Tramadol

Pain relief Tramadol is used primarily to treat mild to severe pain, both acute and chronic. There is moderate evidence for use as a second-line treatment for fibromyalgia, but it is not FDA-approved for this use. Its use is approved for treatment of fibromyalgia as a secondary painkiller by the UK NHS. Its analgesic effects take approximately an hour to be realized, and it takes from two to four hours to reach peak effect after oral administration with an immediate-release formulation. For moderate pain, its effectiveness is roughly equivalent to that of codeine in low doses and hydrocodone at very high doses. For severe pain, it is less effective than morphine. that is, RLS that does not respond adequately to treatment with first-line medications such as dopamine agonists (e.g., pramipexole) or gabapentinoids, often due to augmentation. Premature ejaculation Tramadol, due to its activity as a serotonin reuptake inhibitor, is effective in the treatment of premature ejaculation per systematic reviews and meta-analyses and is used off-label for this indication. ==Contraindications==

Pregnancy and lactation Use of tramadol during pregnancy is generally avoided, as it may cause some reversible withdrawal effects in the newborn. A small prospective study in France found, while an increased risk of miscarriages existed, no major malformations were reported in the newborn. The FDA lists age under 12 years old as a contraindication. Elderly The risk of opioid-related adverse effects such as respiratory depression, falls, cognitive impairment, and sedation is increased. Liver and kidney failure The drug should be used with caution in those with liver or kidney failure, due to metabolism in the liver (to the active molecule desmetramadol) and elimination by the kidneys. ==Side effects==

The most common adverse effects of tramadol include nausea, dizziness, dry mouth, indigestion, abdominal pain, vertigo, vomiting, constipation, drowsiness, and headache. Other side effects may result from interactions with other medications. Tramadol has the same dose-dependent adverse effects as morphine including respiratory depression. Dependence and withdrawal Long-term use of high doses of tramadol causes physical dependence and withdrawal syndrome. These include both symptoms typical of opioid withdrawal and those associated with serotonin–norepinephrine reuptake inhibitor (SNRI) withdrawal; symptoms include numbness, tingling, paresthesia, and tinnitus. Psychiatric symptoms may include hallucinations, paranoia, extreme anxiety, panic attacks, and confusion. In most cases, tramadol withdrawal will set in 12–20 hours after the last dose, but this can vary. Tramadol withdrawal typically lasts longer than that of other opioids. Seven days or more of acute withdrawal symptoms can occur as opposed to typically 3 or 4 days for other codeine analogs. ==Overdose==

The clinical presentation in overdose cases can vary but typically includes neurological, cardiovascular, and gastrointestinal manifestations. The predominant neurological symptoms are seizures and altered levels of consciousness, ranging from somnolence to coma. Seizures are particularly notable due to tramadol's lowering of the seizure threshold, occurring in approximately half of acute poisoning cases. Patients often exhibit tachycardia and mild hypertension. Gastrointestinal disturbances such as nausea and vomiting are common, and agitation, anxiety, and cold and clammy skin may also be present. While less common, severe complications like respiratory depression and serotonin syndrome can occur, particularly in polydrug overdoses involving other CNS depressants (such as benzodiazepines, opioids, and alcohol) and agents with serotonergic activity. Additionally, individuals with genetic variations leading to CYP2D6 enzyme duplication (rapid metabolizers) may have an increased risk of adverse effects, due to faster conversion of tramadol to its active metabolite. Acute tramadol overdose is generally not life-threatening, with most fatalities resulting from polysubstance overdose. Management includes cardiovascular monitoring, activated charcoal administration, hydration, and treatment of seizures. Naloxone, an opioid antagonist, can partially reverse some effects of tramadol overdose, particularly respiratory depression. Its use may increase the risk of seizures due to unopposed alpha-adrenergic stimulation, but some studies suggest naloxone may not significantly increase risk of seizure in acute overdose. In 2013, England and Wales recorded 254 tramadol-related deaths, while Florida reported 379 cases in 2011. In 2011, 21,649 emergency room visits in the United States were related to tramadol. The likely explanation for these observations is due to increase in frequency of prescriptions and use due to easier access due to lighter regulatory scheduling by authorities but this is starting to change. In 2021, Health Canada announced tramadol would be added to Schedule I of the Controlled Drugs and Substances Act and to the Narcotic Control Regulations due to tramadol being suspected of having contributed to 18 reported deaths in Canada between 2006 and 2017. ==Interactions==

Tramadol can have pharmacodynamic, pharmacokinetic, and pharmacogenetic interactions. Tramadol is metabolized by CYP2D6 enzymes which contributes to the metabolism of approximately 25% of all medications. Any medications with the ability to inhibit or induce these enzymes may interact with tramadol. These include common antiarrhythmics, antiemetics, antidepressants (sertraline, paroxetine, and fluoxetine in particular), antipsychotics, analgesics, and tamoxifen. Due to tramadol's serotonergic effects, tramadol has the potential to contribute to the development of an acute or chronic hyper-serotonin state called serotonin syndrome when used concurrently with other pro-serotonergic medications such as antidepressants (SSRIs, SNRIs, tricyclics, MAOIs), antipsychotics, triptans, cold medications containing dextromethorphan, and some herbal products such as St. John's wort. Concurrent use of 5-HT3 antagonists such as ondansetron, dolasetron, and palonosetron may reduce the effectiveness of both drugs. Tramadol also acts as an opioid agonist and thus can increase the risk for side effects when used with other opioid and opioid-containing analgesics (such as morphine, pethidine, tapentadol, oxycodone, fentanyl, and Tylenol 3). Tramadol increases the risk for seizures by lowering the seizure threshold. Using other medications that lower seizure threshold – such as antipsychotic medications, bupropion (an anti-depressant and smoking cessation drug), and amphetamines – can further increase this risk. ==Pharmacology==

Mechanism of action Tramadol induces analgesic effects through a variety of different targets on the noradrenergic system, serotonergic system, and opioid receptors system. Tramadol affects serotonin and norepinephrine reuptake inhibition similarly to certain antidepressants known as serotonin–norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine. Tramadol exists as a racemic mixture, the positive enantiomer inhibits serotonin reuptake while the negative enantiomer inhibits noradrenaline re-uptake, by binding to and blocking the transporters. All of these actions may work synergistically to induce analgesia. Tramadol has been found to possess these actions: As such, desmetramadol is exclusively responsible for the opioid effects of tramadol. Both tramadol and desmetramadol have pronounced selectivity for the MOR over the DOR and KOR in terms of binding affinity. The serotonin releasing effects of tramadol could be blocked by sufficiently high concentrations of the serotonin reuptake inhibitor 6-nitroquipazine, which is in accordance with other serotonin releasing agents such as fenfluramine and MDMA. In addition to serotonergic activity, tramadol is also a norepinephrine reuptake inhibitor. The estimated median effective dose (ED50) for SERT occupancy hence was 98.1 mg, which was associated with a plasma tramadol level of about 330 ng/mL (1,300 nM). Some accumulation of tramadol occurs with chronic administration; peak plasma levels with the maximum oral daily dosage (100 mg ) are about 16% higher and the area-under-the-curve levels 36% higher than following a single oral 100-mg dose. Conversely, brain levels of desmetramadol "only slowly approach those in plasma". Correspondence to effects Co-administration of quinidine, a potent CYP2D6 enzyme inhibitor, with tramadol, a combination which results in markedly reduced levels of desmetramadol, was found not to significantly affect the analgesic effects of tramadol in human volunteers. However, other studies have found that the analgesic effects of tramadol are significantly decreased or even absent in CYP2D6 poor metabolizers. Pharmacologically, tramadol is similar to tapentadol and methadone in that it not only binds to the MOR, but also inhibits the reuptake of serotonin and norepinephrine Tramadol has inhibitory actions on the 5-HT2C receptor. Antagonism of 5-HT2C could be partially responsible for tramadol's reducing effect on depressive and obsessive–compulsive symptoms in patients with pain and co-morbid neurological illnesses. Nausea and vomiting caused by tramadol are thought to be due to activation of the 5-HT3 receptor via increased serotonin levels. Phase II hepatic metabolism renders the metabolites water-soluble, which are excreted by the kidneys. Thus, reduced doses may be used in renal and hepatic impairment. Its volume of distribution is around 306 L after oral administration and 203 L after parenteral administration. ==Chemistry==

Tramadol is marketed as a racemic mixture of both R- and S-stereoisomers, Tramadol has two stereogenic centers at the cyclohexane ring. Thus, may exist in four different configurational forms: • (1R,2R)-isomer • (1S,2S)-isomer • (1R,2S)-isomer • (1S,2R)-isomer The synthetic pathway leads to the racemate (1:1 mixture) of (1R,2R)-isomer and the (1S,2S)-isomer as the main products. Minor amounts of the racemic mixture of the (1R,2S)-isomer and the (1S,2R)-isomer are formed as well. The isolation of the (1R,2R)-isomer and the (1S,2S)-isomer from the diastereomeric minor racemate [(1R,2S)-isomer and (1S,2R)-isomer] is realized by the recrystallization of the hydrochlorides. The drug tramadol is a racemate of the hydrochlorides of the (1R,2R)-(+)- and the (1S,2S)-(−)-enantiomers. The resolution of the racemate [(1R,2R)-(+)-isomer / (1S,2S)-(−)-isomer] was described employing (R)-(−)- or (S)-(+)-mandelic acid. This process does not find industrial application, since tramadol is used as a racemate, despite known different physiological effects of the (1R,2R)- and (1S,2S)-isomers, because the racemate showed higher analgesic activity than either enantiomer in animals and in humans. Detection in biological fluids Tramadol and desmetramadol may be quantified in blood, plasma, serum, or saliva to monitor for abuse, confirm a diagnosis of poisoning or assist in the forensic investigation of a sudden death. Most commercial opiate immunoassay screening tests do not cross-react significantly with tramadol or its major metabolites, so chromatographic techniques must be used to detect and quantify these substances. The concentration of desmetramadol in the blood or plasma of a person who has taken tramadol is generally 10–20% that of the parent drug. Discrepant reports on natural agency In 2013, researchers Michel de Waard (then at Université Joseph Fourier, Grenoble and Grenoble Institute of Neuroscience, La Tronche) reported in Angewandte Chemie that tramadol was found in relatively high concentrations (>1%) in the roots of the African pin cushion tree, Nauclea latifolia, concluding that it was a natural product in addition to its being a later human synthetic, and presenting a putative biosynthetic hypothesis for its origin. In 2014, Michael Spiteller (Technische Universität Dortmund) and collaborators reported results, also in Angewandte Chemie, that supported the conclusion that the presence of tramadol in those tree roots was the result of tramadol having been ingested by humans and having been administered to cattle (by farmers in the region); Spiteller et al. presented data that tramadol and its metabolites were present in animal excreta, which they then argue contaminated soil around the trees. The point was made that samples were taken from trees that grew in national parks, where livestock were forbidden, and it quoted de Waard extensively, who stated that "thousands and thousands of tramadol-treated cattle sitting around a single tree and urinating" would be required to produce the concentrations discovered. ==Society and culture==

Formulations Available dosage forms include liquids, syrups, drops, elixirs, effervescent tablets, and powders for mixing with water, capsules, tablets including extended-release formulations, suppositories, compounding powder, and injections. ER Tramadol was protected by US patents nos. 6,254,887 and 7,074,430. The FDA listed the patents' expiration as 10 May 2014. Legal status Effective August 2014, tramadol has been placed into Schedule IV of the federal Controlled Substances Act in the United States. Before that, some US states had already classified tramadol as a Schedule IV controlled substance under their respective state laws. Tramadol is classified in Schedule 4 (prescription only) in Australia, rather than as a Schedule 8 Controlled Drug (possession without authority illegal) like most other opioids. Effective May 2008, Sweden classified tramadol as a controlled substance in the same category as codeine and dextropropoxyphene, but allows a normal prescription to be used. In June 2014, the United Kingdom's Home Office classified tramadol as a Class C, Schedule 3 controlled drug, but exempted it from the safe custody requirement. In October 2023, New Zealand's Medsafe reclassified tramadol as a Class C2 Controlled Drug (in addition to its existing status as a prescription only medication). Effective 22 August 2025, the government of Liberia increased regulations on tramadol. Its use was "strictly limited to licensed hospital settings under the direct supervision of professional medical staff" according to the Liberian Observer. Liberian health authorities claimed that tramadol was the "most widely abused drug" in the country. Misuse Illicit use of the drug is thought to be a major factor in the success of the Boko Haram terrorist organization. When used at higher doses, the drug "can produce similar effects to heroin." It is also abused in the United Kingdom. From March 2019, the Union Cycliste Internationale (UCI) banned the drug, after riders were using the painkiller to improve their performance. ==Research==

Investigational uses of tramadol that are or have been researched include: • Diabetic neuropathy  • Antidepressant • Postherpetic neuralgia  • Adjunct to local anesthesia ==Veterinary medicine==

Tramadol was the most common opioid prescribed by American veterinarians from 2014 to 2019; however, usage has declined in subsequent years due to more recent evidence suggesting that dogs do not metabolise tramadol into O-desmethyltramadol effectively. As metabolisation of tramadol relies on cytochrome P450 enzymes, it is species dependent and even individual genetics can have a profound impact on the efficacy of tramadol. A 2021 meta-analysis of tramadol use in dogs found that although tramadol was more effective than nalbuphine and codeine, it was less effective than methadone, COX inhibitors and multimodal analgesia with poor evidence to support the use of it is an analgesic for dogs. One study comparing tramadol to meperidine found tramadol to be more effective at providing analgesia for cats undergoing ovariohysterectomy. however, when administered with paracetamol (acetaminophen) tramadol provides short-acting mechanical antinociception and when administered with ketamine oral tramadol provides adequate analgesia for chronic laminitis. Based on this evidence tramadol is not recommended to be provided on its own for analgesia in horses. ==See also==