea as a primary symptom. However, elevated blood pressure and diarrhea may still occur as secondary withdrawal symptoms as a result of potentially heightened anxiety or irritability.

The underlying mechanism for serotonin withdrawal is thought to be due to transient deficiency of synaptic serotonin.⁶ On the other hand, opioid withdrawal is mediated by increased noradrenergic activity, which is the likely reason that clonidine (an alpha-2-agonist) is generally effective for managing opioid withdrawal.⁷ Therefore, clonidine is not expected to circumvent serotonin withdrawal from abrupt cessation of tramadol.

Tapering Strategy

Clinicians need to be familiar with strategies for the prevention and treatment of serotonin withdrawal and recognize that symptoms are often difficult to differentiate from mild to moderate opioid withdrawal. Preventive strategies include educating patients about the potential of experiencing serotonin withdrawal syndrome if tramadol dosages are abruptly stopped; providers may recommend a taper prior to discontinuation.⁸

Treatment strategies may also include reassurance, symptomatic control, and replenishing synaptic serotonin followed by taper is necessary. For example, fluoxetine is a selective serotonin reuptake inhibitor with long half-life that essentially is self-tapering.⁹ In the authors’ experience, although fluoxetine is not FDA-indicated for antidepressant discontinuation syndrome, 10 to 20 mg may be administered daily for 1 to 2 days to circumvent serotonin withdrawal symptoms.

This article is the sole work of the authors; stated opinions or assertions do not reflect the opinions of employers or employee affiliates listed. The article was not prepared as part of the authors’ duties as federal employees.

Last updated on: December 7, 2017

Chronic Pain and Substance-Related Disorders

“I wanted her to rest a little” The Russian doctor tried to relieve the patient of pain. For this he was accused of selling drugs: Society: Russia: Lenta.ru

On the instructions of the president, the Ministry of Health should simplify the procedure for prescribing psychotropic and narcotic pain medications by the end of the summer. Now doctors are afraid to deal with these drugs, fearing criminal prosecution for mistakes. Their fears are justified. In the Sverdlovsk region, in the small town of Novaya Lyalya, a gynecologist will be tried in August, who hastened to help an elderly woman suffering from severe pain and can now get a sentence as a drug dealer.Lenta.ru correspondent Natalya Granina understood the history of the doctor.

In March 2019, 74-year-old Olga Nikolaevna Mikhailova was admitted to the hospital in the city of Novaya Lyalya, Sverdlovsk region. (name has been changed) . It was assumed that she might need surgery – the patient was diagnosed with complete prolapse of the uterus. She lived in this state for a long time. The ulcers stuck to the diaper she wore and was constantly bleeding. Olga Nikolaevna’s clothes and bed were red spots.Gynecological problems were aggravated by senile dementia. The woman behaved inappropriately, did not perceive either herself or those around her. She didn’t complain about anything, she just cried and moaned.

Mikhailova’s attending physician, obstetrician-gynecologist Oleg Baskakov, on that day, bandaged and treated her ulcers.

“It was felt that the patient was exhausted, that she was in pain,” he says. – The nurses said that she did not sleep for two nights from the moment of admission to the hospital. I was told that Olga Nikolaevna was our colleague in the past, she worked as a dentist all her life.I wanted to help, do at least something to get her a little rest.

Baskakov thought that the pain relieving tramadol and the soothing sibazon would help the woman. In the recent past, these drugs were sold in pharmacies without a prescription, now they are included in the lists of potent and narcotic. The procedure for prescribing such drugs is formalized, requires special care and takes a lot of time, so doctors often try not to touch the “registration” drugs once again.

Materials on the topic

00:01 – July 18, 2019

According to the regulations, Baskakov had to make a record of the prescription of the medicine in the patient’s card, and then notify the head nurse, who usually manages the safe where all the drugs from the list are stored.The doctor in such a situation fills out a lot of forms and protocols. it was in the evening, and the head nurse’s working day ends at 17 o’clock.

“I remembered that I have the necessary medicines in my closet,” the doctor says. A year ago, Baskakov’s mother in Chelyabinsk died of leukemia. After her death, a whole cabinet of various expensive medicines, not only oncological ones, remained. Baskakov brought the remaining packages to the Novolyalinskaya hospital and distributed them to different departments. Tramadol and sibazon, since there were only a few ampoules, left in his room at the hospital.

– So I just went downstairs, took two ampoules of the medicine and gave it to the nurse who worked in my department. I asked for one injection to be given to the patient immediately, and another before going to bed.

In 2013 Alevtina Horinyak, a physician from Krasnoyarsk, was convicted of “illegal trafficking in potent substances for the purpose of marketing”. The reason is the discharge of tramadol to the patient from a “foreign” site. True, despite the demand from the prosecutor’s office to put her in prison for nine years, the court was limited to a fine of 15 thousand.After a public outcry in 2014, the sentence to a doctor with 50 years of experience was canceled.

In 2014, General Vyacheslav Apanasenko shot himself to death in Moscow. He had oncology, severe pain syndrome. However, there was no pain reliever – the relatives could not overcome all the bureaucratic obstacles in time to get the drugs. After that, the procedure for prescribing narcotic and potent drugs began to be simplified. But until now, doctors face criminal punishment for mistakes.

From 2010 to 2015, 153 criminal cases were initiated against medical workers for violations in the work with drug-containing drugs.Although not all of them ended in real prison terms, this led to the fact that doctors now do not want to prescribe potent drugs. According to a survey by the Vera hospice fund, 37.8 percent of doctors are afraid to work with such drugs.

In the corridor, the head nurse took the ampoules from a colleague, locked them in a safe and threatened to complain.

– I, of course, was upset that it happened, – says the doctor, – but did not attach any importance. We had conflicts with the head nurse before.There were too different views on everything. Probably the antipathy was mutual. We tried to calm the patient with improvised means. They made bandages with lidocaine, picked up more comfortable diapers …

Two days later, Baskakov’s apartment (or rather, the room where he lived) was searched. The police seized another ampoule of tramadol. A criminal case was opened against the gynecologist for the illegal sale of potent and psychotropic substances (Article 228, Part 2 of the Criminal Code). The maximum sentence is eight years in a penal colony.They did not arrest the doctor, they took a written undertaking not to leave the place.

Novaya Lyalya is a town almost 300 kilometers from Yekaterinburg. The population is about 11 thousand people, and it is getting smaller every year. According to some sources, the city is 116 years old, according to others – it is a hundred years older. In Soviet times, a pulp mill was considered the city-forming enterprise. Now it is more and more difficult to find work in the town.

The building of the Novolyalinskaya hospital was built in the 1970s. Then, for a provincial town, the appearance of a five-story hospital complex was a “social breakthrough.”In addition to the children’s and adult clinics, there was a hospital with all possible medical profiles, a maternity hospital, a women’s consultation and so on.

Today the hospital is gradually dying out. In 2013, the hospital was closed at the Central Regional Hospital. We optimized other hospital departments: reduced hospital beds, removed the staff. Locals say that they try not to contact the Novolyalinskaya Central Regional Hospital. A cold usually goes away on its own, and if there is something serious, then even the doctors who remained in Novaya Lyala themselves recommend going to the hospital in the city of Serov, which is 70 kilometers away.There are more specialized specialists, better equipment, which means more opportunities for diagnostics.

From time to time, Lyalinsky activists send angry letters to the Sverdlovsk regional government and other government departments. The regional Ministry of Health, in particular, is asked to stop the collapse of medicine in the city. The activists receive detailed answers from the department that everything is very good in Novaya Lyala. On average, in the Sverdlovsk region, the staffing of medical personnel is 66.7 percent, for Novolyalinsky – more than 74 percent.If there are not enough specialists, then the available personnel are actively improving their professionalism and acquiring new medical specialties. A radiologist, for example, retrained as a psychiatrist, and a dermatovenerologist became a functional diagnostics doctor.

In addition, officials of Novolyalinsky calm down, the district administration cooperates with recruiting sites and, with their help, recruits specialists from other regions to the city. One of the advertisements for vacancies was seen in the newspaper by a gynecologist, 58-year-old Oleg Baskakov.Prior to that, he lived and worked for 30 years in the Chelyabinsk region.

– In Chelyabinsk, then, too, layoffs began in hospitals, – he says. – In Novaya Lyala, they offered a good salary, and the work was interesting. My son is an adult, he is studying in Moscow, at the Gnessin Music Academy. My wife and I are divorced. It seemed that nothing kept me in my hometown, so I responded to the ad. I was immediately invited.

It was said that the hospital or the city authorities of Novaya Lyalya will provide the visiting doctor with office housing.They kept the promise, but they settled him in a closed maternity hospital. More precisely, a room was allocated on the second floor of the Central District Hospital and allowed to settle down. Baskakov says that at first he had thoughts of renting an apartment in Novaya Lyala, but then he got used to it.

“Even convenient,” he explains enthusiastically. – I am always there, always at work. What if something happens and I need it urgently? No need to waste time getting from home. All the doctors who come to us on a business trip to Novaya Lyalya also live in the hospital.

For two and a half years in Novaya Lyala, the visiting doctor did not become one of his own. The name of one of the heroes of Jules Verne – Jacques Paganel, an absent-minded professor of geography – has become a household name for scholarly eccentrics. To some extent, Baskakov was such an eccentric Paganel for Novaya Lyalya. I did not drink, did not smoke, obscene vocabulary, that is, mat, did not use at all. I did not pursue material things. In the literal sense, he wore some kind of incomprehensible shirts, stretched sweaters, baggy pants.

The doctor loved to read.Curious residents of Lyalin unearthed his page on one of the literary Internet sites. There are several stories and novellas written by Baskakov himself. The selection has not been updated for a long time. When asked about creativity, the doctor, noticeably embarrassed, says that after moving to Novaya Lyalya, he left writing.

– There is no inspiration, – my interlocutor tries to explain. – Everything is not easy in the city. There is a lot of work, it is often dangerous. Recently I operated on a woman with an ectopic pregnancy – an emergency situation, that is, you don’t think about anything when you need to save someone’s life.A few days later, the test results of this patient for HIV and hepatitis came. They turned out to be positive. And you suddenly remember that during the operation your glove broke …

As Baskakov says, that time, while he was waiting for his analysis (usually the virus in the blood can be detected no earlier than 2-6 weeks after infection), I thought that if he was healthy, he would return to Chelyabinsk, to his homeland. However, he did not have time. Became accused of drug trafficking.

“To be honest, I still cannot believe that this is happening to me,” the doctor finds with difficulty.- At first it seemed to me that it was a joke. I even stopped sleeping at night. I never had any dealings with the police, I never violated the laws. Yes, and I live as if in a window – in the hospital, after all, everything is in plain sight. If he was a drug addict or drank, everyone would immediately see. I was advised to get tested for drug use. At first, the investigators did not even want to attach this certificate to my criminal case, since the result of these analyzes is negative. But the lawyer forced them.

Lawyer Marina Gluzman explains that the investigation into the case of the “drug dealer” Baskakov lasted for several months.True, it was conducted quite formally. The investigator interviewed only two nurses – the eldest who initiated the police call and the one who was instructed by the doctor to administer the drug. Both signed statements that the patient could well have done without this medication. Others endure and are alive.

“It’s stressful that there is not a single testimony from a doctor in this criminal case,” says Gluzman. – We asked the investigator to request in Chelyabinsk the medical record of Baskakov’s deceased mother, from which it would be clear that she was prescribed both tramadol and sibazon.The investigation is trying to present the case in such a way that the doctor criminally obtained this medicine. The document would clearly show that this is not the case.

Materials on the topic

00:01 – May 28, 2018

00:06 – March 7, 2017

00:01 – June 14, 2018

medical secrecy law. But the police did not consider it necessary to petition for the reclamation of this document in Chelyabinsk.

“They just ate it in the collective,” says Marina Gluzman. – Baskakov – indeed, like that absent-minded professor whose image was glorified in books – may appear in holey socks, only work is on his mind. The staff at the hospital is mostly female, jokes and giggles began. This is a common story – this is how everyone who is unlike is treated.

Gluzman delicately notes that even she herself, seeing the doctor for the first time, gently hinted to him to go to the store and buy a new jacket.

“He was offended,” the lawyer continues. – “What, I really look bad? – is talking. – But after all, according to the mind, they should be welcomed. What can I say to this? He is a normal, positive guy. If he had a family …

Polina Gabai, health lawyer:

– According to Part 2 of Art. 14 of the Criminal Code of the Russian Federation, an action (inaction) that formally contains signs of any action provided for by this Criminal Code is not a crime, but due to its insignificance does not pose a public danger.If the investigators and the court nevertheless see the corpus delicti in this whole story, even then, I believe, the doctor can avoid criminal punishment if Article 14 of the Criminal Code of the Russian Federation is applied. His actions could not pose a public danger – in particular, lead to the uncontrolled distribution and use of restricted substances in circulation.

The doctor acted in general with good intentions (if, of course, rely on his comments), wishing to save the patient from the greatest suffering.Moreover, his actions are largely correct from a medical point of view, and the transferred drugs were supposed to be used to relieve pain, that is, in accordance with medical indications. And such an introduction of a substance should not be classified as illegal sale (clause 13 of the Resolution of the Plenum of the RF Armed Forces No. 14).

In the worst case, that is, when passing a guilty verdict, I would draw attention to the fact that the doctor was clearly not acting out of selfish or personal interests.He was guided by a humane desire to help the suffering patient as soon as possible. Such circumstances should be taken into account by the court as mitigating punishment, which is provided for in paragraph “d” of Part 1 of Art. 61 of the Criminal Code of the Russian Federation.

To summarize: yes, the doctor violated the rules for the circulation of these drugs on the territory of the hospital, but this, in my opinion, does not constitute a crime. Administrative offense – I admit, disciplinary sanction – I admit too, but all these misdemeanors do not drag on to a criminal case.

Especially Baskakov was struck by the fact that the investigator in charge of his case suggested that he conclude a pre-trial agreement on a special procedure for considering his case in court. That is, admit your guilt. In this case, law enforcement officers do not need to present evidence of the crime, and the accused will face a milder punishment for confessing. Usually.

– They said that in this case I can count on a suspended sentence, – explains Baskakov. – But I flatly refused. For what? This is not fair.And, besides, because of a criminal record, and even on a drug-related article, I will have to leave the profession.

Now there is a lull in the Central District Hospital of Novaya Lyalya. Everyone tries to pretend that nothing happened, they don’t talk about the “incident” out loud. Baskakov is sure that his colleagues sympathize and support him. Many promise to come to court to testify that the doctor’s sole purpose in this whole story was to try to alleviate the patient’s suffering.

I called acting. head physician of the Central Regional Hospital Tatyana Surovneva.She categorically refused to say anything about the fact and about the doctor. She only said that the situation in Novaya Lyala, as in all provincial towns, was tense. Young people are leaving, there is no work. There is no optimism that this will change soon.

– Maybe you are going to write some kind of collective letter in defense of Baskakov? – I ask.

– We are not going to do anything.

Former head physician of the Novolyalinskaya Central Regional Hospital Konstantin Ostrikov, when he learned that a drug dealer had been caught in his hospital, was surprised.He says the accusation looks absurd from the outside. In terms of form, everything seems to be correct, but questions arise in terms of content.

– Formally, the nurse is right that she did not take the unknown medicine, – comments Ostrikov. – The only correct way out of this situation is to throw this ampoule on the floor and crush it with your heel.

True, Ostrikov left Novaya Lyalya for 15 years already. Now he is the head of the department of the Sverdlovsk Center for Disaster Medicine in the Northern District. During the years that he did not work in the Novolyalinskaya hospital, 11 chief doctors were replaced there.

– Do you know what doctors used to be in Novaya Lala? – he recalls. – Now our staff is dispersed throughout the Sverdlovsk region. And everyone is fleeing from Novaya Lyalya. Now the local hospital has gathered doctors whose pages in the labor office have run out. That is, they have “War and Peace” there. This does not mean that they are popular and their employers are ripping off with hands and feet. They just drink. The trouble is that sometimes drunks have access to drugs. And then a normal doctor committed, of course, garbage, but for this they put him in a corner once and even forgive, and they fanned some nonsense out of the blue.Who will treat the patients?

Forensic medical expert, doctor Valery Yezhkov disagrees. According to him, the instructions on medical safety that health care institutions must follow, although they look absurd, but each paragraph there is written in blood.

“The road to hell is paved with good intentions,” says Yezhkov. – In the instructions, in the internal labor regulations, in other documents it is clearly stated: you cannot use medicines that have not been officially purchased by a medical institution.The explanation is very simple: if something happens, then at least you won’t have to sin on medicines. Either this is an individual reaction of the body, or a violation of the dosage. By and large, it is forbidden to use medicines that relatives buy for patients.

Moscow surgeon, member of the independent trade union “Alliance of Doctors” Olga Andreitseva humanly understands her colleague Novolyalinsky.

“Any doctor or nurse working in the hospital will secretly confirm to you that there is not enough medicine,” she says.- It is often necessary to ask patients to buy something. Of course, relatives of patients bring to the hospital what they have left after the treatment of a loved one. They say, thanks for everything that you have done, we still have drugs – take it, maybe someone will need it. Of course they do.

Andreitseva emphasizes that this makes doctors vulnerable. Therefore, some, in order to avoid problems with the authorities and law enforcement agencies, may remain silent about the difficulties in treatment.

– Now it is quite easy to initiate a criminal case against the doctor, – Andreitseva continues.- In health care, the problems are growing. And if it is impossible to patch holes with a little blood, then the anger of society about the fact that medicine is becoming inaccessible must be redirected to something else. For example, killer doctors and drug dealers.

P.S: . The first court hearing in the case of Oleg Baskakov, an obstetrician-gynecologist, accused of selling and storing narcotic and psychotropic substances, will take place in August at the Novaya Lyalya court. It is quite possible that the case of the gynecologist-drug dealer will be the last in the history of this court.They want to “optimize” it – to attach to the court of the neighboring town of Serov, which is 70 kilometers away. Over the past two years, in addition to the maternity hospital, the city morgue, the tax inspection, and the military registration and enlistment office have been liquidated in Novaya Lyala. The city’s website says that a similar fate awaits the Novolyalinsk branch of the pension fund. Today one of the most stable companies in the city is a penal colony. One of the main news of recent times on the Novolyala Internet portal is about the visit of diplomats from Kyrgyzstan to their fellow countrymen, who are kept in IK-54.

How to quickly get help in case of severe pain – Rossiyskaya Gazeta

On July 1, amendments to the law came into force, simplifying the procedure for receiving potent drugs for seriously ill people. In order to get help on time and not suffer from pain, both patients and their relatives should know what they have the right to do and how to behave, what to demand from health workers.

These are the major changes that are important for patients.

Not only the oncologist, but also the attending physician – therapist, family doctor, paramedic (if the patient lives in a remote place where only FAP works) has the right to prescribe a potent pain reliever.
The validity period of a special prescription has been increased from 5 days to 15 days, and in some cases (for example, when a patient leaves for a summer residence), the norm of a medicine prescribed for dispensing according to one prescription can be increased, but not more than twice.
The rule of obligatory delivery of empty ampoules and packages of used drugs, used anesthetic patches (previously it was a prerequisite for getting the next prescription for the next portion of the medicine) has been canceled.
When a patient is discharged from a hospital, he must either be provided with painkillers, or write a prescription for their receipt until the moment when he is registered at the place of residence.
It is forbidden to discharge patients with severe pain from the hospital on the eve of weekends and long holidays, if the person is not provided with a supply of painkillers for these days.

At the same time, patients who are faced with pain syndrome usually have many questions and concerns.How to determine that it is time for a patient to switch from “conventional” painkillers to hard drugs? How to convince the doctor that the drug is not helping, that you need to replace it or increase the dose?

Employees of the Moscow Scientific Research Institute of Oncology. PA Herzen, together with public figures from the Vera hospice fund and the Gift of Life charity fund, collected the most “sore” questions and developed a kind of memo for such patients.

Infographics WG / Mikhail Shipov / Irina Nevinnaya

By the way, the basic principles of pain treatment are established by the World Health Organization and are recorded in its documents.

Basic rules for the treatment of pain

Pain cannot be tolerated. This is a fundamental rule that patients are often unaware of, and doctors ignore. In fact, only together with the patient can the doctor develop a treatment plan and evaluate the effectiveness of therapy. In order for the attending doctor and the patient to speak the same language, to understand each other, WHO recommends using a pain scale, according to which the patient assesses his condition, and the doctor decides on the appointment.
As long as non-invasive drugs (sustained release tablets, pain relieving patches) help, they should be used.And injections are used in extreme cases, when more gentle forms of painkillers do not help.
Getting enough drugs is often difficult. Therefore, patients often make the mistake of saving medicines, postponing the intake until the last, when the pain can no longer be tolerated. It is not right. Analgesics are taken on schedule, in the dosage and at the time prescribed by the doctor, without waiting for the pain to intensify. Experts explain: pain syndrome is better controlled by strict adherence to this rule.
The following rule is intended for the doctor, but both the patient and his family need to know about it. With the correct treatment tactics, analgesics are prescribed in an ascending order: first, the doses of a weak drug are increased, when the effect of their action decreases, they go to low doses of a potent one.
The patient’s individual reaction must be taken into account: what works well for one person does not “work” for the other. It is necessary to monitor not only the effectiveness of the drug, but also its side effects.
For mild pain, traditional pain relievers are used – analgin, paracetamol, non-steroidal anti-inflammatory drugs. For moderate pain, the mild opioid tramadol is usually prescribed. It is not a drug and not only relieves pain, but also helps relieve depression. In addition to tramadol, prosidol (sublingual tablets), a patch with fentanyl, and morphine tablets may be prescribed. With severe and unbearable pain, prolonged-action tableted morphine, a patch with fentanyl are also used.In their absence, injections of morphine or omnopon are prescribed.

Specifically

The Vera Foundation’s website contains a lot of useful data: addresses and telephones of hospices, rules for receiving palliative care at home for adults and children. The “Vera” foundation has also launched a mobile application, using it you can also get the necessary information, and also become a member of charitable programs.

What patients ask about

How to get the medicine quickly?

– The appointment procedure has been simplified.If a patient is seen by a local therapist or oncologist and there is a need for pain relief, the patient himself or his representative goes to see a doctor without an appointment. The doctor must write a prescription and tell you which pharmacy to get the medicine from. If the attending physician is absent, you need to contact the deputy chief physician for the medical part and clarify who else has the right to make an appointment.

For how many days is the medicine dispensed from the hospital?

– The medicine should last for five days.It is also allowed to write a prescription to get the drug at the pharmacy. The Ministry of Health has banned the discharge of the patient on the eve of weekends and holidays, without providing him with painkillers.

What if the patient is not able to come for a prescription?

– The doctor must write it out at home, during a visit to the patient. At the health facility, a prescription can be given to a relative or social worker. For non-relatives, you will have to issue a power of attorney from a notary, and when contacting a medical institution, have your passport and a copy of the patient’s passport.

Is it possible to increase the amount of medication prescribed in one prescription?

– Yes, you can. The doctor can adjust the appointment on the eve of long holidays, as well as, for example, if the patient is taken to the country. But not more than twice.

Prepared based on materials from the Russian Ministry of Health and the Vera Hospice Fund

“RG” reference

The Roszdravnadzor hotline has been operating since April, which accepts applications from citizens who have difficulties in prescribing and prescribing pain medications.Free 24-hour number:

8 (800) 500-18-35.

As of today, 1000 people called on the “hot” phone, in 600 cases it was about anesthesia, the federal service told RG.

“Urgent measures are taken for each appeal,” the Federal Service for Surveillance in Healthcare says.

By the way

Document regulating the dispensing of narcotic drugs: order of the Ministry of Health of Russia N 1175 “On approval of the procedure for prescribing and prescribing drugs, as well as the form of prescription forms, their accounting and storage.”

Delivery (O80 – O84) / ConsultantPlus

Nosological form

Code according to ICD-X

Diagnostic measures, consultations of related specialist doctors

Scope of treatment measures

List of medicines used

Singleton delivery, spontaneous delivery

O80.0 Spontaneous delivery in occipital presentation

O80.1

Spontaneous labor in breech presentation

O80.8 Other spontaneous singleton birth

O80.9 Unspecified singleton spontaneous delivery

1. For breech presentation – obstetric hospital of the second (third) group.

2. Examination by an obstetrician-gynecologist.

3. Control of blood pressure, pulse, urine output, assessment of the birth canal (Bishop, Khechinashvili).

4. Fetal ultrasound and dopplerometry.

5. CTG of the fetus.

6. Auscultation of the fetus during labor (every 30 minutes in the 1st period, after each attempt in the second period).

7. Laboratory spectrum at admission to childbirth (if not examined at the outpatient stage).

8. Long-term or continuous CTG during labor (induced labor, post-term pregnancy, placental insufficiency, etc.).

9. Maintaining partographs during childbirth.

10.Ultrasound of the pelvic organs in the postpartum period.

11. Consultation of an anesthesiologist-resuscitator.

Delivery.

Delivery allowance.

1. Analgesics (non-steroidal anti-inflammatory drugs).

2. Derivatives of diphenhydramine hydrochloride.

3. Belladonna alkaloids (Atropine sulfate).

For fatigue – obstetric sleep, premedication.

1. Amniotomy.

2. Benefit in childbirth with cephalic presentation.

3. Allowance in childbirth with breech presentation (manual manual according to Tsovyanov, classic manual manual reception Morisot-Levre-Lashapelle).

4. Mediolateral episiotomy / median perineotomy.

5. Examination of the soft birth canal in the mirrors.

6. Suturing of tears of the soft tissues of the birth canal.

1. NaCl solution

2. Solutions for intravenous and intramuscular (hereinafter – intramuscular) administration

3. Procaine, lidocaine

4.Methyl ergometrine

5. Oxytocin

6. Ketorolac

7. Trimeperidine

8. Fentanyl

9. Midazolam

10. Diphenhydramine hydrochloride

11. Atropine sulfate

12. Ketamine

13. Propofol emulsion for intravenous administration

14. Bupivacaine

15. Ropivacaine

16. Benzodiazepine derivatives

17. Narcotic analgesics

18. Ethanol

19.Anesthetics general other

20. Human immunoglobulin anti-rhesus RHO [D]

O81 Singleton delivery, delivery with forceps or vacuum extractor

Deleted:

unsuccessful attempt to use a vacuum extractor or forceps (O66.5)

O81.0 Application of low [exit] forceps

O81.1 Application of medium [cavity] forceps

O81.2 Application of medium [cavity] forceps with rotation

O81.3 Application of other and unspecified forceps

O81.4 Application of the vacuum extractor

O81.5 Delivery with combined forceps and vacuum extractor

1. Management of pathological childbirth by an obstetrician-gynecologist.

2. Ultrasound of the fetus.

3. Assessment of the state of the fetus (CTG + Doppler, continuous CTG).

4. Ultrasound of the pelvic organs in the postpartum period.

5. Consultation of an anesthesiologist-resuscitator.

1. See the heading “Singleton delivery, spontaneous delivery”.

2. Application of obstetric forceps.

3. Applying a vacuum extractor.

4. Control manual examination of the walls of the uterine cavity after the application of abdominal forceps.

See section “Singleton delivery, spontaneous delivery”.

O82 Singleton delivery, delivery by caesarean section

O82.0 Conducting elective caesarean section

O82.1 Conducting an urgent caesarean section

O82.2 Cesarean section with hysterectomy

O82.8 Other singleton births by caesarean section

O82.9 Delivery by caesarean section, unspecified

1. Management of pathological childbirth by an obstetrician-gynecologist.

2. Consultation of an anesthesiologist-resuscitator.

3. Fetal ultrasound + dopplerometry.

4.CTG of the fetus.

5. Complex of studies during transfusion.

6. General (clinical) blood test, general urine test, biochemical blood test, coagulogram.

7. Ultrasound of the pelvic organs in the postpartum period.

1. Laparotomy (lower midline / transverse suprapubic incision / according to Joel-Cohen).

2. Caesarean section in the lower uterine segment.

3. Caesarean section in the lower uterine segment followed by total / subtotal hysterectomy (large uterine myoma, impossibility of myomectomy due to cervical / isthmus location of the node).

4. Anesthetic treatment (including early postoperative management).

1. Methyl ergometrine

2. Enzaprost

3. Calcium preparations

4. Acetic acid derivatives

5. Penicillins in combination with beta-lactamase inhibitors

6. Cephalosporins 2 or 3 generations

Anesthetic management:

1. Atropine hydrochloride

2. Diphenhydramine hydrochloride

3.Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6. Midozolam

For caesarean section / laparotomy:

1. Barbiturates (sodium thiopental)

2. Choline derivatives (suxamethonium chloride and iodide)

3. Quaternary ammonium compounds (pipcuronium bromide, rocuronium bromide instead of vecuronium bromide)

4. Halogenated hydrocarbons (sevoflurane liquid for inhalation)

5.Narcotic analgesics (trimeperidine, fentanyl)

6. Opioids (tramadol)

7. Cholinesterase inhibitors (neostigmine methyl sulfate)

O83 Singleton delivery, delivery using a different obstetric aid

O83.0 Extraction of the fetus by the pelvic end

O83.1 Other obstetric manual for breech delivery

83.2 Childbirth with other obstetric manipulations [manual techniques]

O83.3 Delivery of a live child during abdominal pregnancy

O83.4 Destructive operation during delivery

O83.8 Other specified types of obstetric benefit for singleton birth

O83.9 Obstetric allowance for singleton birth

unspecified

1. Management of pathological childbirth by an obstetrician-gynecologist.

2. Consultation of an anesthesiologist-resuscitator.

3. Fetal ultrasound + dopplerometry.

4.Assessment of the condition of the fetus. CTG, continuous CTG.

5. Complex of studies during transfusion.

6. General (clinical) blood test, general urine test, biochemical blood test, coagulogram.

7. Ultrasound of the pelvic organs in the postpartum period.

1. Manual on Tsovyanov.

2. Reception of Morisot-Levre-Lachapelle.

3. Classic manual manual.

4. Removing the fetus by the stem.

5.Extraction of the fetus at the pelvic end.

6. Extraction of the fetus by the pelvic end.

7. Classic external-internal (combined) obstetric rotation of the fetus on the pedicle.

8. Laparotomy.

9. Fruit-cutting operations.

10. Cleidotomy (with shoulder dystocia). Anesthetic management (including early postoperative management).

1. Methyl ergometrine (0.2 mg i.v.)

2. Oxytocin and its analogues

3.Calcium preparations

4. Acetic acid derivatives

5. Penicillins in combination with beta-lactamase inhibitors

6. Cephalosporins 2 or 3 generations

Anesthetic management:

1. Atropine hydrochloride

2. Diphenhydramine hydrochloride

3. Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6.Midozolam

For caesarean section / laparotomy:

1. Barbiturates (sodium thiopental)

2. Choline derivatives (suxamethonium chloride and iodide)

3. Quaternary ammonium compounds (pipcuronium bromide, rocuronium bromide instead of vecuronium bromide)

4. Halogenated hydrocarbons (sevoflurane liquid for inhalation)

5. Narcotic analgesics (trimeperidine, fentanyl)

6. Opioids (tramadol)

7. Cholinesterase inhibitors (neostigmine methyl sulfate)

O84 Multiple delivery

If it is necessary to identify the mode of delivery for each fetus or child, use an additional code (O80 – O83).

O84.0 Multiple births, completely spontaneous.

1. Conducting pathological childbirth by an obstetrician-gynecologist, keeping a partogram.

2. Consultation of an anesthesiologist-resuscitator.

3. Fetal ultrasound + dopplerometry.

4. Assessment of the condition of the fetus. CTG, continuous CTG.

5. General (clinical) blood test, general urine test, biochemical blood test, coagulogram.

6. Ultrasound of the second fetus after the birth of the first.

7. Ultrasound of the pelvic organs in the postpartum period.

See section “Singleton delivery, spontaneous delivery”.

1. NaCl solution

2. Calcium preparations

3. Acetic acid derivatives

4. Penicillins in combination with beta-lactamase inhibitors

5. Cephalosporins 2 or 3 generations

Anesthetic management:

1. Atropine hydrochloride

2.Diphenhydramine hydrochloride

3. Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6. Midozolam

O84.1 Multiple labor, complete with forceps and vacuum extractor

See the heading “Multiple births, completely spontaneous”.

1. See the heading “Multiple births, completely spontaneous”.

2. Application of obstetric forceps.

3. Applying a vacuum extractor.

1. NaCl solution

2. Human immunoglobulin anti-rhesus RHO [D]

3. Calcium preparations

4. Acetic acid derivatives

5. Penicillins in combination with beta-lactamase inhibitors

6. Cephalosporins 2 or 3 generations

Anesthetic management:

1. Atropine hydrochloride

2. Diphenhydramine hydrochloride

3.Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6. Midozolam

O84.2 Multiple births, completely by cesarean section

1. Management of pathological childbirth by an obstetrician-gynecologist.

2. Consultation of an anesthesiologist-resuscitator.

3. Ultrasound of fetuses, dopplerometry.

4.Assessment of the condition of the fetus. CTG.

5. Complex of studies during transfusion.

6. General (clinical) blood test, general urine test, biochemical blood test, coagulogram.

7. Ultrasound of the pelvic organs in the postpartum period.

1. Laparotomy (lower midline / transverse suprapubic incision / according to Joel-Cohen).

2. Caesarean section in the lower uterine segment.

3. Intraoperative:

Stem Extraction / Pelvic End Extraction.

Anesthetic benefits (including early postoperative management).

1. Methyl ergometrine

2. Enzaprost

3. Oxytocin and its analogues

4. Prostaglandins

5. Calcium preparations

6. Acetic acid derivatives

7. Penicillins in combination with beta-lactamase inhibitors

8. Cephalosporins 2 or 3 generations

9. Calcium preparations

10. Acetic acid derivatives

11.Penicillins in combination with beta-lactamase inhibitors

12. Cephalosporins 2 or 3 generations

Anesthetic management:

1. Atropine hydrochloride

2. Diphenhydramine hydrochloride

3. Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6. Midozolam

For caesarean section / laparotomy:

1.Barbiturates (sodium thiopental)

2. Choline derivatives (suxamethonium chloride and iodide)

3. Quaternary ammonium compounds (pipcuronium bromide, rocuronium bromide instead of vecuronium bromide)

4. Halogenated hydrocarbons (sevoflurane liquid for inhalation)

5. Narcotic analgesics (trimeperidine, fentanyl)

6. Opioids (tramadol)

7. Cholinesterase inhibitors (neostigmine methyl sulfate)

O84.8 Other delivery in multiple births

O84.9 Multiple delivery, unspecified

1. Management of pathological childbirth by an obstetrician-gynecologist.

2. Consultation of an anesthesiologist-resuscitator.

3. Ultrasound of fetuses, dopplerometry.

4. Assessment of the condition of the fruit. CTG, continuous CTG (with a living fetus).

5. Complex of studies during transfusion.

6. General (clinical) blood test, general urine test, biochemical blood test, coagulogram.

7. Ultrasound of the pelvic organs in the postpartum period.

1. See the heading “Multiple births, completely spontaneous”.

2. Classic external-internal (combined) obstetric rotation of the fetus on the pedicle.

3. Removal of the fetus by the pelvic end.

4. Removing the fetus by the stem.

5. Manual on Tsovyanov.

6. Reception of Morisot-Levre-Lachapelle.

7. Classic manual.

8.Laparotomy.

9. Caesarean section.

10. Control manual examination of the walls of the uterine cavity (during childbirth outside the medical facility O84.9).

Anesthetic benefits (including early postoperative management).

1. Methyl ergometrine

2. Oxytocin and its analogues

3. Antihistamines

4. Penicillins in combination with beta-lactamase inhibitors

5. Cephalosporins 2 or 3 generations

6.Calcium preparations

7. Acetic acid derivatives

Anesthetic management:

1. Atropine hydrochloride

2. Diphenhydramine hydrochloride

3. Narcotic analgesics (trimeperidine, fentanyl)

4. Other general anesthetics (ketamine, propofol)

5. Amides (bupivacaine, ropivacaine)

6. Midozolam

For caesarean section / laparotomy:

1. Barbiturates (sodium thiopental)

2.Choline derivatives (suxamethonium chloride and iodide)

3. Quaternary ammonium compounds (pipcuronium bromide, rocuronium bromide instead of vecuronium bromide)

4. Halogenated hydrocarbons (sevoflurane liquid for inhalation)

5. Narcotic analgesics (trimeperidine, fentanyl)

6. Opioids (tramadol)

7. Cholinesterase inhibitors (neostigmine methyl sulfate)

“Doctors just do not know and are afraid” Sick Russians live in pain and die.Their drugs are considered drugs: Society: Russia: Lenta.ru

“If it hurts, it will pass faster,” “You have to endure it.” With these and other similar phrases, thousands of patients throughout Russia, especially outside Moscow, are deprived pain. Meanwhile, taking opioid analgesics is often the fastest way to get out of a hospital bed, and for the terminally ill – a chance to spend the last days of life without suffering. But doctors are in no hurry to write prescriptions. Not finding help from their doctor, people go to find pain relievers themselves.Some of them are from dealers or relatives of deceased patients, others are trying to smuggle them from abroad, and others are forced to replace with drugs, which are sometimes easier to get. How can we make a difference and make doctors allies with patients in the fight against pain? Lenta.ru was looking for answers to these and other questions in a conversation with Nyuta Federmesser, director of the Moscow multidisciplinary palliative care center, founder of the Vera hospice fund.

Lenta.ru: Do you know of cases when people had to resort to the black market or smuggling to get pain relief?

Federmesser: Yes, alas, in the regions it still occurs.If you look at the statistics on the consumption of narcotic analgesics in the country, then in 2017, 23 percent of the total volume of opioid analgesics produced in Russia were used in Moscow – this is the largest percentage in the country. More than in any federal district.

What does this mean?

This means that the situation with pain relief is much better here, so patients and their loved ones do not need to break the law – they already receive pain relief.

But is it different outside the Moscow Ring Road?

Exactly.Recently, a patient from the region was admitted to the Palliative Care Center, who, through the efforts of his relatives, was anesthetized with heroin. The son said that it is much easier for him to get heroin than morphine. And it’s a shame, of course, that it’s not far from Moscow.

Lack of availability of opioid analgesics leads relatives to violate drug trafficking laws. A seriously ill person dies in the family, and the drug remains. According to the law, the started packaging must be returned, but the relatives remember that it was difficult to get the medicine, and they keep the medicine for themselves: you never know what.And when friends or acquaintances need pain relief, they pass this drug on. From the point of view of the law, this leakage into illegal circulation is a matter of jurisdiction. Moreover, they not only transferred, but also kind of appointed, without knowledge, medical education, or a license. God knows what will happen – maybe it’s a pain reliever and cannot be prescribed to the patient.

There is also a category – those who travel abroad for treatment. When they return, they bring drugs for themselves or for their child.

European doctors know that in our country pain relief is not easy: they prescribe the necessary drugs to a person who, for example, will soon need palliative care. But they do not know in advance which drug will help better, so they give, for example, three prescriptions for hydromorphone, oramorph, extended-release morphine in tablets and a six-month supply for each drug. Can you imagine how much a person brings in more than he really needs? And then it stays and spreads to acquaintances in the same way.

Photo: Maxim Kimerling / “Kommersant”

People are forced to do this, for fear of being left alone with pain. It turns out that now control leads to the opposite effect, and this needs to be changed. The medical legal turnover of narcotic drugs is no more than 0.04 percent of the total turnover, and they regulate it as if the numbers are completely different.

Children’s pain relievers are often sold.

Yes, especially when it comes to non-invasive forms – that is, not about injections, but, for example, about plasters or syrups.When the child died, there was a bottle of strawberry-flavored morphine solution, you look at this bottle and think that this is a salvation for the suffering children. And you can’t do anything with it – in theory, you can’t even transfer it to a medical facility so that it can be stored there and help someone, and it’s a pity to pour it out, and you can’t leave it at home. It can only be destroyed in the presence of a commission with the drawing up of an act. But the commission still needs to explain where you got the drug from. Therefore, everyone is silent.

But this morphine can help others.Enchanting hypocrisy – to say that everyone is anesthetized, that we do not need anything. If we come to a family where there are children who need anesthesia, mothers we know have the imported drugs they need through one. And not all of them went abroad. These parents have forums and chat on the Internet. Until recently, it seemed to me that I’ll tell this – and that’s all: they will go to wool for their mothers. No, we must talk about it! They won’t. Because the drug policy needs to be changed. Let them try to wool and take away morphine in syrup, if mom can’t get legal morphine in ampoules – she’s just not prescribed it.

Why aren’t they discharged?

Doctors simply do not know how to prescribe and are afraid. Quite recently, in the Ivanovo region, where the governor is aware of this problem, the foundation had a seriously ill child under his care who needed morphine. Each time they had to knock him out with the support of the Deputy Minister of Health Tatiana Yakovleva. She called the regional health minister. He saluted and called the head physician of the polyclinic. The head doctor referred to the fact that the child’s parents can call an ambulance, they can be hospitalized in a hospital to be given anesthesia.But mom doesn’t want to be admitted to the hospital! She knows that there are no round-the-clock visits in the hospital, she will be kicked out of there and the one-year-old child will be left alone in the hospital. Mom is already trained, she knows her rights, she called the Vera Foundation hotline or the Roszdravnadzor hotline – she knows that she has the right to get morphine at home.

Photo: Sergey Stroitelev / “Kommersant”

Just imagine: the bell rings, the chief doctor is horrified because the minister called him, in a panic he writes out a prescription for a one-year-old child for morphine.Here is the manual control. In the meantime, we solve it manually, the child hurts all the time.

But the problem is this: further, the district doctor must anesthetize the child at home with morphine. So this doctor calls in tears from the child’s apartment and says: “I came, I have everything, but I will not do it. I will kill the child. Even if you call the police, I still won’t. ” After all, she first went to fulfill such an appointment, she has no experience. She grew up in this country, in this legislation, received a domestic education, and she believes that if she gives the child morphine, she will kill him and go to prison.She regards this in such a way that she is almost forced to do euthanasia. And I understand her, although this is blatant illiteracy.

As a result, the child did not receive anesthesia for another three days, and all these three days, the chief specialist in palliative care of the Ministry of Health of the Russian Federation, Diana Nevzorova, spoke with the local doctor on the phone, explained to her what and how, in fact, formed her.

Yes, in the end we got morphine, everything was done, but in such a strange mode. This is not normal in a country where 146 million people live and 2.5 thousand children need opiate pain relief every year.

But these are doctors, they are obliged to help people and they are also obliged to relieve pain. Why should they be afraid?

The Vera Foundation conducted a survey in 2017 to identify the reasons that impede pain relief. About 40 percent of healthcare providers said the risk of being prosecuted was a major barrier. And they will spend time and energy dissuading the patient from opiates, even if less potent drugs do not help.

How can you even dissuade a person who is in pain?

Well, they say, they say, “be patient”, “these are drugs, nothing will be stronger”, “early”, they scare you with addiction, premature death.

Is the law really that cruel? Even if the doctor is just doing his duty?

There is article 228.2 in the Criminal Code, which essentially states: it is possible for both physicians and pharmacists – that is, those who, due to their activities, are faced with different volumes of opioid analgesics – to be prosecuted, regardless of whether they are intentional or unintentional. made a mistake.

And the person is punished in any case: the drug got into illegal circulation, or the remains of the drug after the injection were poured into the sink, or if he accidentally crushes the ampoule with his knee, locking the safe.Punished with either a fine or a suspended sentence. But the test is still a crucible.

Even our conversation with you, by and large, can be considered a violation of the law. I tell you that in some cases morphine is good, and if, God forbid, you have surgery, you have the right to demand pain relief with opioid analgesics. And in the Federal Law No. 3 “On Narcotic Drugs and Psychotropic Substances” the concepts of “propaganda” and “informing” are not divorced. And if you want, this interview can be regarded as propaganda, and I can be brought not just to administrative, but to criminal liability in accordance with Article 46 of the Federal Law No. 3.

Alevtina Horinyak

Shot: MILOSERDIE.RU / YouTube

How it happened with Alevtina Horinyak, whom they tried to imprison for nine years for a prescription for a cancer patient …

Horinyak is a well-known case: three years in the courts. Can you imagine how much public money it took to ultimately justify her, and even two million in compensation to pay her? But she’s not alone.

But such cases are negligible. In 2016, only five people were convicted under Article 228.2. Isn’t this a reason, if not to cancel, then at least revise it?

Sotnikov, deputy chief of the GUNK of the Ministry of Internal Affairs, tells us: “There are so few of these cases that we see no reason to decriminalize.” And I answer: “These cases, thank God, are few, this is one more confirmation that this article should be removed, because this small number of cases is so resonant that doctors do not go into this area of work at all. Even one case of Alevtina Khorinyak was enough to sharply reduce the prescription of opiates in the Krasnoyarsk Territory.This is the sword of Damocles. ” They, the Ministry of Internal Affairs, you know, have the opposite logic.

Ok, sorted it out. But there are few cases, the persecution, in general, is not very large-scale, and medical workers still do not want to deal with opiates. Why?

I can say from my own experience that they simply do not go into this area, they refuse to work. It is very difficult to find a pharmacist in a hospice who will work with drugs. Every time a new nurse comes to us, we ask if she has a drug work permit.No. She doesn’t want to go and learn how to work with drugs, she is already intimidated. And it makes life incredibly difficult. I’m not even talking about the fact that today a nurse, in order to get admission to work with drugs, needs to collect certificates – you have to sweat, because all this can be done only at the place of registration, not residence.

In the eyes of the police, the pain patient who is shown morphine is a potential addict?

Yes, that’s right! And the morphine doctor is a potential drug dealer.The same Sotnikov told us at a meeting that a doctor with morphine is worse than an inadequate policeman with a pistol in his hands. Because, in his opinion, morphine is perfect murder. He spoke about it openly, although it contradicts both common sense and world medical standards.

This is the Russian drug policy. I’m trying to explain to them that with modern drug distribution methods, where spice and acid are bought over the Internet, such a drug policy regarding medicinal opiates is meaningless.Why should they go to the clinic, looking for morphine in this way? We need to work with these stereotypes. Drug policy needs to be changed. Although the fact that the FSKN has been abolished is already happiness.

Why happiness?

We are a country with a plan and reporting. The FSKN also had the task of reporting to the top. What did they report about? On the number of violations identified. When your task is not only to prevent, but also to identify, you behave in a completely different way: you came to a medical institution, and there is this sister who poured the remains of the drug into the sink.Well, great, here’s the intruder. The problem now is that the GUNK of the Ministry of Internal Affairs, headed by Andrei Khrapov, is a department formed from former employees of the Federal Drug Control Service. With the same policy. There are fewer of them, they have a different approach in something, but in general …

What is needed to reverse this situation?

It is necessary that all control over the legal turnover be at Roszdravnadzor, and not at the Ministry of Internal Affairs. A two-tier control system: first, doctors and medical officials react to an error in documents, and the police only connect if the check revealed that there was a crime.That is, a case must be reported to the police, which is absolutely definitely recognized by Roszdravnadzor as a violation of traffic with consequences that have led to harm to the health of other citizens.

It’s bad when the state creates additional difficulties for doctors and patients, who are already having a very hard morale. People do not need tests and pressure, but comfort and support, which are often not found anywhere, even in the church.

What’s wrong with the church?

For me personally, this is a difficult and somewhat acute question.We live in a country where Christianity is a key religion, where the concept of Christian suffering and atonement through it is dominant. In a society with a slave psychology, in a society accustomed to suffering, this concept is perverted, and this suffering is seen by Christians and, unfortunately, is implanted, imposed as purely physical suffering.

You see, they are people like doctors, like shop assistants. This is such an army. The percentage of fools there is no less than in any other structure.And they largely condone this Middle Ages, when a person is afraid to ask for help if he has pain. They impose this formula: pain is the atonement for sins, suffer.

Photo: Yegor Aleev / TASS

Pain cannot be tolerated. Any pain must and can be cured. Almost any pain can be relieved. Actually, based on this position, an approach to all pain therapy is built. It is not so important what a person is sick with and how serious this disease is: the presence of pain is not normal.This is especially abnormal when a person experiences pain while under medical supervision in a medical organization.

But there is a point of view that pain is an important signal that should not be overlooked?

Quite right. When we are healthy and suddenly pain appears, this is a signal that something is wrong. But when a person has already come to the doctor, has already complained of pain, this signal becomes unnecessary. Once diagnosed, pain reduces the effectiveness of any therapy because the person spends energy fighting their pain.

How to relieve pain – with constant injections?

Not always. Pain relief itself is a therapy aimed at eliminating pain. It doesn’t have to be painful. That is, optimal pain relief should be carried out using non-invasive methods (patches, syrups, tablets), not injections. I myself am afraid of injections. And for me this is a serious choice: if I have pain and need an injection to get rid of the pain, then I will most likely suffer pain than pain plus an injection, although it will feel better after that.Everyone has their own cockroaches.

This is as terrible as the wording that children suffer for the sins of their parents. When my mother has a sick child, and the priest says to her: “Did you have abortions? Well, what did you want. ” Yes, once Patriarch Kirill said that those priests who say this should not work in the church. But speaking on this topic once, you cannot change the situation, because there are tens, and maybe hundreds of thousands of priests all over the country and it is not a fact that they even heard it.

Vyacheslav Apanasenko

After the death of Rear Admiral Apanasenko, who shot himself due to the inability to get an anesthetic, there was a lot of talk about the fact that the turnover would be simplified. Did they keep this promise?

Partially. After these events and thanks to Law 501, which Nikolai Gerasimenko initiated in the Duma, the rules are simplified in the outpatient sphere – when a person needs to go and get a drug or a prescription. Unfortunately, nothing has changed inside the inpatient medical organization.And it’s still very difficult for doctors. Here in our treatment room sits a nurse with huge stacks of magazines. And in such an institution as a hospice, designed for only 30 beds, a separate human unit is needed, which only fills these magazines all day long. An employee with a medical degree, by the way. But imagine that I have 200 patients in the Palliative Care Center, of which 112 are on opioid analgesics. But I also have only one such nurse.What is the chance that she will never be wrong? And you can bring to court for any mistake that led to the loss.

But has something changed for the patients?

Yes, a lot. The validity period of the recipe has changed: it was not 5, but 15 days. This means that a person can be fully supplied with drugs for long holidays. In addition, the patient no longer has to hand over the used ampoules and packs from the plaster to receive the next pack of narcotic painkillers. The Vera Foundation published consistent instructions for patients and their families about all the changes.All important telephones are also there.

And now – and this is one of the key changes – each hospital, when discharging a patient home, has the right to give him drugs on hand, home, for up to five days.

And they give them?

Very few places.

That is, there is a norm according to which you need to give painkillers to your home, but they do not give it? What’s the logic?

The clinics do not even have the necessary drug, they do not buy or give it. This problem is also associated with the method of calculating the need, in which nothing is included for the delivery to the patient at home.And the doctors just say: “You understand, if we give someone home, then we simply will not have enough for someone in the hospital.” Because the wrong approach.

You’ve probably heard another argument against opioid drugs. They say that a person cannot make adequate decisions …

A person will no longer be able to sign any notarial statement if he receives morphine. Do you understand what this means? With all the apartments …

Photo: Pavel Smertin / TASS

A huge number of our patients who want to write a will and fix it all officially at the end of their lives are simply denied.And when it hurts – without morphine you can sign anything you like as cute. Like torture.

I have a very low pain threshold: not so long ago I was in the hospital with pancreatitis, and it just hurt like hell. And I know for sure that I was generally inadequate until I was anesthetized. I just didn’t physically hear the doctor. As soon as I was stuck with an anesthetic plaster, injected with morphine, after a few minutes I began to calm down, fell asleep and woke up in a relatively normal state.That’s when I was absolutely adequate, I didn’t have a cloudy head, nothing like that. I called the children and found out how they were. From the point of view of our legislation, in this situation I could not write a will, make a decision, sign, as the head of a medical organization, any financial document. My signature is invalid these days – I was on opiates, you know?

It turns out that a person gritting his teeth in pain is more adequate than an anesthetized person.

Yes, and this is absolute nonsense.

But as I understand it, pain relief in the world is not an obstacle to decision-making?

Quite right. A person’s adequacy is assessed by a doctor and a notary. In the same way as during the period when he is not receiving opiates. Answers to questions. The same answer to the same question. Can you imagine if a person receives opioid analgesics, and we remove him from morphine for three days, for example, so that he can make a will or make other decisions …

How strong should the drug be? Is there a danger that the patient will receive too strong an analgesic? Maybe very “dangerous” drugs should be given only to the dying who are experiencing terrible death throes?

It is important to understand that opioid analgesics (just the most powerful and dangerous, from the point of view of the Ministry of Internal Affairs) are required not only at the end of life, at the stage when a person needs to relieve pain without thinking about the consequences.Prescribing such drugs after surgery or severe injury is the WHO medical standard. “Strong” and “dangerous” analgesics, which are called narcotic, are prescribed in the world for acute pancreatitis, urolithiasis, and severe burns. I repeat, this is not an exceptional case, not an out of the ordinary event, this is a standard.

Photo: Oleg Kharseev / Kommersant

In our country, unfortunately, there is no such standard, and high-quality pain relief can be obtained either in a paid clinic, or… by pull, if you call a spade a spade. Many chief doctors of the leading private and public clinics, which are considered the best, told me that they simply do not have such drugs. And they have, for example, promedol – a highly toxic drug, it can be used for a maximum of a day. But the necessary painkillers are not available simply because there is no understanding of the expediency of purchasing. Because these drugs are quite cheap. But our patients do not complain about pain, they are ready to endure, so why buy?

However, there are positive changes: recently we have simplified the circulation of tramadol – a weak opiate, and another strong one – fentanyl.It is a synthetic opiate in the form of a patch that sticks to the skin, and you can live with it for three days. With regard to tramadol and transdermal fentanyl, which drug addicts are not interested in, the rules have been simplified. They are prescribed on a different prescription, they are easier to write off, and the workflow is less.

So everything is fine?

Such a double-edged sword turned out. Having simplified the rules for discharging in one part and leaving it as it was in the other, the state forced doctors to disregard the recommendations for the prescription of certain opiates: a person obviously needs morphine, but he is prescribed tramadol.For example, people over 65 should not be prescribed tramadol at all – its side effects are higher than the analgesic effect. And fentanyl is not allowed for those with a body temperature above 37.2, it immediately gives away all the active substance at once, in half an hour. It turns out to be a serious overdose. Fentanyl is often prescribed at home for cancer patients at the last stage. But for those who are very emaciated and dehydrated, like many cancer patients, it simply cannot be prescribed, because in order for it to enter the blood in the correct volume, a normal volume of subcutaneous fat is needed.

But is everything all right in Moscow?

Moscow has the best anesthesia situation in the country. For example, two days before the New Year, all the chief doctors of the capital – both polyclinics and hospitals – were gathered. They were harshly told that if any issue of pain relief is not resolved within two hours, consequences will follow, up to and including the loss of their position. That is, there should not be a situation in Moscow at all that a person is not anesthetized. And I have been living for the second year without emergency calls in Moscow, can you imagine? That is, such calls may concern a nonresident who finds himself in the city, there are still certain difficulties with this.But at the same time, even in Moscow, emergency rooms, for example, are not equipped with either a drug trafficking license or opioid analgesics. That is, a complex fracture will not be anesthetized to a person until he is in the hospital.

And when a person who is in pain comes to the clinic, it is difficult for him to get a prescription?

Not easy. This is the problem of doctors’ lack of skill. When you and I come to the clinic, there are a number of questions that we will surely be asked: about temperature, pressure. You even get annoyed: you came about a specific problem, why is all this? And the question: “Do you have any pain? How does it hurt? ” – just don’t know how to ask.The Vera Foundation has agreed with the Moscow Department of Health on the preparation of a reminder on pain relief, and this reminder is two-component – one for the patient, the second for the doctor, expanded.

Photo: Valery Sharifulin / TASS

The patient also needs to be taught that on a ten-point scale “0” is not a small pain, but when it does not hurt at all, but “10” is such pain that a person cannot imagine at all, as it never hurt in my life and should never get sick in principle.This is a hell of a hell.

Let’s finally talk about funds. Are there enough of them?

It’s not about the means. There are funds for drugs! But not all are anesthetized. In Russia, annually need anesthesia, according to various estimates, from 400 thousand to 800 thousand people, and receive only 30 thousand.

Where does this data come from – 800 thousand?

Folded. We look at mortality and morbidity according to ICD-10 (Tenth revision of the International Classification of Diseases) and we see that the statistics for oncology are the same, for HIV – such, tuberculosis – the third, dementia – the fourth.International experience and evidence-based medicine say that 80 percent of cancer deaths, 50 percent of AIDS deaths, 34 percent of Alzheimer’s deaths and 37 percent of Parkinson’s deaths require opiates. We also use the WHO calculation methodology – a course from one to three months before death.

So there is a production problem, right?

Not really. There is the Moscow Endocrine Plant – a monopolist that produces opioid analgesics with public funds.The regions of the country calculate how many opiates they will need for the next year and order this amount from the factory. The calculation is carried out according to several parameters: consumption of the past period, mortality and morbidity. The problem is this: hospitals and clinics, based on international calculation methods, prescribe fewer drugs than were ordered. This means that each time there is a surplus of unused opiates and each time the region orders more than it “eats”. It turns out that all the time there are unused, “extra” drugs, although the region’s satisfaction in pain relief in fact may remain below 30 percent.

Photo: Yegor Aleev / TASS

The plant is destroying the remains of drugs at the state expense, and this is also a gigantic waste of budgetary funds. That is, in fact, it is not necessary to produce more, but to appoint. And here we come back to the fact that doctors do not know, do not know how, are afraid, relatives are afraid, patients are afraid – all these reasons together. Lack of a competent drug policy that would set the rules for legal and illegal trafficking.

This is a complex problem.To solve it, it is necessary to amend the legislation, to the Criminal Code, train doctors, inform the public and the medical community, and yes – develop and produce additional non-invasive drugs that are not interesting to drug addicts, which will simplify the rules of circulation.

And only then we all will not be afraid. Doctors are not afraid of prescribing opiates and treating pain. Anyone who faces pain will not be afraid to get sick, because they will be anesthetized.

Roszdravnadzor anesthesia hotline: 8 800 500-18-35

Hotline for terminally ill people: 8 800 700-84-36

Nirvana: pechalka_jalka – LiveJournal

The first time I saw her was at a party.She almost completely sucked in the gloomy guy’s head. All the time that I was there, and this is about five hours, they sat on the armchair, soldered tightly in the area of the lips.

Then I found out her name. Katya Nirvana. Actually, Burakova, but I will find out later, when we go to Crimea together and I see my passport. Yura Burakov was the name of the founder of the Moscow Sistema, the first Soviet hippies. Katka was not a hippie, but a shit. The anarchy badge was painted on a black T-shirt with bleach, torn jeans on a bulky ass.The figure in a jug is a thin torso, small chest and arms, but at the bottom it expanded into a heavy, large ass and large legs.

She had some kind of sore, eye disease, her eyelids were always bright red, as if she had just been crying. And the same red sharp nose. In general, the skin was reddish, inflamed. A little tone and a couple of strokes of mascara – and Katya turned into a real beauty. It’s a pity that she wasn’t interested in that at all.

Katya was injected with a screw. Or saw the screw (yes, there is also such a way of using this drug).They cooked at home, she lived alone in a dilapidated ruin on Upper Khortytsya. It was exotic, none of us had a separate home. And she somehow broke off from her daddy-drug and mom, who was left in Krasika, Krasnoarmeisk, Donetsk region.

Then it turns out that an evil fungus lives in this separate hut under the floor, which will eat part of her lung, and there will be operations. Katya, unlike us, did not smoke or drink, she used drugs. If you smoke, then only weed, if you drink, then tramadol.

She told scary stories about her sister, born of an alcoholic father, who was diagnosed with cirrhosis of the liver at the age of seven, had a transplant, but she still died at 10 or 12.Eastern Ukraine, huli …

Katya had a screw girlfriend – Verochka, Verushka. She was weird. A doll’s face, goldilocks’ straw curls, a thin voice, clean eyes … Vera was constantly pushing. How such a fragile organism could process such a quantity of substances is a mystery to me to this day.

Vera is fat and sad now. She gave birth to a child (how? !!), lives in Kharkov, is engaged in easel painting, exhibits (how? !!).

Once I also got into this terrible screw hut.The kitchen was more like a laboratory – ampoules, tablets, saucepans …

And Katya came to visit me. We were vying with each other to shout “Civil Defense” to a frustrated guitar, interspersed with Yanka Diaghileva. Katya had no hearing. There was a voice, but due to the latter circumstance, it did not fit into the necessary notes and tonalities in any way. This did not bother her at all, she cheerfully took the guitar away every time she got into the guitar company, and started “Borders, the key is broken in half …”.

Then there was the Crimea.Katya was snow white and on the very first day of felting naked in Fox Bay, she was burned to a purple crunch. I spent the rest of the week in a tent, serving as an excellent sinker against strong coastal winds.

Katya was a child of nature, fully accepting herself in all manifestations. The pubis was unshaven and wild, in the middle hung a dirty tampon thread …

Honestly, I was afraid of her. Her free life, so careless and fearless, seemed impossible and dangerous to me.

Imagine my amazement when I learned that Katka WORKS at the BANK, not in her last position.The boss of something is there. She was handed and eventually lured to another structure. Social networks were not yet monitored so closely and next to the photos from the lists, photos of Katya in dress-code outfits and behind the desk began to appear.

She earned decently, did not like to spend. Was saving up. Not for something specific, but just like that, childhood memory.

I was surprised at such a contrast and could not move it in my head from the “Finished” shelf to the “Normal” shelf. I think this is the root of why people find it difficult to accept our success.Because you have to make an effort and rearrange the statuses in your head. And this is both tiring and angry.

And then Katya got overwhelmed. Hara-krishna got overwhelmed. At first I just went to the local church, then I quit my job, then I began to work in the church. I asked, but I did not understand what she was doing there. Dress up the puppet gods. Gives them “sacrifices” – flowers and food. Sings and dances.

She migrated after her newfound faith, finding herself now in Moscow, now in the Crimea, now suddenly in Singapore.She complained that the most difficult thing for her was the vow of purity. All the time that I knew her, she was turned on for sex. We could come to the concert of a local band in the Palace of Culture. Katya disappeared for 15 minutes, came back happy and announced loudly: “And I had sex!” Where, with whom, under what bush … Child of nature, I say the same. She could write to me on Skype, for example, during working hours. Asking for a chat. I can’t, I say, once, and the boss looks like a wolf. And she starts making video calls in response …

Despite her vows, Katya, like a sailor, had a lover in every port.Opening my mouth, I listened to her stories, not understanding how with such an ass you can even persuade someone. But hare-krsna did her good. Katya practices various extreme things, like prolonged dry fasting. The face got rid of the redness, the features became thinner, the ass melted. We changed places – now I am a stone woman next to fragile Katya.

The last time we saw each other was in Kiev, three years ago. I, with the fervor of a convert, took her through the streets, poking her into every house, strewed with stories, legends and surnames.Katya was frankly bored, asked to sit down and was more interested in the cost of the capital’s real estate than in her stories. The second person in my memory who remained indifferent to my excursion service.

I remember we were walking about something, chatting, I complain about the neighbors, then about the peasants, I say so dashingly: “Yes, I don’t care about them at all, and how I look!” Katka looks around me with a sarcastic look, and says – “Yes, I see …”.

Wrote this morning. Traveling through Kiev. And would you please me to take a walk.And I dislike it. At all.

And Maruska called after the New Year, we haven’t seen each other for over a year. Praise the coronavirus, you can always say “Sorry, I have covidophobia.”

And don’t walk.

Tramadol and diphenhydramine in one syringe – Telegraph

Tramadol and diphenhydramine in one syringe

Tramadol and diphenhydramine in one syringe
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hurt. We had a course of chemotherapy, red, Mom recovered very quickly, nothing bothered her.The operation took place in November. In the summer of August, my mother felt pain in the area of the scapula of her left arm. Bone scan was performed, revealed multiple metastases in all bones. During the year, they were first treated with zometa, in the fall they also began to irradiate the areas that bothered the mother the most – the elbow, shoulder joint, spine, head, pelvic bones, knee. The test results were normal, after the irradiation the pain dulled, but at the beginning of this month. At the end of February, my mother was released for a ‘vacation’, they said that for now, let her rest from treatment.The district oncologist told me that, in principle, given the multiplicity and remoteness of metastases, my mother is already at that stage when they are not treated, but simply support more or less the patient’s condition and wait for the end. Not at the oncology center, nor the district oncologist did not give any recommendations for pain relief. They just listed the drugs and told me to take them according to the situation. Since March, this has not been relieving her pain at all. Possible drugs were listed for us: They also told us to combine with ketanal, analgin, diclaberl.Nothing specific – according to the situation, see how it works. During the week, we experimented with new drugs, in different combinations and at different intervals. There is no particular effect, except that my mother vomits after nalbuphine and all the time feels sick from everyone else – dexalgin and akkpan, heartburn and a feeling of nausea, drowsiness appeared. Mom has two types of pain. She cannot lie down, cannot relax her body and sleep due to the fact that after a couple of minutes in the supine position there are severe pains in the bones of the pelvis, arms, spine.As a result, my mother is forced to sit almost all the time, we cover her with pillows and she dozes like that from time to time. Since she is immobilized and cannot move in any way, her whole body aches, breaks and twists, such an itchy pain, not strong, but very tiring, depressing both physically and mentally. The second type of pain is pain in the pelvis and legs, arm. There is an acute pain, burning and piercing, with the slightest movement, and after it there is a painful sensation of anxiety, aching, tugging at the muscles, like a current pierces along the bones and muscles.Added to this is the tiredness of not being able to sleep. There is no constipation, my mother is taking bisacodyl, with great difficulties we put her on the toilet until everything goes well. Until recently, the gastrointestinal tract also worked very well, now, after a week of nalbuphine, nausea, a feeling of intoxication, as during pregnancy, to smells, food, and drink, an acute gag reflex appeared. We managed to get a few 3pcs of tramadol ampoules. We tried to anesthetize him for a day. Only tramadol was injected at 10 pm. Mom slept all night. Of course, in fits and starts, they laid her down, then sat down, but she slept and in the morning felt rested, the mood was good, there were no side sensations, nothing but tramadol was injected.The next time they injected at 10 am, the third ampoule again at 10 pm. The pains did not go away at all, but the general physical condition was much better, the mood was good, did not vomit, did not vomit, the sharp pains in the bones were dulled. But tramadol is over, there is nowhere to buy it, or rather there is no recipe. I went to the district oncologist, asked for a prescription for tramadol. Clearly, no one could explain anything to me, except that no one prescribes tramadol in Ukraine .. The doctor began to offer all the same nalbuphine, dexolgin, also suggested transferring my mother to omnopon – 1 ampoule divided into three parts in combination with dexalgin and diphenhydramine…. He said on Monday to come up so that he would give a referral to receive an omnopon. Today we managed to buy three packs of tramadol tablets. And here’s the actual question I read here on the forum more than once that omnopon is a highly toxic drug from it, there are many side effects, the body’s reaction is stronger. Moreover, I read about how to determine the degree of pain. And apparently, my mother is clearly not yet at the stage when she needs morphines. She is adequate, she is an optimist, she is in quite a good mood when she sleeps and the pain is somehow dulled, her internal organs work quite well…. And now I have nalbuphine, there are three packs of tramadol in tablets, there is declaberl, dexalgin, akkpan Can you advise how to choose the optimal pain relief without running ahead and transferring my mother ahead of time to stronger drugs, oppressing her personality, the possibility of still being with us an adequate person. Thank you very much for your reply and consultation, and the opportunity to receive it. I am also worried about how to properly give tramadol in tablets after what time, how many tablets I have only the thought of where to get this tramadol in my head. I really need something to advise me…. I forgot to write that the second hand began to hurt today. At 5 pm they gave a capsule of tramadol, 50mg, they saw that during these few hours my mother immediately came to life, began to move less stiffly, she was even able to change to a gurney with our help herself. We decided to give tramadol according to the instructions every 6 hours. What to drink in order to reduce side effects, Karsil? It is very difficult to get tramadol. We were frightened by the fact that tramadol very quickly develops a terrible drug addiction, how can this affect? Mirta, excuse me for interfering with your topic, I sympathize with you very much, it’s not without purpose here.But if you want to get a scheme and answers on drugs from Dr. answers to which he simply cannot help you.Therefore, in order not to waste precious time, I will copy them here. Good luck and patience. Just in case, here is a list of questions that must be answered in detail and accurately: Accurate information on the diagnosis, how it was proven, how it was treated. All the latest research methods are clinical and biochemical blood tests, general urine analysis, ultrasound, chest x-ray, ECG. Age, weight, consciousness, physical activity, concomitant diseases, allergic reactions, pressure, pulse. If there is pain, where does it hurt, where does it give away? The nature of the pain presses, whines, burns, etc.What, besides pain, worries about shortness of breath, constipation, urinary disorders, etc. What drugs generally get the name, dosage, effect? Primary tumor – biopsy – carcinoma in the breast, mastocomia of the right breast. Bone metastases – according to the results of MRI, bone scan, x-ray. Treatment – zometa, once a month. Now, according to the last examinations in November, there was a diagnosis – multiple metostasis in all bones. The irradiation was stopped due to the opposite effect, the pain began to intensify, and not go away, as before.No further treatment was prescribed, only pain relief and palliative measures. According to the analyzes, I can’t say anything concretely, they remained in the card in the oncology center, they are not given out. I can only say in general that the last months. The urine analysis is good according to the doctor, ultrasound was done only of the internal organs back in November, all organs were in good condition without metastases, the ecg was the same good analysis, the x-ray was done only on the arms and shoulder, where the very first lesion was, on the last x-ray it began to be visualized distorted bone, the doctor noted that the bone recovered a little, before that there was just a dark spot.We wanted to do an x-ray of the pelvic bones and chest, MRI, and other examinations, but the doctor did not consider it necessary, and the mother’s condition became acute, she cannot move or lie down .. Parallel aching pain, like after swollen legs or after training – they whine muscles throughout the body. There is an involuntary muscle contraction, twitching, lumbago in different parts of the body. There is a burning sensation in the legs.If the mother takes a horizontal position and tries to stretch her legs, then after a couple of minutes she begins to whine and shoot in the coccyx, pelvis, knees, muscles on her legs ache.A few days ago, the right hand also began to hurt, sharp lumbago when trying to raise the hand. Well, the general state of fatigue and weakness of the whole body from immobility. Mom cannot stand, cannot move her left hand, and the left legs are worse, the right ones are better, she can only move her arms very slowly so that she can move a little. 5. Constipation – uses bisacodyl – candles, helps. Several times, on the contrary, there was diarrhea, but not much. Nausea, vomiting not often, were on nalbuphine. Fatigue, depression were on nalbuphine, on tramadol it was released, the mood was quite good, no side effects were observed.Heartburn, belching, gas, swelling of the legs is not strong, but in the evening they swell from sitting, we somehow cope with all this in different ways. The first week after the irradiation was interrupted, while the mother was irradiated, she was on diclaberel, ketonal, analgin-diphenhydramine, nimesil tried all these drugs, they stopped working altogether, zero effect. The second week, we tried akkpan, did not relieve the pain at all, caused lethargy. Nalbuphine was combined with dexagin, declaberl, the effect is the same. Nalbuphine causes depression, lethargy, vomiting and nausea, mom says she hears voices like in a trumpet with an echo.Sleepiness, but cannot sleep due to the fact that he cannot take a comfortable position, is tense all the time. We tried the tramadol injection, it had a good effect, injected at 10 pm, my mother slept all night, it is clear that with waking up, shifting, etc. Now my mother has been taking from yesterday March 24 4 tablets of 50 mg of tramadol with an interval of 6 hours, omeprazole 2 times a day for 1st capsule, bisacodyl put a candle yesterday, there was mild diarrhea, urge, and water came out with black feces, went to the toilet once a day.So far, everything seems to be good on the tramadol. Omeprazole 2 capsules a day, bisacodyl as needed, suppositories, furasemide as needed in the evening. The doctor advised sonatas – sleeping pills for the night, but we did not give them, because we do not know if it is possible with tramadol, and how can my mother sleep without it without problems when the pain subsides. Due to problems with obtaining tramadol, the doctor suggests omnopon, divide the ampoule into three parts and inject three times a day with diphenhydramine, alternate with nalbuphine and dexagin. The effect is so far only visible from tramadol.Last edited by MirtaGroffman, All research methods will have to be taken from the map or new ones if you really want professional advice. In a biochemical blood test, indicators of potassium, sodium, calcium are mandatory. How common is stool? Nalbuphine is not used to treat chronic pain. For now, leave tramadol tramadol at 50 mg by the hour or tramal retard at mg Omnopon is absolutely not needed, diphenhydramine too. I do not understand yet why omeprazole, furosemide? If you have a good sleep on the background of the tram, sleeping pills are not needed.Please write if you could open the PDF document and see. Mark Azraelivich, such symptoms still appeared, my mother’s leg began to swell, the one that hurts more in the pelvis and knee, the left one. Should you drink furosimide? Also about sonatas – for insomnia. The second night I give my mom 1 tablet to drink before going to bed, she sleeps with him almost all night, but I don’t know if it is possible with tramadol? It’s just that she sleeps on tramadol, but all the time she needs to be shifted every 15 minutes because she is numb and aching in the joints.Bisacodyl, we have candles, but there are pills .. If a candle is not put on every day, but at least once a day, then it works adequately – there is an urge to stool and a chair. But if more often it causes diarrhea. Advise how and what is best. There are no analyzes on your link. Until I understand what the edema is connected with, until there are tests, including potassium, sodium, blood calcium, etc. Sleeping pills are possible, if really indicated. Tablets or suppositories, no difference. The main thing is that the chair was at least 1 time in 3 days. Mark Azraelievich, rewrote all the results that were sent to me from the laboratory.Calcium is a unit of measure. But it looks like it has been promoted. When was Zometa last administered? I did not understand what is the indicator of potassium. I wrote about my mother in the topic ‘help me choose an anesthesia regimen’. They seem to have decided on anesthesia until tramadol .. There was a problem and we do not know what to do. Two days ago, my mother complained that it was difficult to write, I noticed a slight acetone odor from the mouth, a decrease in appetite .. This morning I had vomiting several times, then in the evening again, with water and something very sour, according to my mother, I put a candle in the afternoon bisacodyl, tramadol every 6 hours…. By the evening, it became bad – she could not pee at all, although she had a very strong urge, constantly, she had not been writing for hours, nausea, nausea, the smell of acetone from the mouth, very dry mouth, the pressure was high for her by 94, they called an ambulance, they offered to take put a catheter in urology, her oncologist said to inject dexamethasone and noshpa, so they sent my father to the pharmacy for them, what else can be done now? Where can I go with my illness? Send by email. Search this thread: Page 1 of 3. Search this thread.Find all posts by MirtaGroffman. Find all posts by nat Find all posts by vmark. Print version Send by e-mail. Linear View Combined View Tree View. Your rights in the section. You cannot post topics You cannot reply to messages You cannot attach files You cannot edit posts BB codes On.
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bid.How to eat if you go to the toilet more than once a month 1 rate. How much Novopassit in the mixture can you drink at one time in order to fall asleep without causing harm to your health? What could it be? Category leaders Anton Vladimirovich Artificial Intelligence. Mikhail Uzhov Artificial Intelligence. Can tramadol and diphenhydramine be combined? LazyDemon Master, closed 2 years ago I think everything is clear from the question, but I will explain in more detail: And to such a state that he could not move her and did not feel any external influences, but periodically several times a day he grabbed his leg and his father felt wild pain.About two weeks ago, he still fell on crutches and broke the same leg. My leg began to hurt more, pain-relieving injections do not help. Previously, a tramadol injection a day was enough for my father. Now he puts in four – it doesn’t help. And now the question: Thank you, of course, but phenazepam will definitely not help him. He has such pains. It doesn’t look like drug addiction – when the leg doesn’t hurt, the father feels great. And the whole effect of drugs is enough only to dull the pain a little. Convallaria Student 5 years ago diphenhydramine enhances the action of analgin, ketorol, and tramadol itself is a strong drug, only promedol and morphine are cooler, try something soothing like phenazepam at least at night.Andrey Enyutin Artificial Intelligence 5 years ago your dad was just a drug addict. Denis, psychiatrist-narcologist Master 5 years ago Not possible, but necessary. We are constantly adding new functionality to the main project interface. Unfortunately, old browsers are not able to work well with modern software products. For correct operation, use the latest versions of Chrome, Mozilla Firefox, Opera, Internet Explorer 9 browsers or install the Amigo browser.
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“With tramadol, I ride like a Jaguar”: a qualitative study of motivations for non-medical purpose tramadol use among commercial vehicle operators in Kumasi, Ghana | Substance Abuse Treatment, Prevention, and Policy

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“I wanted her to rest a little” The Russian doctor tried to relieve the patient of pain. For this he was accused of selling drugs: Society: Russia: Lenta.ru

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