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Hindawi Journal of Addiction Volume 2017, Article ID 6716929, 9 pages https://doi.org/10.1155/2017/6716929 Research Article High Rates of Tramadol Use among Treatment-Seeking Adolescents in Malmö, Sweden: A Study of Hair Analysis of Nonmedical Prescription Opioid Use Martin O. Olsson,1 Agneta Öjehagen,1 Louise Brådvik,1 Robert Kronstrand,2,3 and Anders Håkansson1 1 Psychiatry, Department of Clinical Sciences, Lund, Faculty of Medicine, Lund University, 221 00 Lund, Sweden 2Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linkoping,¨ Sweden 3Division of Drug Research, Linkoping¨ University, 581 85 Linkoping,¨ Sweden Correspondence should be addressed to Martin O. Olsson; martin [email protected] Received 21 September 2017; Accepted 6 December 2017; Published 24 December 2017 Academic Editor: Leandro F. Vendruscolo Copyright © 2017 Martin O. Olsson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Nonmedical prescription opioid use (NMPOU) is a growing problem and tramadol has been suggested as an emerging problem in young treatment-seeking individuals. The aim of the present study was to investigate, through hair analysis, NMPOU in this group and, specifically, tramadol use. Methods. In a study including 73 treatment-seeking adolescents and young adults at an outpatient facility for young substance users, hair specimens could be obtained from 59 subjects. Data were extracted on sociodemographic background variables and psychiatric diagnoses through MINI interviews. Results. In hair analysis, tramadol was by far the most prevalent opioid detected. Thirty-two percent screened positive for opioids, and of those, all but one were positive for tramadol. Ninety-eight percent reported problematic cannabis use. Significantly more opioid-positive patients also screened positive for other (noncannabis) drugs, compared to nonopioid users. Sixty-four percent fulfilled criteria of DSM-IV psychiatric disorders, other than substance use disorders according to MINI. Fifty-three percent met the symptom criteria count of ADHD above cut-off level. Conclusion. In the present setting, tramadol, along with high rates of cannabis use, may represent a novel pattern of substance use among young treatment-seeking subjects with problematic substance use and high rates of concurrent psychiatric problems. 1. Introduction Tramadol, classified as a weak opioid, with an analgesic effect similar to that of codeine, has evoked increasing Nonmedical prescription opioid use (NMPOU) is defined concern for the risk of developing tramadol dependence as the consumption of an opioid medication that is not [5–7] and a risk of serious adverse reactions, including prescribed to a user or is consumed in a manner not intended epileptic seizures and fatal intoxications [8–12]. The question by the prescriber (such as tampering, snorting, or injecting). of tramadol misuse has been addressed in the Middle East A substantial increase in the use and abuse of prescription and Africa [13–16], as a problem drug among adolescents and drugs has been noted during the past two decades in the US young adults. In many settings, such as the one studied here, [1] and in the European Union [2, 3]. Zozel and colleagues [4] cannabis is still the most frequently used illicit drug among investigated more than 16,000 identified cases of adolescent adolescents both in population-based surveys [17, 18] and (age 13–19 years) prescription drug abuse in the US between in treatment-seeking samples [19], and tramadol, although 2007 and 2009, where the most frequent opioids were primarily a prescription drug, has been described to be asso- hydrocodone (32%), oxycodone (15%), and tramadol (11%). ciated with more traditional illicit drugs, including cannabis 2 Journal of Addiction [14]. In Europe, on the other hand, data from the UK have parents and relatives. The facility has an upper age limit of 25 associated tramadol misuse with risk-taking behavior rather years, without any formal lower age limit, although patients than with marginalization and other addictive disorders [20]. are almost exclusively aged 13 or above. In Sweden, Richert and Johnson [21] investigated the illicit use of buprenorphine and methadone among adolescents 2.2. Study Population. Patients were recruited to the facility and young adults and concluded that benzodiazepines and from October 1, 2012, to December 31, 2013, taking part tramadol were used by adolescents to a far greater extent, in an RCT assessing the potential effects of an Interactive indicating that tramadol misuse may have increased during Voice Response with automated personalized feedback on the past few years. Data from police authorities in Sweden treatment retention and clinical improvement in treatment have shown that tramadol is the second most common [33]. seized pharmaceutical drug on the drug scene nationwide in During the study period from October 2012 to December Sweden [22] which lends support to the assumption that the 2013, 367 patients (30% women) were referred to or applied tramadol used in this milieu comes from other sources than for treatment at Maria Malmo.¨ The inclusion procedure is prescription. presented in Figure 1. Out of 235 patients potentially eligible In addition, Tjaderborn¨ et al. [23] found that tramadol for the study, 73 patients entered the RCT study, while 158 wasthethirdmostcommonpharmaceuticaldrugamong either were not approached for study recruitment or did not young drug-impaired drivers with mixed substance use, participate. Thus, only 20% of all subjects referred to the intoxicated with nonprescribed drugs. facility were included. In order to test the representability Like substance use in general, NMPOU has been of our sample, we performed comparisons between our described to be associated with psychiatric symptoms [3, participants and subjects not included in our study and found 24,25],and,specifically,ithasbeendemonstratedthata no significant differences with respect to gender or the type large proportion of tramadol misusers in Egypt [26] had a of facility from which they had been referred. In addition, psychiatric comorbidity. we also performed a comparison with all subjects applying An objective way of investigating a drug use history is for treatment the entire following year (2014), which did through hair analysis. Drugs circulating in the bloodstream not demonstrate any significant differences with respect to are trapped in the forming hair when it keratinizes and gender, criminal convictions, and primary drug of abuse. thus produces a temporal map of a person’s drug use [27]. Out of 73 patients included in the study, 14 patients did Over the years, several applications have been approved for not provide a hair specimen. The analysis is therefore based hair analysis in both forensic and clinical work [28–30]. on 59 correctly obtained hair specimens. An attrition analysis The analysis of opiates and opioids in hair is of particular showed that, among patients with missing baseline hair interest since it may reveal a period of abstinence prior to fatal analyses, all 14 (100%) were male, and a higher proportion, intoxication suggesting lowered tolerance [31], but it has also 10 out of 14 (71%), reported problematic opioid use compared been used to investigate compliance in medication showing to included patients (21 out of 59, 36%, = 0.019). However, underreporting of opioid intake in general and especially excluded subjects did not differ significantly with respect to tramadol [32]. age, criminal involvement, MINI psychiatric disorders, or In the present analyses, based on a sample from a ADHD symptom screen. treatment study [33], the first aim was to determine the prevalence of NMPOU, including tramadol, and other sub- 2.3. Assessment. All patients entering the study were assessed stances, through drug screening in hair, in treatment-seeking by the staff at the clinic (nurses, social workers) according adolescents and young adults. A second aim was to provide to standard procedures at the clinic, including the interview a description of prescription opioid users, with special ref- instrument Ung-DOK [34], which is used in Sweden at juve- erence to use and misuse of other substances, psychiatric nile detention institutions, residential treatment centers, and comorbidity, and sociodemographic data. A third aim was outpatient facilities for young patients with substance use. tofindoutwhetheropioidsfoundinhairanalysiswerealso The assessment includes questions on sociodemographic fac- reported as the problem drug to be addressed in treatment. tors, self-reported substance use patterns, and self-reported psychiatric symptoms. All patients entering the study had 2. Materials and Methods been given information on hair analysis in the patient information and in the form for written consent. 2.1. Clinical Setting. Maria Malmoisanoutpatienttreatment¨ In order to describe the sample, we used data from facility for adolescents and young adults with substance use the Ung-DOK questionnaire for sociodemographic variables, disorders and problematic substance use in Malmo,¨ Sweden. such as sex, age, ethnicity (parents born outside Sweden), The clinic serves the city of Malmoaswellassuburbanand¨ criminality (convicted for crime), crime victimization, and rural areas surrounding the metropolitan

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