Tramadol Addiction and Abuse

Tramadol is a prescription opioid painkiller generally used for treating moderate to moderately severe pain such a post-operative pain management or chronic pain due to fibromyalgia.

Tramadol is most widely prescribed as a 50 mg, 100 mg, 150 mg, 200 mg, and 300 mg tablets that are taken orally. Tramadol can never be used in conjunction with any other opioid, as they are very similar to opioid analgesics. The extended-release form of this medication provides patients with around-the-clock pain relief.

Tramadol brand names include:

• Ultram ER
• ConZip
• Ryzolt
• Ultram

Tramadol provides a multimode of functions as it acts upon certain nociception as well as opioid receptors in the brain that relieves pain. This medication is considered to embody a low potential to cause drug dependence compared to morphine.

The use of tramadol at higher doses or longer than prescribed is considered abuse. Combining tramadol with other substances to increase its effects is also a form of abuse. Tramadol is generally abused due to its ability to manifest opioid-like effects. Patients are prescribed tramadol only for short term use due to its capacity to cause dependence with prolonged use.

Symptoms and side effects of tramadol abuse may include the followings:

• Changes in appetite
• Drowsiness
• Slurred speech
• Headaches
• Nausea or vomiting
• Impaired co-ordination
• Pinpoint pupils
• Constipation
• Dizziness
• Trouble concentrating
• Fever
• Muscle aches
• Sweating
• Depression

Abuse or misuse of tramadol can lead to adverse consequences, such as seizures, CNS depression, coma, or respiratory depression. These symptoms are more common when tramadol is consumed at high doses over a prolonged period. Although fatal overdoses are less common, they can occur when tramadol is consumed with other drugs.

Most painkillers are Schedule II substances according to drug classifications under the Controlled Substances Act. However, In 1994, the Drug Enforcement Administration (DEA) reclassified tramadol as a Schedule IV Controlled Substance due to an increase in tramadol abuse. Although tramadol is considered relatively safe compared to morphine, It does, however, hold the potential to form an addiction if the drug is abused or consumed by patients with a history of drug addiction.

Prolonged abuse of tramadol can cause the development of tolerance and dependence on the drug. During this stage, patients will require higher and higher doses to achieve the desired effect. Patients who form a dependence on the drug will experience tramadol withdrawal symptoms during the abrupt cessation of consumption.

Common street names for tramadol include:

• Chill pills
• Trammies
• Ultras

Patients who abuse tramadol generally combine their medication with other medications or substances to elevate their effects. This form of abuse is referred to as polydrug abuse.

Tramadol is most commonly combined with substances such as:

• Other painkillers
• Sedatives, like benzodiazepines and sleeping pills
• Cold medicine
• Alcohol

The risk of developing a tramadol addiction is higher during polydrug use. As a CNS depressant, it can be quite risky to mix tramadol with other depressants, such as sedative-hypnotics, alcohol, and opioids. Mixing these substances can result in an overdose that could have fatal consequences.

Symptoms of tramadol overdose can include:

• Unconsciousness
• Seizures
• Coma
• Sweating or clammy skin
• Weak muscles
• Abnormally low blood pressure
• Pinpoint pupils
• Sleepiness
• Death

Another potentially hazardous side effect of tramadol misuse is serotonin syndrome, which can be life-threatening if left untreated. This is caused by an excess amount of serotonin, a chemical that transmits signals to the brain is produced or persist in the brain. Serotonin syndrome is most common in patients taking antidepressants and tramadol combined.

Symptoms of serotonin syndrome include the following:

• Agitation
• Rigid muscles
• Tremors
• Jerky muscles
• Lack of co-ordination
• Coma
• Seizures
• Confusion

• 84 Percent: A 2005 study revealed that 84% of patients who consumed tramadol at very high doses experienced seizures within 24 hours.
• 1.5 Million: In 2013, for the first time, 1.5 million people had abused painkillers, such as tramadol.
• 60 Percent: From 2012 to 2013, more than 60% of individuals who used painkillers, such as tramadol, obtained the drug from friends or relatives.

Not all who misuse tramadol form an addiction. The development of both a psychological and physical dependence on tramadol is required to form an addiction.

According to the Diagnostic and Statistical Manual of Mental Disorders 11 factors define the formation of addiction. The severity of a patient’s addiction is measured depending on how many criteria the patient fulfills.

The following signs and behaviors are commonly associated with tramadol addiction:

• Social or interpersonal issues related to tramadol use
• Mood swings
• Excessive sleepiness
• Neglecting duties at home, work, or school
• Compulsive use of tramadol
• Using tramadol without a prescription or buying it from the street
• Apathy
• Unable to feel pleasure
• Impaired co-ordination
• Difficult to focus
• Vomiting from high doses
• Hiding or leaving empty prescription bottles
• Withdrawal signs following cessation of use
• Spending huge amounts of money on tramadol
• Having to consume higher doses to have the same effects
• Continued use of tramadol despite negative consequences
• Spending much of the time using, healing from, or attempting to get tramadol
• Visiting multiple physicians to obtain more tramadol (doctor shopping)

An intervention for alcoholism and drug abuse for someone who has an addiction to tramadol should be carefully staged. It is not uncommon for a SUD patient to feel ambushed or to respond aggressively to an intervention. Gaining the services of a professional interventionist provides essential guidance and support to all individuals involved in the intervention process. Interventionists can help provide vital information to families and addicts about addiction, and help them plan and perform the intervention. When an intervention is carried out correctly, it can be a vital first step towards recovery.

When a person develops an addiction to tramadol,, quitting the medication can cause painful withdrawal symptoms. Even the use of tramadol, as recommended by a doctor, may lead to dependence and withdrawal.

Withdrawal and tolerance results from the user’s body being chemically reliant or changed by taking tramadol continuously. This may occur even after a few weeks of tramadol consumption. When a patient develops a tolerance to the drug, they may require higher and higher doses to feel the desired effects. This is caused by the body’s gradual resistance to tramadol. In comparison, dependence causes patients to consume the drug on a daily basis to function as normal. Due to the abundance of tramadol, the brain tries to self-regulate by speeding and slowing down some of its processes. If the patient abruptly ceases consuming the medication, the brain may experience an imbalance, causing mild, moderate, or extreme withdrawal symptoms.

Generally, the withdrawal effects of tramadol should last just 5-7 days if a suitable tapering procedure is used. Some symptoms that last more than a week are called post-acute withdrawal symptoms or PAWS symptoms. PAWS can last from 18-24 months, but may decrease in intensity over time.

Symptoms of PAWS may include:

• Anxiety
• Mood swings
• Depression
• Insomnia
• Reduced appetite
• Poor concentration
• Irritability

Tramadol alleviates pain better than other opioids, such as hydrocodone, as it relieves discomfort by activating opioid receptors in the brain and inhibiting the reuptake of two neurotransmitters: norepinephrine and serotonin. As a result, tramadol patients may experience two types of withdrawal: conventional opioid withdrawal and atypical opioid withdrawal syndrome. This is unconventional as it does not occur in other opioids. This could also mean that patients who experience tramadol withdrawal may encounter two separate sets of symptoms.

Standard withdrawal signs of opioid include:

• Gastrointestinal pain
• Vomiting
• Muscle aches
• Diarrhea
• Body pains
• Nausea

Atypical opioid withdrawal syndrome symptoms include:

• Intense paranoia
• Confusion and disorientation
• Depersonalization
• High anxiety and panic attacks
• Unusual sensory experiences, including numbness and prickling in the extremities
• Hallucinations

Although these atypical symptoms are usually not life-threatening, they place users at significant risk of making poor decisions or placing themselves in risky situations. Hence, it is strongly advised to detoxify in an inpatient, medically controlled detox center.

The signs of tramadol withdrawal may differ from patient to patient.

Common tramadol withdrawal symptoms may include:

• Cravings
• Nausea and vomiting
• Headaches
• Restlessness
• Sweating
• Confusion
• Muscle pain
• Blurred vision
• Tingling sensations
• Agitation
• Diarrhea
• Dizziness
• Abdominal cramps
• Tremors
• Nightmares

Withdrawal symptoms typically begin within hours of discontinuation and may last for a few weeks. Many factors can affect the duration and severity of withdrawal symptoms, such as the duration of tramadol addiction, how frequently the medication was administered, and the dosage.

Withdrawal symptoms during tramadol detox can be severe and should be performed under medical supervision. The tapering down method is best suited when detoxing from tramadol. During this process, a doctor will gradually lower your doses of tramadol over a certain period to help alleviate severe withdrawal symptoms. Although this process may take weeks to complete, it is the safest method of detox.

If symptoms are not well managed, a doctor can prescribe medications (Medication-assisted or MAT) to help alleviate certain withdrawal symptoms, such as:

• Loperamide for diarrhea
• Clonidine for anxiety and sweating
• Valium for anxiety and insomnia
• Ibuprofen or acetaminophen for muscle aches
• Suboxone (a combination of Buprenorphine and Naloxone) for relieving withdrawal symptoms and eliminating the euphoric effects of opioids
• Buprenorphine (Subutex) for relieving withdrawal symptoms
• Metoclopramide for nausea and vomiting

Recovering from tramadol addiction generally involves drug detox, an inpatient or outpatient treatment program along with ongoing therapy and support groups. Medically-assisted detox is necessary to overcome tramadol addiction, and detox is available in most inpatient and outpatient rehab services. While detoxification helps patients relieve their physical dependence on tramadol, therapy provided at inpatient or outpatient treatment centers help address their psychological dependence on the medication.

Inpatient treatment & recovery is the best choice for patients diagnosed with severe addiction and co-occurring psychiatric illnesses. Inpatient treatment services offer a high degree of care and allow tramadol patients to immerse themselves in treatment without any distractions. Residential recovery facilities typically provide services lasting from 28 to 90 days. However, the duration of stay can be extended depending upon the patient’s needs and requirements. Many inpatient rehabilitation centers operate under strict guidelines and require their patients to comply with the timetable.

Medical rehabilitation is provided by many inpatient rehabs to help tramadol patients conquer their physical dependence on opioids. Residential centers also offer many treatment strategies to address the psychological aspects of addiction, such as:

• Biofeedback therapy
• One-on-one counseling
• Holistic therapy
• Group therapy
• Dialectical behavior therapy (DBT)
• Art therapy
• Yoga therapy
• Motivational enhancement therapy (MET)
• 12-step programs
• Support groups
• Equine and pet therapy
• Cognitive-behavioral therapy (CBT)

Outpatient care is best suited for those diagnosed with mild to moderate addictions. It is also a sound choice for those who cannot join a residential program due to unavoidable commitments such as jobs, education, or children. Outpatient treatment is normally less expensive than inpatient rehabilitation.

Outpatient treatment programs are also prescribed as post-treatment or step-down programs for patients who complete inpatient treatment, as it provides them the additional support they require to help them gradually transition back to society. During this process, tramadol patients can consult with a doctor regularly to help them manage withdrawal symptoms. Outpatient treatment also includes attending support groups and counseling to assist with anxiety, cravings, and other psychological aspects of tramadol addiction.

Continuing with counseling and support groups, such as Narcotics Anonymous and SMART Rehabilitation, are excellent follow-up services after inpatient and outpatient treatment programs. Continued counseling helps tramadol patients address their psychological issues under the guidance of a psychiatrist. Connecting with other recovering patients at support group meetings help patients expand their support network and be held accountable for their actions.
Tips for avoiding relapse following treatment for tramadol addiction may include:

• Exercise and eat healthy: Give your body the right nutrition and exercise. The healthier you are, the better you are going to feel.
• Sleep: Sleep plays a significant role in how a person feels both mentally and physically. Consistently having a good night’s sleep will boost focus, energy levels, and mental clarity.
• Stick to the schedule: Following a strict schedule helps keep cravings at bay as it keeps your mind occupied.
• Identify the triggers: Avoid friends, locations, and events that make you want to use tramadol. Please make your support network aware of these causes.
• Build your support network: Having a strong support group around you is critical. These people can help you avoid triggers and get back on track when you relapse. A support network can consist of family, colleagues, therapists, sponsors, counselors, and others you meet at support groups.
• Get involved: Discovering new, sober interests and activities will help you greatly prolong your sobriety. It provides a great opportunity to socialize without the use of addictive substances as well as provide you with a fun distraction to keep you occupied.
• Find alternative pain management methods: Those who consumed tramadol to treat chronic pain will require alternative pain management treatments such as yoga, hot pads, massage therapy, ice packs, physical therapy, or acupuncture.