A Country Doctor Writes:

My Swedish morning paper had an article about the increased use of tramadol by criminal gang members. When an investigator asked if there was anything special about tramadol, she was again and again told that this drug made it easier to commit crimes. Maria Almazidou, quoted in the article, said “the chemical has a double effect. You can get turned on and feel more focused, while at the same time it blunts your emotions. That is one reason it fits in with the criminal lifestyle”.

I was intrigued, but not surprised. After all, tramadol hits the opioid mu receptor and also has serotonergic properties, making it reduce anxiety as well as blunting affect.

Although I don’t think I have come across tramadol addiction here, I realize its potential to destabilize mood in bipolar disorder. I have seen florid psychosis and tremors in combination with duloxetine. But have never seen it cause full blown serotonin syndrome.

There are many case reports and news articles, like this one, of people with tramadol addiction and overdoses committing violent crimes. But then, there are also FDA black box warnings about traditional serotonergic drugs causing suicidal ideation.

I started looking for more information on the link between tramadol and murders. The connections are all there, in many countries.

First of all, it is a more common drug of abuse in many countries, especially in Africa, and as such, the trade of it is linked with crime. But its use by criminals to enhance their unscrupulousness is actually well documented.

Here are some quotes I ran across:

“Tramadol is regularly found in the pockets of suspects arrested for terrorism in the Sahel, or who have committed suicidal attacks.” – The United Nations Office of Drugs and Crime

AP NEWS writes:

“One woman said children stumble down the streets, high on the opioid; parents add it to tea to dull the ache of hunger. Nigerian officials said at a United Nations meeting on tramadol trafficking that the number of people there living with addiction is now far higher than the number with AIDS or HIV.

Tramadol is so pervasive in Cameroon scientists a few years ago believed they’d discovered a natural version in tree roots. But it was not natural at all: Farmers bought pills and fed them to their cattle to ward off the effects of debilitating heat. Their waste contaminated the soil, and the chemical seeped into the trees.

Police began finding pills on terrorists, who traffic it to fund their networks and take it to bolster their capacity for violence.”

So, by now I have even more respect than I used to for the dark side of this unique (next to tapentadol/Nucynta) analgesic and all other drugs that work on so many neuroreceptors at the same time.

The World Health Organization has a comprehensive summary on Tramadol here.

Last year I saw an elderly man with mild peripheral neuropathy that had not been evaluated before. He was not a diabetic. I ran some basic tests and his vitamin B-12 level was extremely low. We started him on injections and monitored his response. He needed the injection every two weeks to stay in range. He said he felt better.

Recently, he saw a very respected neurologist for something unrelated. The in-depth report stated that the patient had undergone no testing for his peripheral neuropathy and the neurologist ordered a very extensive, undoubtedly expensive, set of bloodwork, part of which was eventually denied by the man’s health insurance. All of those tests were normal, starting with the first one on his list – an RPR test for syphilis.

This illustrates what I see as a fundamental issue in the practice of medicine, not often talked about: How far do you take the workup for mild, common symptoms?

In my 42 years in medicine I have never heard of a single case of syphilis (even before I stopped testing for it) in any patient I or a colleague saw, for example. But there it is, a recommendation passed down from the days of the Wassermann test (1906) and Portnoy’s RPR (1963). The incidence in Maine (1 million people) is reported to be about 50 cases per year. How likely is my octogenarian with mildly tingly toes one of them? Especially if we already know his B-12 was extremely low?

The syphilis test probably doesn’t cost much, but it is a fair illustration of consideration of probability. That is happening in some areas where the unreliability of testing is perhaps more accepted: Cardiac tests have different accuracy depending on pretest probability. Why have we forgotten that blood tests are also fraught with sensitivity and specificity problems that make them less useful in low probability clinical scenarios?

Maybe it’s the Swede in me, but my thinking is that healthcare spending cannot be limitless and needs to match the risk of the clinical situation.

When I trained, we didn’t compete about who could come up with the greatest number of esoteric differential diagnoses. There was more emphasis of what was common and what were the most dangerous and significant pitfalls in diagnosis.

We now have the insurance companies curtailing our workups, albeit often for profit reasons. Wouldn’t it have been better if we as diagnosticians practiced more stewardship and common sense in ordering tests?

Nora Lippmann was a new patient. She was only 52, but she had a large dossier of old medical records from multiple contacts with many kinds of medical providers.

Our first visit was fairly brief, accelerated in my schedule because she was running out of some of her medications. She had moved to this area after an episode of domestic violence downstate.

Her prescription needs were fairly straightforward, but as she had already run out of her blood pressure medication, it was hard to know if that was the right one at the right dose.

She mentioned she had been to the emergency room a couple of days earlier. I pulled up the report from Maine Health InfoNet. She had gone there for tingling of the left side of her face. It was all better by the time she was evaluated. Her neurological exam was normal and she was discharged without a diagnosis.

Our visit was a little scattered, but I did a quick physical exam. She had a very loud bruit in her right carotid artery. I felt a chill in my spine. She had had a transient ischemic attack, and that was one of the loudest carotid bruits I’ve ever heard. What if she had a critical carotid artery stenosis?

I now know she appears to have just that. Her ultrasound showed a “greater than 70% to near total occlusion” of her right Internal carotid artery. She needs a CT angiogram of her carotid arteries ASAP.

I routinely listen to carotid arteries, although the current US Public Health Service Taskforce on Prevention doesn’t recommend it. So maybe it is no surprise nobody had listened for bruits and caught this whopper before I did, but when somebody has a possible TIA, it should be standard operating procedure to listen for bruits.

More than a decade ago, I confessed to not picking up a critical carotid artery stenosis until the third visit of a new patient without symptoms. It all ended happily, but I still remember how humbled I was when I realized I almost missed it.

A Quick Listen

“Can I run a case by you”, my younger colleague asked.

“Certainly”, was my obvious answer.

She proceeded to tell me about a patient who had been to the emergency room recently with abdominal pain, jaundice, profound fatigue and itching. Her liver enzymes were elevated but her imaging did not show anything abnormal, from the appearance of her liver to her gallbladder, bile ducts, pancreas and everything else.

My colleague saw the patient in follow up and all the hepatitis and mononucleosis tests from the emergency room had come back negative.

She asked “What do you think this could be?”

“Well they checked for all the usual things“, I said and started googling on my laptop. “I have an idea.“

I soon found what I wanted, and said “I’m printing an article. This is something I learned about not all that long ago, but it made a big impression on me.“

The printer rattled behind me and my phone rang. It was a specialist at Cityside needing to talk to me. I said to my colleague “read this and see what you think”.

After I finished my call I went down to her office. Her nurse exclaimed as I walked through the door “you’re a genius”.

Sally was reading the article I had printed about G.I. manifestations of tickborne diseases. “It fits”, she said as she ticked (Sorry, but love puns…) off all her patient’s symptoms from the table in the article.

I told her about the lesson I learned from Dr. Kim about anaplasmosis and very soon afterward was able to share with a young colleague. It still isn’t that well known a disease, but its incidence in Maine is increasing dramatically.

So Sally softend her nurse’s compliment and said “experience counts“. I don’t deserve to be called a genius, but I do like being recognized as experienced. After all, it’s been 42 years since I graduated from medical school.

A Lesson Learned