Tramadol— available in the branded, immediate-release form Ultram and an extended-release formulation known as ConZip—is an opioid pain medication for moderate to moderately severe pain.1 The extended-release capsule formulation may be used to manage chronic, around-the-clock pain.1,2
Tramadol is Schedule IV controlled substance available only by prescription.3 As a Schedule IV medication, tramadol may have a lower potential for abuse and addiction than some other scheduled drugs but, like other opioid painkillers, the potential is still there. In fact, reported diversion and abuse of tramadol is why the medication became a scheduled drug; when first introduced on the pharmaceutical market in 1995, tramadol was not listed as a controlled substance.3
How Tramadol Is Used and Misused
When prescribed by a physician, tramadol should be taken exactly as directed. Taking more of the medication than prescribed, taking it more often than prescribed, and taking it for a longer period of time than prescribed are considered forms of misuse. Using tramadol nonmedically, or in a manner other than prescribed, is considered abuse of the drug.
Misuse of a drug like tramadol can increase several health risks and could contribute to the development of compulsive patterns of substance abuse common to addiction. Particularly with extended-release formulations, intentional misuse may include chewing, crushing, injecting, or snorting tramadol. Bypassing the time-release mechanism in this manner can more easily result in overdose, toxicity, or death.
If tramadol is combined with certain other depressants such as alcohol, other opioids, or anesthetics, its effects may be intensified. This can be dangerous, as it can cause an individual’s breathing to slow or even stop, which could result in fatal overdose.2
Effects on the Body
Tramadol is a centrally acting opioid agonist thought to work as an analgesic by targeting mu-opioid receptors. Unlike many other prescription opioids, tramadol is thought to also inhibit the reuptake of two neurotransmitters—norepinephrine and serotonin.2,3 While this somewhat unusual pharmacologic mechanism may contribute to its pain modifying capability, it also gives tramadol a side effect profile somewhat different than other drugs in its class.
Many of the side effects of tramadol are similar to those of other opioid pain medications, however. Some of these tramadol side effects include:2,3,4
- Dry mouth.
- Nausea and vomiting.
Tramadol may also produce more serious side effects. These effects are less common and may include:1,2,4
- Hypersensitivity reactions—e.g., hives, bronchospasm, angioedema (skin and mucosal tissue swelling).
- Orthostatic hypotension (a drop in blood pressure upon standing).
- Serotonin syndrome (a condition made more likely when individuals are taking two medications that result in excessive serotonergic activity).
- Slowed or shallow breathing.
Individuals who have experienced seizures should avoid tramadol, although it can also cause seizures in those without a seizure disorder as well (especially at higher-than-recommended doses).3
Adverse Effects and Overdose
According to the Substance Abuse and Mental Health Services Administration, there were approximately 54,397 tramadol-related emergency room visits in 2011, with roughly half of these due to adverse reactions to the drug.5 The DEA states that the American Association of Poison Control Centers reported 10,932 tramadol exposures in 2017; and five related deaths.3
Several other medications are contraindicated when using tramadol, including sedatives, tranquilizers, and muscle relaxants, but also a range of other drugs including some antifungal agents, antiviral drugs, and certain psychiatric medications.2,4 Concurrent use of these medications can increase the risk of life-threatening respiratory issues, over-sedation, coma, and death.4
Individuals should not take more tramadol than prescribed by a physician. Overdose deaths have been reported in connection with the misuse of tramadol. As mentioned, the risk of overdose increases should tramadol be used at the same time as other opioids or CNS depressant substances such as alcohol.2
Signs and symptoms of acute tramadol overdose may include:2,4
- Pinpoint pupils.
- Slow or shallow breathing.
- Slowed heart rate.
- Low blood pressure.
- Cold, clammy skin.
- Muscle weakness.
- Extreme drowsiness/over-sedation.
- Loss of consciousness.
In the event of an overdose, emergency services should be contacted immediately.
Compulsive Tramadol Misuse
Though the risks of misuse and dependence to tramadol are thought to be relatively lower than they are for some other opioid drugs, addiction is possible. Addiction to tramadol may develop as individuals begin to display certain behaviors, such as drug-seeking behaviors and the use of tramadol even if they have experienced negative consequences from its use.
Some individuals may engage in illegal behavior to obtain tramadol, including doctor shopping. Doctor shopping occurs when individuals attempt to obtain prescriptions by visiting multiple doctors, and it is both illegal and dangerous. Others may even forge prescriptions if their physician will no longer prescribe tramadol, which is also highly illegal. Individuals may also ask for refills earlier, claim their tramadol was lost or stolen when it was not, or ask loved ones to obtain a tramadol prescription for use. People who begin to compulsively misuse prescription medications like tramadol may find themselves in financial trouble as well, as they may begin to devote increasingly large amounts of time and money to purchase the medication illegally.
Other signs, symptoms, and behavioral changes characteristic of an addiction involving tramadol—or an opioid use disorder—may include:6
- Taking tramadol in larger amounts or for longer than prescribed.
- An inability to cut back on or altogether stop using tramadol, despite one’s intention to do so.
- Development of withdrawal symptoms when use slows or stops.
- Development of tolerance to the effects of tramadol.
- Spending large amounts of time to obtaining, taking, and recovering from tramadol use.
- A decreased ability to manage responsibilities at home, work, and school because of tramadol.
- Strain on personal relationships due to tramadol use.
- No longer participating in work or social events due to tramadol use.
- Continuing tramadol use, even if it has led to worsening physical or mental health issues.
Because of the risk of an unpleasant withdrawal, abruptly discontinuing tramadol after a period of regular use (and without the supervision of a medical professional) may be discouraged.4