Tramadol is an opioid that can be deadly
There are people who think that tramadol is not an opioid. Tramadol is an opioid. It is different from other opioids due to its unusual characteristics. Some of these characteristics offer an advantage for tramadol over other opioids, but on the other hand, these unusual characteristics make tramadol more dangerous than other opioids.
Tramadol is the generic drug name, and there are various brands in Canada: Tramacet, Zytram, Ralivia, Ultram, and Tridural. Today, I will answer 10 common questions that people ask about tramadol.
Question #1. How does tramadol work?
Tramadol is a synthetic opioid. This means it is done in the laboratory as opposed to naturally occurring opioids such as codeine and morphine which are found in the opium poppy. When a person takes tramadol, a pill, a tablet, a suppository, or even by injection, tramadol will need to be converted in the liver to a more potent substance called O-desmetyl-tramadol or M1. Some people do not have the ability to transform tramadol into M1 and will not produce the more potent form of tramadol. Approximately 5% of Caucasian people do not have the enzyme to transform tramadol to M1, so they will not respond to tramadol, even if they are prescribed higher doses. They will only get the side effects.
But tramadol will have an additional effect on the pain system, which is very helpful for people who have chronic pain. Tramadol will block the reuptake, or reabsorption of serotonin and noradrenaline, two substances that are needed in the central nervous system in people who have chronic pain. In chronic pain, we use antidepressants called SNRIs or serotonin-noradrenaline reuptake inhibitors with the intention to increase serotonin and noradrenaline. But tramadol is like taking 3 pills for one. Or 3 in one. However, it is hard to treat depression with tramadol because the effects will be unpredictable, so it is safer to prescribe one medication for pain and another for depression.
What seems to be a big advantage especially for people with chronic pain and depression is what makes tramadol so unpredictable and dangerous. People with chronic pain who take tramadol usually take other medications that also increase serotonin in their brain, like antidepressants, anti-migraine, other opioids, anti-nausea and even some herbal supplements. When too much serotonin accumulates in the brain, there is the risk of “Serotonin Syndrome”, one of the first symptoms is mental confusion, and if this condition is not recognized quickly, may progress to severe serotonin syndrome which leads to seizures and death.
Question #2. Is tramadol a good painkiller?
Tramadol and M1 will activate opioid receptors in the brain, spinal cord and peripheral nerves, and will stop the pain, this is called analgesia. Tramadol is similar in potency compared to codeine, and for this reason, is commonly referred to as a weak opioid. However, the concept of weak and strong opioids is relative. What this really means is that you need a high dose of tramadol to get the same effects as low-dose morphine. So, people usually say that tramadol is weak and morphine is strong. In this case, fentanyl is super strong because you would need micrograms of fentanyl to have the same analgesic effects of hundreds of milligrams of tramadol.
There are various systematic reviews of randomized trials of tramadol for chronic pain. I’ll summarize some of them:
A Cochrane review published in 2019 showed moderate-quality evidence that tramadol alone or in combination with acetaminophen probably has no important benefit on pain intensity and physical function over placebo in people with osteoarthritis.
A Cochrane review published in 2017 showed low or very low-quality evidence that tramadol could have some benefit for neuropathic pain.
A Cochrane review published in 2013 showed very low-quality evidence that tramadol makes little difference for low-back pain compared to an NSAID celecoxib.
A systematic review published in 2020 showed low-quality evidence that tramadol as a single agent was not better than a placebo for patients with fibromyalgia.
Question #3. What is the proper dose of tramadol? How do I know if I need a higher dose?
We usually start tramadol with the lowest possible dose. Tramadol can be found as a short-acting or long-acting medication. The short-acting usually starts in 30 minutes and lasts about 4 hours. The long-acting tramadol takes longer to start but lasts about 8 to 12 hours. In some parts of the world, there is extended-release tramadol that is taken once a day as the effects last 24 hours. And there are also some pills that contain a mix of short and long-acting tramadol. I recommend that you ask your doctor or your pharmacist and find out what type of tramadol preparation you are receiving, as there are many different options in the market.
Because of the risks of serotonin syndrome that I explained before, tramadol has the maximum dose allowed. It depends on the brand of tramadol.
For short-acting tramadol pills, if the pill contains 37.5 mg of tramadol, then we recommend taking no more than 10 per day.
If the short-acting tramadol pill contains 50 mg, then we recommend no more than 8 per day.
For the long-acting tramadol, they come in pills of 50, 100, 150, 200 and 225 mg, depending on the brand. The maximum dose is 400 mg per day. The dose limit is mainly because of the risks of serotonin syndrome that can lead to death.
Question #4. Can I take tramadol with other painkillers like acetaminophen or gabapentin?
Some tramadol pills come already mixed with acetaminophen. For example, Tramacet, the pill contains tramadol plus acetaminophen. So, you need to be careful if you take additional doses of acetaminophen because the maximum that your liver can tolerate is around 4,000 mg a day. Acetaminophen is the type of drug that is hidden in a lot of other medications, like cold, cough, headaches, etc. It is very important that you don’t take more than 4,000 to preserve your liver function.
People who take gabapentin can also take tramadol, but you need to be very careful because the two medications can cause sedation, sleepiness and poor concentration. And combining the two will only accentuate these side effects.
Question #5. Is tramadol a risky pain medication?
The short answer is yes. Tramadol can cause death because it is an opioid, and opioids can cause the person to stop breathing while they are sleeping. This is even more common when tramadol is taken with other sedating drugs like gabapentin, baclofen, benzodiazepines, antidepressants, anti-psychotics, alcohol and even when the person is taking other opioids.
Naloxone is an antidote used to revert an opioid overdose. However, overdose by tramadol is not completely reversed by the administration of naloxone.
The other risk of tramadol, that we already mentioned is serotonin syndrome, and this is common in people who take other medications that also increase serotonin in the brain.
Question #6. Is tramadol safe during pregnancy and breastfeeding?
Tramadol crosses the placenta. We do not have any evidence that it causes any malformation to the fetus. However, prolonged use during pregnancy can result in withdrawal symptoms in the neonate, and we know that neonatal opioid withdrawal can be life-threatening. So, we recommend that pregnant women discontinue opioids as soon as they know they are pregnant, but this tapering should be done very slowly and under medical supervision to avoid uterine contractions and premature labour or miscarriage.
For breastfeeding women, tramadol is found in breast milk, and in some cases, the doses are quite high and could cause serious overdose to the baby leading to brain damage due to lack of oxygen, or even death.
Question #7. Will tramadol help me sleep or keep me awake?
Opioids are known as narcotics because they produce a state of stupor, paralysis, sleepiness and relaxation. Morphine, which has been used for thousands of years was named after Morpheus, the Greek god of dreams.
However, tramadol has those unusual characteristics that I mentioned before, increasing serotonin and noradrenaline, and in some people, it will disrupt sleep causing insomnia and poor quality sleep.
Question #8. Can I drive if I use tramadol?
When the person is starting treatment with tramadol, it is better to avoid driving or operating heavy machinery until the dose is stable and no more adjustments are being made in the dose. Once the person is on a stable dose, the doctor can reassess if the person is too drowsy and dizzy. Drowsiness and dizziness are the two most common adverse effects of tramadol. But most people will adapt to tramadol and these adverse effects will diminish over time. Then, when the person is not feeling sleepy or drowsy anymore, then they can resume driving.
Question #9. Do I need to stop using alcohol if I am prescribed tramadol?
Both alcohol and tramadol inhibit brain function and cause the same effects of sleepiness, dizziness and can also make the person stop breathing, which may lead to overdose and death.
Question #10. Can people abuse tramadol?
Yes, tramadol is a drug that can be abused. It is an opioid, and some people may have euphoria similar to other opioids like oxycodone, or fentanyl. A person who uses tramadol regularly will have withdrawal symptoms if they stop taking it abruptly. These withdrawal symptoms are very unpleasant. Tolerance to tramadol develops very quickly. Even when the pain condition has resolved the individual will continue using tramadol just to avoid these withdrawal symptoms.
A small proportion of people will develop an opioid use disorder, which is basically losing control of how much tramadol they are taking. This is a serious mental health disease, and it has to be treated as soon as possible. Opioid Use Disorder or OUD occurs in about 5% of people who use opioids every day.
This article is not intended to give you medical advice. Please talk to your physician or healthcare professional if you have any health issues. If you leave a comment about your own medical condition, I will not be able to provide you medical advice. But, please, leave a comment if you feel that this article has helped you to learn something new.
This article is available as a YouTube video on my channel https://youtu.be/ApO24eoeQVo
