Why is it that after 50 years of research there is no better opioid than morphine?

[James]

If you have ever seen a decent Tramadol overdose you will never prescribe it. They fit, fit some some, then continue fitting until the end of your shift. Sometimes they are still fitting the next day when you come on shift again.

[andy2]

if we used the effects of overdose as the guide as to what to prescribe then one would never prescribe paracetamol, Tri-cyclic anti-depressants, methotrexate, or infact many other commonly used and effective drugs contained in the BNF - all of the above named drugs are excellent in their place, but all can kill you in very nasty ways.

Tramadol has its place, although the serotinergic and adrenergic effects do lead to disproportionate levels of confusion in the elderly. The evidence for tramadol in neuropathic pain is not great, although it works better than placebo there is little comparative work (i.e. is it better than morphine, or morphine plus adjuvants, which is the real question which needs answering). Tramadol is a weak opioid, not a strong opioid and certainly could not replace morphine or fentanyl in most acute post-operative pain situations (other than day surgery when strong opioids are seldom prescribed). In addition if one looks comparative efficacy tramadol is less effective than codine/paracetamol (60mg/1G) - although it is less constipating.

As with all drugs you need to know the side effect profile and the comparative utility. It is useful to have a range of medications at your disposal so that you can choose the right one for the right patient -and be able to modify your therapy if required. As a house officer/FY1 its worth having a few drugs you know really well, but as you get more senior (and build on your pharmacology knowledge) you should be able to expand your repertoire. I would always caution against the advice of someone who claims 'this is the best drug for X', or anyone who says 'never use Y' - rigid dogmatism is seldom helpful.