Drug experts call for stronger regulation of tramadol to reduce misuse

BMJ 2013; 346 doi: (Published 25 February 2013) Cite this as: BMJ 2013;346:f1264
  1. Susan Mayor
  1. 1London

The UK government should make the analgesic tramadol a controlled class C substance that carries a potential fine and prison sentence for anyone found using it without a prescription or dealing in the drug, an expert group has said.

The Advisory Council on the Misuse of Drugs made its recommendation after conducting a review in response to the rise in deaths from misuse of the drug.1

Tramadol is a synthetic opioid that is not currently classified under the Misuse of Drugs Act 1971, which controls the availability of drugs considered to be have potential for harm and misuse.

If the government adopts the recommended change, anyone convicted of possessing tramadol without a prescription for it could receive up to two years in prison or an unlimited fine, or both. Anyone found guilty of dealing in a class C drug can receive a prison sentence of up to 14 years in prison, an unlimited fine, or both.

The council, which advises the government on issues related to drugs, reviewed the harms associated with the non-medical use of tramadol after NHS reports showed increasing misuse. Deaths in which tramadol was mentioned on death certificates rose from 83 in 2008 to 154 in 2011. Most of these deaths were of people who had obtained tramadol without a prescription for it.

The rise in deaths linked with tramadol has occurred against a background of increased prescribing of the drug. The number of daily defined doses (which is based on the average daily maintenance dose when used by adults for its main indication) in England nearly doubled in seven years from around 5.9 million in September 2005 to 11.1 million in September 2012. The 2011 Street Drug Trends survey also showed a rise in tramadol use during 2010 in 16 of 20 areas investigated in the United Kingdom.2

In the report the council warns, “Tramadol’s unique dual action pharmacological profile increases the risk of adverse effects, particularly in overdose.” The drug has weak agonist activity at opiate receptors in the brain, which may cause euphoria and respiratory depression. It also enhances serotoninergic and noradrenergic systems in the brain by inhibiting their reuptake mechanisms. The fact that only the opioid effects of tramadol are reversible with naloxone makes it more likely to cause harm than other opioids, particularly when combined with other monoamine active drugs.

In a letter to the home secretary and the health secretary, Les Iversen, chairman of the council, said, “The [council’s] review of the evidence has caused it concern, particularly the increase in tramadol related deaths.”

He concluded, “The [council] advises that tramadol be controlled as a class C substance under the Misuse of Drugs Act 1971 and listed in schedule III of the Misuse of Drugs Regulations 2001, which it considers would provide the correct controls to prevent diversion and misuse.” In addition, the council recommends that prescribers and other health professionals in contact with people who use tramadol should have training on its misuse and adverse effects.

Prescriptions of schedule III drugs must include the dose, form, strength, and total quantity of the preparation in words and figures, but record of supply does not need to be kept in a special register, as is the case for schedule II drugs.


Cite this as: BMJ 2013;346:f1264