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Tramadol Abuse Potential and Addiction Treatment Options
Tramadol is a synthetic opioid medication prescribed to treat pain.1 As the rate of abuse of prescription opioids has increased, so have rates of dependency and overdose. Taking tramadol in larger amounts or for longer than prescribed, or using the drug in combination with other drugs or alcohol can lead to serious health consequences such as addiction or, even worse, death. When stopping or cutting down on tramadol use, an individual may experience withdrawal symptoms such as anxiety, depression, insomnia, and nausea. Tramadol withdrawal may be best managed in a supervised detox setting where any medical complications that arise may be immediately addressed. Read on to learn more about the drug’s effects and risk for dependence.
What Is Tramadol?
Tramadol is a somewhat atypical opioid pain medication used to treat moderate to moderately severe pain. As an opioid agonist drug, tramadol’s potency is estimated to be 1/10 that of morphine.2 In addition to its opioid effects, tramadol has some activity as a norepinephrine and serotonin reuptake inhibitor. In the U.S., tramadol is available under the following brand names:3
Tramadol was first used to treat post-operative pain in Germany during the 1970s.3 In 1994, it was approved for medical use in the U.K. and, in 1995, it was approved by the FDA for use in the United States.1
Originally, it was believed that the risk for dependency and addiction to tramadol was low, but recent data suggest that abuse of the drug is on the rise. In 2016, nearly 19 million people aged 12 or older reported using tramadol in the past year and more than 1.5 million reported misuse of the drug in the past year.4
How Does It Work?
Tramadol, in addition to activating our brain’s opioid receptors like many other prescription painkillers, interacts with the serotonin and norepinephrine neurotransmitter systems via a mechanism similar to that of some antidepressant medications.5 Besides pain relief, people who take tramadol may experience a pleasant rush of euphoria, for which the drug is sometimes abused.
What Are the Side Effects?
Even when used as prescribed, tramadol may have a number of potentially serious side effects. It is important to be aware of these effects and any health conditions, such as COPD or asthma, that may be exacerbated by tramadol use. When used by pregnant women, tramadol can pass from the mother to the fetus, and traces of the drug can be found in breast milk.5
Side effects and their severity vary depending on the user, specific tramadol medication, and the dose taken. In general, side effects of tramadol products include:1,6
- Abdominal pain.
- Changes in blood pressure.
- Dry mouth.
- Respiratory depression.
As tramadol use results in some norepinephrine and serotonin reuptake inhibition in the brain, its side effects profile differs somewhat from many of the more typical prescription opioids, such as hydrocodone and oxycodone. This is especially true if the medication is taken in combination with other drugs that affect the same neurotransmitter systems (e.g., several classes of antidepressant medications such as SSRIs, SNRIs, tricyclics, MAO inhibitors, etc.).
Tramadol risks related to these pharmacologic properties include seizures and what’s known as serotonin syndrome, a potentially life-threatening condition. If you experience any of the following possible side effects after using a tramadol product, call for emergency help immediately:6
- Extreme agitation
- Racing pulse
- Changes in blood pressure
- High body temperature
- Stiff muscles
- Severe nausea, vomiting, diarrhea
Although tramadol has lower potential for abuse compared to some other prescription opioids, it still carries a risk. An increasing number of reports have linked tramadol use to overdose, as well as to the aforementioned serotonin syndrome, which can be fatal.5
Can It Improve Sexual Functioning?
Though it was developed as a pain reliever, tramadol is sometimes used off-label to help prevent premature ejaculation (PE) in men.
Because of these off-label sexual effects, some men may use the drug without a prescription to last longer in bed.In a study of 150 sexually active healthy men, researchers found that tramadol was associated with significant improvements in sexual satisfaction and delayed ejaculation. It is still unclear as to how exactly tramadol delays ejaculation, but its involvement with the reuptake of norepinephrine and serotonin in the body may play a role.7
In a 2015 meta-analysis of 8 studies, researchers found that tramadol was significantly more effective at delaying PE compared to paroxetine (Paxil), an antidepressant commonly prescribed to treat PE.8 Tramadol was even more effective than behavioral therapy or other medications traditionally used to treat PE, such as sildenafil (Viagra) or topical anesthetics (lidocaine).
Because of these off-label sexual effects, some men may use the drug without a prescription to last longer in bed. However, tramadol may cause some adverse health effects that would offset this goal, such as nausea, dizziness, vomiting, constipation, breathing difficulties, and even erectile dysfunction.8 If you are using tramadol off-label for sexual purposes, you should speak to your doctor about your drug use to see if there could be any possible health risks that you should know before continuing to use the drug.
Prescription Opioid Abuse in the U.S.
In the U.S., more people are abusing prescription pain relievers each year for their physical or psychological effects. A steep rise in the number of prescriptions written for opioid medications corresponds with a rise in the number of people addicted to opioids and the number of fatal overdoses involving opioids.
In 2012, more than 259 million prescriptions for opioids were written and 1.9 million Americans were addicted to opioids.9 Since 1999, the number of overdose deaths involving opioids (both legal prescription painkillers and illicit drugs like heroin) quadrupled.10 It is estimated that as many as 91 Americans die every day from an opioid overdose.10
In 2011, tramadol was ranked as the 9th most commonly seized narcotic pain reliever by police and Drug Enforcement Administration (DEA) officials.3 Between 2005 and 2011, the number of emergency room visits involving tramadol increased by 250%.3 Due to the increase in tramadol-related overdoses and emergency room visits, in 2014 the DEA placed it as a Schedule IV drug on its controlled substances list.11
Data collected by the Substance Abuse and Mental Health Services Administration (SAMHSA) between 2005 and 2011 showed some interesting disparities in tramadol abuse between genders and people of different age groups. Women were more likely to abuse tramadol than men, and women accounted for the majority of tramadol-related emergency room visits. Among people age 55 or older, hospital visits for tramadol-related incidents increased by 481% from 2005 to 2011. Given the increased risk for accidents and falls among older patients, this increase in abuse rates is concerning.3
Danger of Overdose
Overdosing on any drug can be harmful to the body, but in the case of tramadol an overdose can be potentially fatal. Below are symptoms that could indicate a tramadol overdose:12
- Cold and clammy skin
- Constricted pupils
- Slow heart rate
- Respiratory depression
Some of these symptoms may result in death if untreated. If you suspect that you or someone else has overdosed on tramadol, call 911 immediately.
While it is possible to overdose on tramadol alone, mixing it with other substances can increase your risk of overdose. Some tramadol formulations (Ultracet and generic combination) contain acetaminophen, which may place the user at additional overdose risk due to acetaminophen toxicity and liver injury.
Mixing with Other Drugs
Medical professionals who prescribe tramadol will warn patients about the dangers of mixing tramadol with other substances. However, data shows that tramadol prescriptions are often diverted for recreational use or for illegal sale on the street or internet. Evidence suggests these illicit users abuse tramadol along with other drugs and alcohol.
In 2011, only 29% of tramadol-related emergency department visits involved tramadol alone:
- 20% of the visits involved tramadol with 1 other drug.
- 26% involved tramadol with 2 other drugs.
- 26% involved tramadol with 3 or more other drugs.
Mixing tramadol with alcohol, benzos, and/or other opioids is a serious health risk.
The most common substances involved in these emergency visits were alcohol and other pharmaceutical drugs, such as opioid painkillers like oxycodone and hydrocodone, or benzodiazepines commonly used as anti-anxiety and insomnia medications.3
Mixing tramadol with alcohol, benzos, and/or other opioids is a serious health risk. All of these substances depress certain key functions in the central nervous system, especially breathing and heart rate. When used in combination, these drugs can have a compound effect that reduces the user’s rate of breathing and circulation to dangerously, sometimes fatally, low levels.3
Addiction and Dependence
Drug addiction is characterized by a strong, uncontrollable desire to continue taking the drug despite medical or social consequences. When a person suffers from addiction, their life revolves around the drug and taking or finding more of it. An important distinction to make when talking about dependence and tolerance is that they aren’t necessarily synonymous with addiction. For instance, a person who follows their prescribed orders for tramadol for some time may very well develop some tolerance and physiological dependence but not otherwise exhibit the compulsive behaviors associated with addiction.
If a person is taking tramadol for chronic pain, they may develop a tolerance to the drug’s effects and need larger doses in order to achieve the desired effects. Tolerance can develop at different rates and severity depending on the individual user.
Long-term use of an opioid analgesic like tramadol can lead to physical dependence, meaning the body becomes accustomed to the presence of the drug and actually needs the drug in order to feel “normal.” Dependence manifests as withdrawal symptoms if the person abruptly discontinues taking tramadol or significantly reduces their dosage. Physical dependence to tramadol may not occur until after many weeks of continued use.
Anyone can develop a drug dependence, but those with substance abuse issues or a history of addiction face a higher risk.13 While clinical studies show that tramadol withdrawal syndrome is not particularly severe, it is possible for users to experience some uncomfortable symptoms.13
If you are withdrawing from tramadol after extended use, you may experience some or all of the following withdrawal symptoms:12
- Abdominal cramps
- Joint pain
- Nausea and vomiting
- Increased blood pressure
- Increased heart rate
These symptoms can be so uncomfortable you may feel the urge to go back to using the drug just to make them go away, which makes quitting the drug without professional help difficult. In a professional rehab facility, however, you may be given medications to help manage your withdrawal symptoms and increase your chances for success.
Detox and Rehab
Should a person develop a significantly severe tramadol dependence, a supervised medical detox may be the safest start to recovery. Even as an atypical, relatively low-potency opioid, because of the risk of an unpleasant withdrawal syndrome, it’s not recommended that users abruptly stop their use of the drug. Professional detox and treatment programs will help patients taper off the drug slowly while using behavioral therapies to address the root cause of drug abuse.
Tapering is the gradual process of slowly reducing the individual’s daily dose of a drug. This steady reduction, as opposed to an abrupt cessation of the drug, gives the body time to adjust to smaller and smaller amounts of the drug without going into shock. Depending on your level of addiction you might taper in a hospital setting, inpatient detox center, or outpatient detox program.
Your tapering schedule will be determined by a number of factors including how long you used tramadol, how much of the drug you were used to using, your health, your age, any co-occurring mental health issues, and whether you are abusing any other substances in addition to tramadol. In general, your doctor will decrease your dose by 10% each week, but if you have been using opioids for a very long time, your tapering may need to go even slower—perhaps a 10% decrease each month.14 If you are pregnant and tapering off of opioids, your care may need to be coordinated with specialists to minimize the risk to your baby.14
After you have completed detox and you are stabilized, your doctor will refer you to the most appropriate next step for your treatment plan.
A tapering detox schedule will likely be effective for those who abuse tramadol alone. As discussed above, however, many people who abuse tramadol do so in combination with other prescription drugs. For those who are physically dependent on more than one opioid drug, medication-assisted treatment (MAT) may be a more appropriate treatment method.
MAT is an approach that is used to help patients with opioid use disorder manage their withdrawal symptoms, reduce cravings, and prevent relapse during recovery. The following medications may be used as part of a MAT program:15
- Methadone: This is the most widely used medication in treating opioid addiction. When used in prescribed dosages, methadone activates the brain’s opioid receptors enough to manage withdrawal symptoms but not enough to generate the euphoric effects of more commonly abused opioid drugs. There is a potential to misuse methadone, so patients taking this medication must visit a methadone clinic once a day to receive their dose. The effects of methadone can last 4 to 8 hours. People may stay on methadone maintenance therapy for several years depending on their situation. Because methadone itself can lead to dependence, a person will need to taper off slowly when they are ready to stop taking the drug.
- Buprenorphine: This medication also binds to opioid receptors but only partially activates them. This helps reduce cravings and limits the drug’s potential for abuse. Buprenorphine comes as a sublingual tablet or an extended-release implant that lasts for 6 months. It is also available in formulation with naloxone, an opioid antagonist that further reduces the potential for abuse.
- Naltrexone: This is a maintenance drug that is useful in the prevention of relapse. As an opioid antagonist, it blocks other drugs from binding to and activating opioid receptors in the brain. So even if the patient uses an opioid drug, naltrexone will block them from feeling any euphoric or sedative effects of the drug.
Research shows that MAT can successfully help people overcome opioid addiction.15 A study of methadone users found that they were more than 4 times more likely to stay engaged in care, compared to those who were not receiving any medication. But the true effectiveness of MAT lies in the combination of approaches.
Another study found that when medications are used in combination with counseling for more than 6 months, people have significantly better treatment outcomes compared to those who just use methadone without any counseling.16 Despite MAT’s effectiveness, it is not used as often as recommended. For example, in 2014, there were an estimated 2.2 million people dependent on opioids, but fewer than 1 million received MAT.17
There are several types of behavioral therapy commonly used to treat prescription opioid addiction:18
- Individual therapy: No matter how severe your addiction to tramadol is, one of the most effective behavioral therapies is one-on-one therapy with a licensed counselor. You will build a relationship with your therapist and, over time, establish a level of trust so that you feel comfortable sharing what’s going on in your world. Working with a therapist can help you resolve any past trauma, understand your own reasons for abusing tramadol, and learn how to cope with stressful situations or other triggers without relying on drug use. For many people, spending time with a therapist can be extremely healthy and productive.
- Group counseling: Most programs rely on some form of group counseling to capitalize on the power of community and peer support. In your treatment program, you will meet for a facilitated group counseling session on a regular basis. During these sessions, you may discuss a specified topic as a group, or the facilitator may ask each individual to share what they are going through that day or week.
- Family behavioral therapy: Depending on your situation, your family may be a great source of support and strength during your recovery. Everyone has a different relationship with their family, and it’s not always a healthy one. Only you know what is going to be best for you, and if you feel comfortable working with your family, you can look for programs that offer family therapy services.
- Cognitive behavioral therapy (CBT): CBT is becoming increasingly utilized as an addiction treatment strategy. CBT teaches you how identify destructive thought patterns and replace them with new ones that don’t lead you down the path of drug use. After transitioning out of treatment, the tools learned in CBT can be extremely useful, as you can begin noting when you feel most triggered to use tramadol. If you struggle with mental health issues such as anxiety, depression, or PTSD, CBT can also help with noticing what types of situations make you feel anxious or depressed.
Break Free from Addiction
Everyone’s experience with addiction is different, and your experience in rehab and recovery will be individual to your situation. Although it’s common for people in the recovery community to share stories and look to each other for support, try not to compare your journey to another’s. What worked for someone might not work for you, and that’s OK. Most people have to try multiple approaches to overcome addiction, so if things don’t go successfully the first time, don’t be discouraged. Stay hopeful.
- Rajabizadeh, G., Kheradmand, A., Nasirian, M. (2009). Psychosis following Tramadol Withdrawal. Addiction & Health, 1(1), 58–61.
- Leo, R., Narendran, R., DeGuiseppe, B. (2000). Methadone detoxification of tramadol dependence. Journal of substance abuse treatment, 19(3), 297–299.
- Substance Abuse and Mental Health Services Administration. (2015). Emergency Department Visits for Drug Misuse or Abuse Involving the Pain Medication Tramadol.
- Center for Behavioral Health Statistics and Quality. (2017). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD.
- Beakley, B., Kaye, A.M., Kaye, A.D. (2015). Tramadol, pharmacology, side effects, and serotonin syndrome: a review. Pain physician, 18, 395–400.
- U.S. Food and Drug Administration. (2017). CONZIP Medication Guide.
- Khan, A., Rasaily, D. (2013). Tramadol Use in Premature Ejaculation: Daily Versus Sporadic Treatment. Indian Journal of Psychological Medicine, 35(3), 256–259.
- Martyn-St. James, M., Cooper, K., Kaltenthaler, E., et. al. (2015). Tramadol for premature ejaculation: a systematic review and meta-analysis. BMC urology, 15(1), 6.
- National Safety Council. (2016). Prescription Nation 2016 American Drug Epidemic.
- Centers for Disease Control and Prevention. (2017). Understanding the Epidemic.
- U.S. Department of Justice Diversion Control Division. (2014). Schedules of Controlled Substances: Placement of Tramadol Into Schedule IV.
- U.S. Food and Drug Administration. (2017). Ultracet Medication Guide.
- Leo, R., Narendran, R., DeGuiseppe, B. (2000). Methadone detoxification of tramadol dependence. Journal of substance abuse treatment, 19(3), 297–299.
- Centers for Disease Control and Prevention. (n.d.). Pocket Guide: Tapering Opioids for Chronic Pain.
- Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
- National Institute on Drug Abuse. (2017). Research on the Use and Misuse of Fentanyl and Other Synthetic Opioids.
- National Institute on Drug Abuse. (2016). FDA approves six month implant for treatment of opioid dependence.
- Iowa Department of Public Health. (n.d.). Medication Assisted Treatment (MAT).