Drug experts call for stronger regulation of tramadol to reduce misuseBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1264 (Published 25 February 2013) Cite this as: BMJ 2013;346:f1264
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Whilst Tramadol is not considered to be as addictive as other opiates of similar analgesic potency, it would appear that the public have been mislead regarding its purported safety apropos its dependence liability, potential for withdrawal states, and safe co-administration with other drugs.
As far back as May 2009, the U.S. FDA (Food and Drug Administration) issued a "Warning Letter" to Johnson & Johnson, alleging that a promotional website had "overstated the efficacy" of the drug, and "minimized the serious risks". The German company which manufactured it, Grünenthal GmbH, were also alleged to be guilty of "minimizing" the habituating nature of the drug, despite reports that the drug displayed minimal abuse potential in clinical trial testing.
Subsequent to these warnings, future Physicians' Desk Reference books contain several alerts which were absent in previous editions. These include more strongly-worded language regarding the habit-forming potential of Tramadol.
Thus, whilst Tramadol may be different from other opiates, it may not be as harmless as we were initially lead to believe. It is a complex synthetic opiate, which has actions on multiple neurotransmitters and receptors over and above the opioids. It is a serotonin releasing agent, a noradrenaline reuptake inhibitor, and an NMDA receptor antagonist. Consequently, the physical withdrawal symptoms may not be as severe as other opiates in relation to the opioid system, but it does produce significant discontinuation symptoms in keeping with its potent serotonergic and noradrenergic properties. These symptoms can be very severe and distressing for the individual, and include severe anxiety, depression, agitation, aggression and insomnia, in addition to physical symptoms. It also possesses a marked induce seizures, and can induce serotonin syndrome when used in combination with other serotonergic psychotropic drugs such as the SSRIs.
I believe that Tramadol's addictive properties, its potential for severe physical and psychological withdrawal symptoms, and the potential for serious drug interactions have all been underplayed to some degree. It is high time that we reconsider our perception of Tramadol as a safer alternative to other opiates of similar analgesic effect.
Competing interests: No competing interests