Tramadol is labeled as a Schedule IV controlled substance by the Drug Enforcement Administration (DEA), as it is an opioid painkiller with known abuse liability. There were almost 44 million prescriptions dispensed for tramadol products in the United States in 2013.
Tramadol acts on opioid receptors, monoamine reuptake systems, and the central nervous system to suppress pain sensations and enhance feelings of calm and relaxation. Regular interference of tramadol with the brain’s chemical messengers can cause physical changes in some of the pathways and structures of the brain. A person taking tramadol regularly may become tolerant to its effects, meaning that the drug will no longer work at the same dosage, and more will need to be taken in order for it to be effective. This is called drug tolerance. The U.S. Food and Drug Administration (FDA) places warnings on the labels and in the prescribing information for one of the common brand name products with tramadol as an active ingredient, Ultram ER, stating that the drug has a potential to create tolerance and dependence in users. Physiological dependence develops when the changes in the brain have become more fixed, and it no longer functions the same way without tramadol’s interaction.
Drug dependence can occur even when a person takes a drug exactly as prescribed, although it often sets in more rapidly when the drug is abused. The DEA reports that 3.2 million Americans had used tramadol for nonmedical purposes at some time in their lives, as indicated by the 2012 National Survey on Drug Use and Health (NSDUH). The potential for becoming dependent on tramadol may be higher for individuals abusing it, or with a history of substance abuse or addiction, although studies have shown that tramadol can induce drug dependence when taken for long periods of time with a legitimate prescription, the World Health Organization (WHO) publishes.
Traditional opioids like oxycodone and hydrocodone increase sensations of pleasure and can produce a “high” when taken in larger doses than prescribed. Tramadol works a little differently by not only activating opioid receptors in the brain but also by blocking neurotransmitters like serotonin and norepinephrine from being reabsorbed back into the system. Thus, tramadol withdrawal may actually take two different forms: traditional opioid withdrawal syndrome or atypical opioid withdrawal syndrome.
Opioid withdrawal generally has two main phases: early and late withdrawal. Early withdrawal starts when the drug leaves the bloodstream, and late withdrawal occurs a little later. Signs of opioid withdrawal vary according to the stage.
- Runny nose
- Tearing up
- Muscle and body aches
- Trouble sleeping and/or insomnia
- Racing heart rate
- Fast breathing
- Chills and goosebumps
- Stomach pain and cramping
- Loss of appetite
- Pupil dilation
- Difficulties concentrating or thinking clearly
- Drug cravings
Tramadol has a relatively short half-life. WHO reports that immediate-release forms of tramadol products are quickly absorbed into the bloodstream, with their effectiveness peaking in 1-4 hours. The effects of extended-release tramadol products may last a little longer, peaking in 4-6 hours.
In general, opioid withdrawal symptoms are thought to start within about 12 hours of the last dose. The DEA publishes that 90 percent of people experiencing tramadol withdrawal suffer traditional opioid withdrawal symptoms while the other 10 percent may experience severe confusion, extreme paranoia, anxiety, panic attacks, hallucinations, and tingling or numbness in their extremities.
The magnitude of physical dependence to tramadol withdrawal may be similar to symptoms of the flu. They are likely to peak within a few days and taper off while the psychological withdrawal side effects may linger a little longer. Everyone will experience withdrawal differently, and certain factors may influence how long it will last and the potential severity of the symptoms.
The level of dependency to tramadol is a major contributor to the duration and severity of the withdrawal symptoms, as a brain that is significantly dependent on tramadol may need extra time to bounce back and restore the balance that may have been disrupted by long-term and chronic drug use. Therefore, individuals taking tramadol for a long time, and especially those taking large doses, may be more heavily dependent on the drug.
The manner in which a person takes tramadol is a factor in withdrawal and drug dependence as well. Someone taking the drug as directed, for example, is less likely to be as dependent as an individual who is injecting, snorting, or smoking it.
Taking other drugs, or alcohol, in combination with tramadol can also increase all of the potential risk factors and impact drug dependence and withdrawal as well.
A person’s personal physiology, genetics, and biology play a role in drug dependence, and one person may become dependent more easily than another. Underlying medical or mental health conditions may impact drug dependence as well. In addition, genetics are believed to be a factor in drug dependence about half of the time, the National Council on Alcoholism and Drug Dependence (NCADD) reports. Someone with a family history of substance abuse and addiction may be more prone to becoming dependent on tramadol than someone without this possible risk factor.
Trauma, neglect, chronic stress, and abuse can contribute to the onset of a substance use disorder, as can the age at which a person first uses or abuses drugs. Adolescent brains are not fully formed, and regions responsible for sound decision-making, controlling impulses, learning, and memory may be damaged by drug use during the teenage years, the journal of Clinical EEG Neuroscience publishes. The NSDUH of 2013 reported that individuals abusing drugs before the age of 14 were more likely to suffer from a substance use disorder as an adult than those who waited until after age 18 to initiate drug use.
Managing Withdrawal Pharmaceutically
Tramadol dependence and withdrawal may be best managed through medical detox, which is the most comprehensive form of drug detox. Like with other opioids, once a person is dependent on tramadol, it is not recommended to stop taking it suddenly and without professional input.
Medical detox offers a high level of care with around-the-clock monitoring by medical professionals. Since chronic tramadol use or abuse affects the regions of the brain involved in feeling pleasure and controlling impulses, individuals dependent on the drug may desire to keep using it, or return to tramadol use in an effort to self-medicate withdrawal symptoms. Some of the more intense psychological symptoms of withdrawal, like depression and drug cravings, may be managed with the help of medications during medical detox.
The FDA approves three types of medications for opioid withdrawal: methadone, buprenorphine, and naltrexone. These medications can ease withdrawal symptoms, manage drug cravings, and help a person refrain from returning to drug use.
- Methadone: A long-acting opioid agonist, methadone has one of the longest durations of action, with a half-life of up to 59 hours. This makes it a candidate for substitution with a short-acting opioid like tramadol as it stays in a person’s system longer, thus keeping withdrawal symptoms at bay. Methadone is still an opioid, however, with its own potential for abuse, dependency, and addiction; it should therefore be used with caution.
- Buprenorphine: Another long-acting partial opioid agonist, buprenorphine also fills opioid receptors for a longer amount of time than tramadol; however, buprenorphine is only a partial opioid agonist, meaning it shouldn’t activate these receptors in the same way. While it can help minimize opioid withdrawal symptoms, it shouldn’t cause a person to feel “high” or produce the same mind-altering effects. Buprenorphine may also have a plateau effect, meaning that if someone attempts to take more than the recommended dose, the drug will no longer produce any effect, thus reducing the desire to abuse it. The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes that there are four types of buprenorphine products approved by the FDA for the treatment of opioid dependency: Subutex and other buprenorphine transmucosal products, Zubsolv, Suboxone, and Bunavail. Suboxone, Zubsolv, and Bunavail all contain buprenorphine and the opioid antagonist naloxone. If the product is abused, naloxone can precipitate withdrawal symptoms and therefore acts as an abuse-deterrent. Buprenorphine products containing naloxone may be helpful to prevent relapse, and they are optimal when used after the initial stages of detox.
- Naltrexone: As an opioid antagonist, naltrexone may be best suited for use after early withdrawal, when tramadol is fully removed from the body to maintain opioid abstinence. Naltrexone products include Vivitrol, ReVia, and Depade, the National Institute on Drug Abuse (NIDA) reports. They work by blocking opioid receptors from being activated by opioid drugs.