|Year : 2012 | Volume
| Issue : 3 | Page : 283-285
Tramadol dependence: A case series from India
Siddharth Sarkar, Naresh Nebhinani, Shubh M Singh, Surendra K Mattoo, Debasish Basu
Department of Psychiatry, Drug De-addiction Treatment Centre, PGIMER, Chandigarh, India
|Date of Web Publication||14-Jan-2013|
Department of Psychiatry, Cobalt Block, Level 3, Nehru Hospital, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Tramadol is an atypical, centrally acting, synthetic analgesic, acting through opioid and non-opioid systems. We present a series of seven cases, all men, who sought treatment at our centre for tramadol-dependence. The majority were using other opioids at some point in their lives. Their tramadol use had begun with a prescription of tramadol for opioid detoxification, for headache and body pains, and as an alternative to injectable opioids. The doses of tramadol used varied from 50 to 1500 mg per day. All subjects reported an experience of euphoria with tramadol use. Four patients were put on naltrexone, but had poor compliance. This case series underscores the need for caution, while using tramadol in substance-dependent patients.
Keywords: Abuse, dependence, series, tramadol
|How to cite this article:|
Sarkar S, Nebhinani N, Singh SM, Mattoo SK, Basu D. Tramadol dependence: A case series from India. Indian J Psychol Med 2012;34:283-5
|How to cite this URL:|
Sarkar S, Nebhinani N, Singh SM, Mattoo SK, Basu D. Tramadol dependence: A case series from India. Indian J Psychol Med [serial online] 2012 [cited 2015 Apr 1];34:283-5. Available from: http://www.ijpm.info/text.asp?2012/34/3/283/106038
| Introduction|| |
Tramadol is an atypical, centrally acting, synthetic, analgesic. Its antinociceptive effects are mediated by a combination of μ-opioid agonist effects, and norepinephrine and serotonin reuptake inhibition, and it can suppress opioid withdrawal.  The drug is easily available and widely prescribed for pain management.
First marketed in the 1970s, tramadol was said to have a low-abuse potential. ,, However, its abuse liability and diversion were soon recognized, with several reports on physical dependence. ,,,,,, The largest series of tramadol-dependence was reported from a study in Sweden,  comprising of 104 patients, where the majority were women. In another series 97% of the abusers had a history of abuse of other substances.  Association with seizures at therapeutic and toxic doses has been reported,  as has been the abuse among occupations like physicians  and air force personnel. 
In India, because of the laxity in drug regulation implementation, opioids are often available over-the-counter; increasing the risk of opioid misuse. However, we could trace only one case report of tramadol-dependence from India.  We present a series of seven cases seeking treatment at our centre for tramadol-dependence.
| Case Reports|| |
The seven cases with tramadol-dependence, diagnosed as per ICD-10,  sought treatment at the Drug De-addiction and Treatment Centre, Department of Psychiatry, PGIMER, Chandigarh [Table 1]. Their age ranged from 24 to 46 years. The dose of tramadol, taken on a regular basis, ranged 50 mg to 1500 mg per day. The reported reasons for initiation of tramadol included, as an alternate to other opioids, to counter opioid withdrawal, and being prescribed for headache and opioid detoxification. Six of the seven patients had been using other opioids at some point in their lives. Four subjects, treated as inpatients and started on oral opioid antagonist naltrexone 50 mg / day, showed poor treatment compliance. One patient, who had earlier relapsed while taking oral naltrexone, was prescribed an oral buprenorphine-naloxone combination. Another patient reported generalized tonic-clonic seizures with therapeutic and toxic doses of oral tramadol. Four patients remained abstinent during the period of follow-up.
| Discussion|| |
As an opioid-type analgesic, which exerts its effects through multiple receptor systems, tramadol carries a dependence producing potential.  This needs to be taken into consideration when detoxifying the patient from other opioids. In three of our patients, initiation of tramadol use had begun with a prescription of tramadol for detoxification; they were not able to taper the doses of tramadol as per prescription. Experience of euphoria with tramadol was also reported. Thus, tramadol is used by opioids-dependent subjects as a substitute for the unavailable 'harder' drugs.
Detoxification of our patients was done largely with oral clonidine and non-steroidal anti-inflammatory drugs (NSAIDs), as reported by some,  but not others who used the buprenorphine-naloxone combination and methadone for tramadol-detoxification. ,
Apart from those patients with medical disorders using tramadol; , the drug has the potential for abuse by opioids-dependent subjects. Given the easy availability of tramadol from pharmacies in India and some other countries, its abuse and diversion may become a bigger challenge in the future. There is a need to effectively regulate the distribution of this medication, and apply the appropriate safeguards, to prevent diversion.
This case series adds to the growing concern about tramadol-dependence. It emphasizes the need for caution before prescribing tramadol to patients, especially those who are opioids-dependent, and to apprise the drug regulatory authorities of such occurrences, for proper scheduling and issue of warnings.
| References|| |
|1.||Duke AN, Bigelow GE, Lanier RK, Strain EC. Discriminative stimulus effects of tramadol in humans. J Pharmacol Exp Ther 2011;338:255-62. |
|2.||Preston KL, Jasinski DR, Testa M. Abuse potential and pharmacological comparison of tramadol and morphine. Drug Alcohol Depend 1991;27:7-17. |
|3.||Woody GE, Senay EC, Geller A, Adams EH, Inciardi JA, Schnoll S, et al. An independent assessment of MED-Watch reporting for abuse / dependence and withdrawal from Ultram (tramadol hydrochloride). Drug Alcohol Depend 2003;72:163-8. |
|4.||Adams EH, Breiner S, Cicero TJ, Geller A, Inciardi JA, Schnoll SH, et al. A comparison of the abuse liability of tramadol, NSAIDs, and hydrocodone in patients with chronic pain. J Pain Symptom Manage 2006;31:465-76. |
|5.||Inciardi JA, Cicero TJ, Munoz A, Adams EH, Geller A, Senay EC, et al. The diversion of Ultram, Ultracet, and generic tramadol HCL. J Addict Dis 2006;25:53-8. |
|6.||Ehrenreich H, Poser W. Dependence on tramadol. Clin Investig 1993;72:76. |
|7.||Freye E, Levy J. Acute abstinence syndrome following abrupt cessation of long-term use of tramadol (Ultram): A case study. Eur J Pain 2000;4:307-11. |
|8.||Yates WR, Nguyen MH, Warnock JK. Tramadol dependence with no history of substance abuse. Am J Psychiatry 2001;158:964. |
|9.||Senay EC, Adams EH, Geller A, Inciardi JA, Munoz A, Schnoll SH, et al. Physical dependence on Ultram (tramadol hydrochloride): Both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend 2003;69:233-41. |
|10.||Barsotti CE, Mycyk MB, Reyes J. Withdrawal syndrome from tramadol hydrochloride. Am J Emerg Med 2003;21:87-8. |
|11.||Stoehr JD, Essary AC, Ou C, Ashby R, Sucher M. The risk of tramadol abuse and dependence: Findings in two patients. JAAPA 2009;22:31-2, 34-5 |
|12.||Pollice R, Casacchia M, Bianchini V, Mazza M, Conti CM, Roncone R. Severe tramadol addiction in a 61 year-old woman without a history of substance abuse. Int J Immunopathol Pharmacol 2008;21:475-6 |
|13.||Tjäderborn M, Jönsson AK, Ahlner J, Hägg S. Tramadol dependence: A survey of spontaneously reported cases in Sweden. Pharmacoepidemiol Drug Saf 2009;18:1192-8 |
|14.||Cicero TJ, Adams EH, Geller A, Inciardi JA, Munoz A, Schnoll SH, et al. A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Drug Alcohol Depend 1999;57:7-22. |
|15.||Jovanovic-Cupic V, Martinovic Z, Nešic N. Seizures Associated with Intoxication and Abuse of Tramadol. Clin Toxicol 2006;44:143-6. |
|16.||Skipper GE, Fletcher C, Rocha-Judd R, Brase D. Tramadol abuse and dependence among physicians. JAMA 2004;292:1818-9. |
|17.||Ojha R, Bhatia SC. Tramadol Dependence in a Patient With No Previous Substance History. Prim Care Companion J Clin Psychiatry 2010;12: / PCC.09100779. |
|18.||Saini R, Prakash J. C. Armed Forces Med J India 2010;66:093. |
|19.||World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. |
|20.||Dayer P, Collart L, Desmeules J. The pharmacology of tramadol. Drugs 1994;47 Suppl 1:3-7. |
|21.||Leo RJ, Narendran R, DeGuiseppe B. Methadone detoxification of tramadol dependence. J Subst Abuse Treat 2000;19:297-9. |
|22.||Ritvo JI, Koonce R, Thurstone CC, Causey HL 3rd. Tramadol dependence: Treatment with buprenorphine / naloxone. Am J Addict 2007;16:67-8. |