Once again, a medication that was supposed to be a safer alternative to opioids proved to be neither; not only does it not mitigate the addiction risk, it isn’t even effective.
This is a perfect example of the inferior medical care we pain patients receive, forced to endure ineffective and possibly dangerous medication because it is becoming taboo to prescribe the only medicine that works best, old-fashioned opioids.
Tramadol is a commonly prescribed analgesic that is used to treat a wide variety of painful conditions. Through a somewhat unique mechanism of action, tramadol acts as a mu-opioid receptor agonist and serves as an antagonist to serotonin and norepinephrine receptors.
When compared to traditional opioids, tramadol, and its active metabolite M1 (O-desmethyltramadol) bind the mu-opioid receptor with 10 times less affinity than codeine and approximately 100 times less affinity than morphine.
While the weak agonist effect of tramadol is thought to provide some pain relief, the inhibition of serotonin and norepinephrine reuptake is thought to provide added analgesia while limiting some of the known adverse effects associated with traditional opioids.
Tramadol has been marketed as a novel analgesic that offers pain relief comparable to opioids without the associated risks of abuse or dependency. As its use has increased, there is emerging data to suggest that tramadol is not a medication that should be routinely used.
From questionable efficacy, risk of dependency/abuse, to a somewhat unique risk of complications, there are three major reasons why providers should be careful when using tramadol.
1 – It May Not Work
To date, there is very limited data in terms of the efficacy of tramadol compared to placebo when used in the emergency departmen
There is little evidence to suggest that tramadol provides better pain relief than acetaminophen or ibuprofen.
Tramadol does not appear to match the analgesic properties of traditional opioids. In prospective study of patients presenting to the ED with acute musculoskeletal pain, patients who received tramadol reported higher pain scores across a range of time intervals when compared to patients who were given a combination product containing hydrocodone and acetaminophen
Overall there is very little evidence that tramadol is more efficacious than any other commonly available analgesics.
2 – It May Hurt Our Patients
There are several significant potential risks associated with the use of tramadol.
Risk of Erratic Metabolism
Tramadol’s active metabolite, M1, is created after tramadol is metabolized by the CYP2D6 enzyme
As with other analgesics such as codeine, a subset of the population suffers from abnormal activity of this enzyme and is at an increased risk of adverse event when taking tramadol.
Risk of Seizure
. While multiple analgesics are reported to lower a patient’s seizure threshold, there is emerging data to suggest that this risk may pose an even heightened risk.
Risk of Hypoglycemia
patients who received tramadol had significant increase in the risk of hypoglycemia that required a hospitalization. The relationship between tramadol and hypoglycemia is still somewhat unclear; however, providers should be aware of this association
Risk of Serotonin Syndrome
When abused or used in conjunction with other agents that limit serotonin reuptake, such as selectiveserotonin reuptake inhibitors, tramadol can increase the risk of a patient developing serotonin syndrome
3 – It Isn’t A “Safe” Opioid
there is increasing evidence that tramadol may pose a significant risk of abuse, dependency, and withdrawal in a certain subset of patients
Due in a large part to this emerging risk of abuse, tramadol has been reclassified as a Schedule IV substance by the DEA .
There is a high rate of neurotoxicity including seizures and lethargy when patients overdose on tramadol that is thought to be due to the blockade of serotonin and norepinephrine re-uptake rather than coming strictly from the opioid agonist activity.
Compared to alternative agents, tramadol may cause significant complications after even relatively minor ingestions with reports of significant neurotoxicity occurring after ingestions of as little as 5 times the recommended dose.
As only a small portion of these symptoms come from the opioid receptor, traditional antagonists such as naloxone have limited efficacy when used to treat a tramadol overdose .
Despite its widespread use, there are significant issues that providers should consider before using tramadol.
In terms of efficacy tramadol has not been shown to consistently outperform other available analgesics.
In addition, tramadol has a set of potential side effects that make it a less than ideal first line analgesics.
Finally tramadol does not appear to be a “safe opioid” as there seem to be significant potential for abuse, dependency, and withdrawal.