Tramadol Addiction and Treatment

The Safer Opioid?

Tramadol Addiction and Treatment

The Safer Opioid?

What is Tramadol?

Tramadol is a prescription opioid used to treat moderate to severe pain, such as pain following a surgery or injury. It is often prescribed when other over-the-counter painkillers don’t work and something stronger is needed. This medication works by changing the way that the brain and nervous system respond to pain, causing a feeling of relief and calmness.  Addiction to tramadol may require treatment in a rehab facility.

History

Tramadol was first created in 1962.  It was used in Germany as a painkiller from 1977 onwards. In 1995, it was approved for use by the United States Food and Drug Administration as a non-controlled pain killer under the brand name Ultram. Shortly after its approval, it was discovered that tramadol has addictive properties, and new warnings were put on labels. It wasn’t until 2014, however, that it became a Schedule IV controlled substance.1

Brand Names

ConZip

FusePaq Synapryn

Rybix ODT

Ryzolt

Ultram

Ultram ER

Street Names

Trammies

Chill pills

Ultras

How Many Prescriptions Are Written Every Year?

According to IMS Health (Intercontinental Medical Statistics), 43.6 million tramadol prescriptions were dispensed in the U.S in 2016. In 2017, approximately 41 million prescriptions were dispensed. In the first half of 2018, 16 million prescriptions were accounted for.2

Can You Become Addicted to Tramadol?

Yes, you can! Although it’s thought to be a safer and less addictive opioid than others such as oxycodone, tramadol still poses a risk of addiction. In fact, almost all pain-killers have a risk of addiction when taken in higher quantities than prescribed or when taken in other ways than intended (e.g., crushing, snorting, injecting the drug). Although it is still believed that tramadol has a lower risk of addiction, research shows that it might be more addictive than is typically believed. Tramadol should be taken as prescribed and not for longer than needed in order to minimize the risk of abuse and dependence.

Those who abuse tramadol might take larger doses than prescribed by chewing it, crushing it up and snorting it, or injecting it into their bloodstream. When tramadol is abused, there is a greater risk of developing dependence and becoming addicted. Once dependence occurs, developing a tolerance typically follows, meaning that larger doses are needed to feel the same effects. This leads to a cycle of using more tramadol more frequently to feel the same previous effects.

Where is Tramadol on the Schedule of Drugs?

Tramadol has been classified as a Schedule IV controlled substance by the Drug Enforcement Administration, meaning it has a lower risk of addiction and abuse than Schedule II opioids such as oxycodone. If you believe that you have a higher risk of developing a dependence to a drug, tramadol might be a better option as an opioid for you compared to similar, but more addictive drugs.

Additionally, although it was approved for use by the Food and Drug Administration in 1995, it wasn’t a legally controlled substance until 2014. This means that even though the drug has been classified as having a lower risk of addiction, it can still lead to substance use disorders and thus should be monitored.

One of the rules that applies to legally controlled substances is that prescriptions can only be refilled up to five times within six months since the prescription was written. Afterward, a new prescription is required, meaning that patients have to visit their doctor again in order to monitor whether there is really a need for the drug or whether a dependence  may have developed.

How Big is the Tramadol Abuse Problem in the US?

Although tramadol isn’t abused as often as other more addictive opioids such as oxycodone, it is still sometimes abused, mainly by people with an addiction to narcotics,  chronic pain patients, and health professionals who have easier access to opioids. In 2016, according to the American Association of Poison Control Centers, there were a total of 12,108 tramadol exposures. Of these 12,108 exposures, 5,712 were single substance exposures, and 3 of these exposures resulted in deaths.

According to the National Survey on Drug Use and Health, 1.6 million people in the U.S. over the age of 12 reported abusing tramadol in the past year in 2016.

In 2018, it was reported by the Drug Abuse Warning Network that over 50,000 emergency department visits were due to tramadol use, with the other half of the visits relating to side effects of the drug.3

What Is Tramadol Used For?

It’s typically used to treat moderate to severe pain, such as the pain you might experience from an injury or after surgery. Sometimes it is used for cancer patients and it might also be prescribed when other pain killers are not working or are not strong enough.

How is Tramadol Used?

It comes as an oral tablet in immediate-release and extended-release forms. Immediate-release tablets mean that the effects of the drug are released immediately and felt soon after taking, whereas extended-release tablets work slowly over a longer period. They also come as oral capsules. Pills should be swallowed orally and taken as directed by your physician. Tablets are typically taken with or without food every 4 to 6 hours as needed. The extended-release formulations should be taken once a day at the same time. You should always take your medication exactly as directed by your doctor, don’t take more than has been prescribed.

Immediate-release tablets should not be used in children younger than 17, and extended-release tablets should not be used in children under the age of 18. This is because significant research has not been completed on the safety for children. It has been reported that children who have received tramadol (e.g., after having their tonsils removed) have suffered from severe breathing problems and some have even died.

What Should You Know Before Taking Tramadol?

As with many other prescription pain killers, tramadol might not be suitable for everyone. Before taking this medication, you should tell your doctor if you:

Have had an allergic reaction to tramadol or other medications before

Have suffered from seizures 

A head injury 

Have/had a substance use disorder

Kidney or liver problems 

Had any type of reaction to painkillers before

Also be sure to tell your doctor if you are taking any other medications, particularly for:

Depression

Mental health problems

Pain relief

Help with sleeping

Allergies 

Infections

You should not take this drug if you have asthma or severe breathing or lung problems, if you have a bowel blockage, or if you are allergic to it. If you have taken a monoamine oxidase inhibitor (MAOI – a drug used for depression) in the last 14 days, you should not take tramadol.

Side effects of Tramadol

Some common side effects are:

  • Anxiety
  • Constipation
  • Diarrhea
  • Dizziness
  • Drowsiness
  • Dry mouth
  • Headache
  • Heartburn
  • Itchiness
  • Stomach pain
  • Sweating
  • Vomiting
  • Weakness

Some less common side effects are:

  • Allergic reaction
  • Confusion
  • Difficulty breathing
  • Discomfort
  • Drop in blood pressure
  • Fainting
  • Frequent urination
  • Hives
  • Rash
  • Rapid heartbeat
  • Weight loss

Serious but rare side effects, for which you should seek emergency medical help include:

Allergic reaction (trouble breathing; welling of face, lips, throat, tongue; severe itching; hives; blistering or peeling skin)

Abnormal heart rhythms 

Addiction and abuse

Overdose

Respiratory depression

Serotonin syndrome 

Seizures 

Suicide/attempted suicide

Withdrawal

Long-term Effects

Although it has long had the reputation of being one of the safest opioids on the market, research and data suggests that it can still be highly addictive. Additionally, it may have long-term health effects that result from extended use. These include:

Seizures: Tramadol is known to cause seizures in some patients, particularly if they have epilepsy.

Adrenal Insufficiency: Adrenal glands produce hormones such as cortisol, adrenaline, and aldosterone, which help your body to control blood pressure, heart rate, and maintain immune system function. Tramadol can interfere with your body’s ability to produce these hormones, causing you to experience muscle weakness, fatigue and a low appetite.

Androgen Insufficiency: Androgens are sex hormones associated with bone and muscle development, metabolism, and sexual and reproductive health. Long-term use of tramadol can cause an androgen insufficiency, which may lead to loss of libido, fertility problems, decreased muscle and bone mass, and mood disturbances.

Respiratory Problems: Tramadol can lead to respiratory depression which can cause fainting, dizziness and confusion.

Liver and Kidney Damage: Long-term tramadol use has been associated with liver and kidney damage, and in extreme situations, liver failure. Over 30% of tramadol is excreted by the kidneys, meaning that too much tramadol could lead to toxic blood levels in patients with kidney disease.3

Substance Use Disorder: Extended tramadol use can lead to dependence and substance use disorders. Such disorders may result in behavioral changes and disruption of personal relationships with friends and family.

Serotonin Syndrome

Serotonin syndrome occurs when there is too much nerve cell activity that disrupts the functioning of the central nervous system. This can lead to agitation, loss of muscle control, rapid heartbeat, rigid muscles, sweating, and coordination difficulties. Severe cases can lead to loss of consciousness, irregular heartbeat, seizures, and potentially death.

Serotonin syndrome typically occurs when combining tramadol with other medications such as selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), or monoamine oxidase inhibitors (MAOIs).

Diagnostic Criteria for Opioid Addiction

The 5th and most recent edition of the Diagnostic and Statistical Manual of Mental Disorders created by the American Psychiatric Association outlines the following criteria for the diagnosis of opioid use disorder:

Opioids are often taken in larger amounts or over a longer period than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

Craving or a strong desire to use opioids.

Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.

Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

Important social, occupational, or recreational activities are given up or reduced because of opioid use.

Recurrent opioid use in situations in which it is physically hazardous.

Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.

Tolerance

Tolerance, as defined by either of the following:

  • Need for markedly increased amounts of opioids to achieve intoxication or desired effect
  • Markedly diminished effect with continued use of the same amount of opioid

Withdrawal

Withdrawal, as manifested by either of the following:

  • Characteristic opioid withdrawal syndrome
  • Same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

Severity

The severity of the substance use disorder depends on how many criteria apply to you.

2-3 Symptoms = Mild

4-5 Symptoms = Moderate

6+ symptoms = Severe

The diagnosis of a substance use disorder can only be given by a licensed professional; however, being aware of the diagnostic criteria might help you to determine whether you or someone you know is suffering from an addiction.

Overdose and Withdrawal

Symptoms of Tramadol Overdose

If you take more tramadol than prescribed or are using it recreationally at high doses, there is a greater risk of overdose. Symptoms of an overdose may include:

Cold, clammy skin

Coma

Decreased pupil size

Difficulty breathing

Drowsiness 

Muscle weakness

Seizure

Slowed heartbeat

Emergency medical assistance should be contacted immediately if you or someone you know is experiencing an overdose. It is always better to be safe than to risk increased harm.

Symptoms of Tramadol Withdrawal

Withdrawal occurs when the use of a substance suddenly stops after it has been taken for a significant amount of time. The reason that withdrawal occurs is that over time, the body becomes used to the drug that is being taken and adjusts itself to function with the drug. This is called dependence. When you stop taking the drug suddenly, your body reacts to the absence of the drug, causing you to feel unpleasant symptoms as your body struggles to function without it.

Withdrawal symptoms include:

  • Anxiety
  • Cough
  • Depression
  • Diarrhea
  • Difficulty falling asleep
  • Hallucinations
  • Muscle pain
  • Nausea
  • Nervousness
  • Pain
  • Panic
  • Paranoia
  • Problems sleeping
  • Psychosis
  • Runny nose
  • Sweating
  • Sneezing
  • Tremors
  • Uncontrollable shaking

Tramadol stays in the body for about 3-5 days after taking the last dose; however, most people need approximately a week before the drug has fully left their system. Withdrawal symptoms kick in shortly after you stop taking tramadol, and while physical symptoms tend to subside fairly quickly, psychological symptoms and cravings might persist for up to a few months after.

How Do You Safely Stop Using Tramadol?

If you are nearing the end of your tramadol prescription and have discussed it with your doctor stopping use, your doctor will typically taper down your dosage to avoid severe withdrawal symptoms. Progressively taking less tramadol over a period of time will allow your body to get used to lower doses of the drug. You should never decide to stop taking tramadol on your own without seeking medical advice!

If you have developed a dependence to tramadol or believe that you have an addiction, the safest way to stop using the drug is under a medically supervised detox. This is because having medical supervision while detoxing can help manage withdrawal symptoms and help prevent relapse.

Treatment Options for Tramadol Addiction

After successfully detoxing, there are a variety of treatment options available. Treatment options include:

Inpatient and outpatient treatment programs such as behavioral modification programs or residential 30, 60 or 90-day programs.

Medically assisted treatment such as the use of methadone or buprenorphine to help relieve cravings and withdrawal symptoms from tramadol.

Mental health Therapy such cognitive behavioral therapy which helps patients identify causes, triggers, and patterns of behavior surrounding their substance use disorder.

Aftercare programs such as sober living environments, check-ins, and follow-up counselling sessions that help to prevent relapse.

12-Step recovery programs such as Narcotics Anonymous. Such programs focus on peer support and having the support of people going through the same things.

Support groups such as Addiction Support Groups, Tramadol Support Groups and Opiate Dependence Support Groups.

Typically, multiple different treatments will be combined to create a treatment plan that is tailored to the individual. Most often, medically-assisted treatments will be combined with therapy and counseling. The medication helps with withdrawal symptoms, allowing you to be stable enough to successfully complete therapy and counseling which target the root causes of addiction rather than just the symptoms.

Ways to Reduce the Risk of Relapse

Although there is no official timeline or maximum length of treatment for substance abuse disorder, there are things you can do to reduce your risk of relapsing. These include:

Avoid triggers: this includes people and places that make you think about drugs or remind you of them

Have a strong support network of family, friends, and healthcare professionals

Find work, interests, or hobbies you are passionate about

Stay active, have a balanced diet, and a good sleep schedule

Prioritize your physical and mental health

Adopt healthier patterns of thinking (e.g. continue to practice what you learn in therapy)

Make plans for the future! Create goals.

Resources

  1. https://www.sciencedaily.com/releases/2019/05/190514090953.htm
  2. https://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf
  3. https://www.drugs.com/article/tramadol-need-to-know.html
  4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013