Is it possible to use analgesics containing opioid derivatives (eg tramadol) in children and adolescents with severe post-traumatic pain or toothache, if paracetamol and non-steroidal anti-inflammatory drugs are ineffective? Which preparations to choose and how to dose them?

He answered Dr. med. Janusz Ziółkowski Clinic of Anesthesiology and Intensive Pediatric Therapy Warsaw Medical University.

According to the principles of pain management, in the case of ineffectiveness of first-line painkillers, a stronger drug should be used. The guidelines of the World Health Organization (WHO) regarding the treatment of cancer pain (the so-called analgesic ladder) are also used in the treatment of other pain syndromes. According to these guidelines, in the case of ineffectiveness of drugs from the first step of the ladder (NSAID, paracetamol), the treatment should be started a higher degree. We have, above all, tramadol and codeine. Both tramadol (in every form) and codeine (if it is a component of the combined preparation) are available without special prescriptions. Ready combinations of paracetamol with codeine (in analgesic doses, not used for colds, eg 500 mg paracetamol + 30 mg codeine) are strong and good preparations in the treatment of pain, including acute and post-traumatic pain. For acute pain, the dose and formulation should be chosen such that a single dose of codeine is 0.75-1.0 mg / kg.

Both tramadol and paracetamol show only a residual anti-inflammatory effect, which is why, for example, after breaking or extraction of the tooth, their action may be weaker than expected. Tramadol has a complex action mediated by opioid receptors and neuronal NMDA receptors (N-methyl-D-aspartate) that activate the antinociceptive system. When prescribing a painkiller, one should always consider the mechanism of pain and, if the inflammatory component is significant, attach NSAIDs according to the principles of combining drugs with different mechanisms of action. The choice of tramadol preparations (including in combination with other analgesics) is high. It must be remembered that both codeine and tramadol can not be combined with alcohol. Some patients may be able to tolerate side effects of tramadol, such as general breakdown, dizziness and nausea. Persistent severe pain (despite the use of NSAIDs and paracetamol in full doses) after tooth extraction or fracture should be a signal for medical supervision. Severe complicated fractures and extensive extractions usually require hospital treatment, where the scope of analgesic intervention is wider than in PE conditions. Situations when the POZ doctor is forced to reach for codeine or tramadol are unique and should be thoroughly analyzed.

When recommending a specific preparation, several rules should be followed:

  • we choose a drug that we know well;
  • we use the drug in accordance with its registration (information contained in the registration materials and the SPC often differ significantly for individual preparations, e.g. in the dose range and the lower age limit at which the drug can be used);
  • we follow the dosage rules for a given preparation or we are looking for such a preparation that will allow us to give you the planned dose.