Author Affiliation James Dunford, MD University of California San Diego, School of Medicine, San Diego, California; McAlister Institute for Treatment and Education, El Cajon, California Aaron Schneir, MD University of California San Diego Health System, Department of Emergency Medicine, Division of Medical Toxicology, San Diego, California

 

We are writing in regard to the following article in the current issue of CAL/ACEP’s Lifeline Volume 4, 2022–23, which was first published in Clinical Practice and Cases in Emergency Medicine in 2022.
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In the report, the authors describe an opioid-dependent patient who was initially prescribed tramadol by her primary care physician but who ultimately began traveling to Mexico to purchase escalating doses of tramadol. The authors appropriately highlight the potential nuances of managing tramadol withdrawal versus that from pure opioid agonists. It is certainly possible that the patient was exclusively ingesting tramadol and that buprenorphine was successful in managing the withdrawal from it.

However, we feel obligated to point out a major limitation: that at least as described in the report, there was not testing of the tramadol product she obtained from Mexico nor of the patient to confirm the presence of tramadol and exclude the presence of other opioids such as fentanyl. There is increasing recognition that counterfeit tablets sold ostensibly as controlled substances in Northern Mexican pharmacies may in fact contain illicit drugs such as fentanyl and heroin.
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Before this case report continues to be cited as evidence of the successful management of tramadol dependence with buprenorphine, we feel this limitation should be recognized.

Thank you.

Footnotes

Section Editor: Rick Alan McPheeters, DO

Full text available through open access at http://escholarship.org/uc/uciem_cpcem

Address for Correspondence: James Dunford, MD, 1986 Linwood Street, San Diego, CA 92110. Email: jdunford@ucsd.edu
8:80 – 80

Submission history: Revision received October 13, 2023; Submitted October 17, 2023; Accepted November 21, 2023

Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

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