Is Tramadol the New OxyContin?
The epidemic of painkiller addiction is well known, and OxyContin (oxycodone) has arguably been the most notorious prescription opioid at the center of this public health emergency. Drugs like OxyContin have filled the news in recent years due to rampant overprescribing, “pill mills,” and staggering rates of abuse.
To counteract the spiraling threat of opioid addiction, drug and medical care providers have taken numerous steps to formulate and dispense drugs that have a lower risk of abuse and dependence than many of the opioid analgesics (painkillers) that exist on the market. Tramadol (another opioid analgesic) was initially thought to be a “safe” alternative to other opiates. However, evidence is showing that abuse rates for tramadol are beyond what anyone expected and that the drug may actually be much more addictive than originally believed.
Is Tramadol as Addictive as OxyContin?
The Food and Drug Administration (FDA) first approved tramadol for use in the US in 1994. Results from animal and human studies indicated that tramadol was less addictive than other opiates, so it was classified as a non-scheduled drug. This meant that tramadol was not regulated by the Drug Enforcement Administration (DEA), and there were far fewer restrictions on its use than other narcotic painkillers.
Some human studies have shown that high doses of tramadol have similar effects to oxycodone, an opioid painkiller with a well-known risk of abuse and dependence. Opioid abusers that were given high-dose tramadol reported that it gave them an enjoyable “high” that was similar to codeine and somewhat less intense than oxycodone 1. Subjects in another study were given a dose of tramadol often prescribed to patients, and they rated the drug as pleasurable and something they would like to “take again” 2.
In addition to positive effects, individuals taking tramadol sometimes experience withdrawal effects. These withdrawal symptoms have been reported both when tramadol is stopped suddenly and sometimes even when a doctor decreases a patient’s dose. Many of these symptoms of withdrawal are similar to those caused by withdrawal from other opiates, including oxycodone.
Tramadol's Unique Withdrawal Symptoms
Tramadol withdrawal symptoms – somewhat unique amongst the opioid analgesics – may include 3:
- Severe anxiety and panic attacks.
- Tinnitus (ringing in the ears).
Symptoms of acute opioid withdrawal may consist of some or all of the following 3:
- Abdominal cramps.
- Chills and goose bumps.
- Muscular and/or bone aches and pains.
- Lacrimation (watery eyes).
- Rhinorrhea (runny nose).
Despite the similarities, there are also some important differences between tramadol and typical opioids. Most of these differences are due to the fact that tramadol not only activates opiate receptors but also increases the brain levels of two important neurotransmitters, serotonin and norepinephrine.
Tramadol’s actions on serotonin and norepinephrine contribute to its pain-relieving effects and also cause side effects and withdrawal symptoms not normally seen with other narcotics.
Tramadol’s unique effects also render the usual antidote for opioid overdose, naloxone, less effective in cases of tramadol overdose, making it more difficult to treat individuals who overdose on this drug.
OxyContin: The Well-Known Danger
In 2013, nearly 59 million oxycodone prescriptions were filled by US pharmacies 4, and its abuse has been a major concern in recent years.
Several studies have shown that when taken either in pill form or injected, oxycodone produced a “high” similar to that of heroin 5. Additionally, heroin-dependent participants in another study described oxycodone as the “Rolls Royce” of opioids and described it as producing a “smooth” high 6.
Following the introduction of an extended-release form of the drug – marketed as OxyContin –rates of oxycodone abuse skyrocketed. This is because each pill of OxyContin contains a high dose of the drug that is intended for slow, controlled release over several hours. However, abusers quickly discovered that by snorting or injecting crushed OxyContin tablets, they could release the full dose all at once and experience the full brunt of its extremely potent and dangerous effects.
Oxycodone is well known to result in the development of physical dependence and, ultimately, opioid addiction in individuals who abuse the drug. Long-time users who stop taking oxycodone suddenly often suffer from classic symptoms of opiate withdrawal.
Oxycodone has been recognized for its abuse potential since the 1960s. The allure of the opioid high is so strong, that problematic users are at high risk of progressing towards heroin abuse should they lose access to a steady supply of pills, or if oxycodone becomes too expensive—and both phenomena happen quite often. In fact, the transition of opioid-dependent individuals from pills to heroin has been largely blamed for the dramatic increase in heroin use in the last decade 7.
Tramadol: The Emerging Concern
Concern is growing that tramadol may become the new opioid of choice for abusers. This drug has addictive potential, and studies in animals and humans have shown that it can produce a euphoric high similar to oxycodone and heroin. Concern is growing that tramadol may become the new opioid of choice for abusers. This drug has addictive potential, and studies in animals and humans have shown that it can produce a euphoric high similar to oxycodone and heroin.
Despite having similar effects to these drugs, tramadol is also up to 20 times cheaper than oxycodone and easier to get from Internet pharmacies 8. This is because, until 2014, tramadol was not a controlled substance and is still offered to those without a prescription by some less reputable online suppliers.
Because of concerns about the possibility of tramadol abuse, the prescribing and usage patterns of this drug were monitored for several years after it was first marketed in the US. After 3 years, abuse rates were reported to be fewer than 2 patients per 100,000 9, which seemed to confirm the idea that tramadol abuse was not a major issue. However, despite this early evidence suggesting that tramadol was not addictive, many experts remained concerned about possible abuse because nearly all known narcotics that activate µ-opioid (mu-opioid) receptors had eventually proven themselves addictive.
These concerns seem well founded according to the following statistics:
- The National Survey on Drug Use and Health (NSDUH) reported that 2 million Americans aged 12 or older used tramadol for non-medical purposes in 2012 10.
- Visits to emergency departments due to side effects of tramadol rose from just over 10,000 in 2005 to nearly 26,000 in 2010.
Because of the evidence of rising tramadol abuse and concerns over its potentially harmful effects, the DEA began regulating the drug as a Schedule IV controlled substance on July 2014 12. Schedule IV drugs are subject to governmental controls but are considered to have a relatively low potential for abuse and dependence.
In seeking public comments on the proposal to regulate tramadol, the DEA received more comments supporting the change than opposing it. One comment from a local prescription drug abuse task force summed up widespread concerns, designating tramadol as a “loophole” drug – both addictive and abused – with a deceptive status as a non-controlled substance leaving many patients and doctors unaware of its dangers 13.
It is very important to realize that abusing tramadol is dangerous, and can even be lethal. Some tramadol abusers crush pills with an extended release form of the drug (Ultram ER) in order to release a large dose all at once, similar in the way some individuals crush OxyContin tablets to get a more intense high. Just as with oxycodone, this method of abusing tramadol can have deadly consequences, especially because the traditional opiate antidote, naloxone, does not completely reverse tramadol overdoses.
The Lesser-Known Dangers of Tramadol
In addition to the typical dangers of an opioid drug, tramadol – with its atypical pharmacologic mechanism of action – can result in a few extra side effects that are relatively unknown but potentially lethal.
Increased serotonin levels in the brain due to excessive tramadol levels can lead to a potentially life-threatening condition known as serotonin syndrome. Left untreated, serotonin syndrome is a potentially grave condition and is marked by widespread muscle spasms and dangerous changes to an individual’s to heart rate, blood pressure, and body temperature. Patients taking antidepressants and those abusing tramadol at high doses are at particular risk of serotonin syndrome 14.
Taking tramadol also appears to carry a risk of seizures, an issue not typically associated with opiate use. Though not well understood, the risk of this side effect is higher in individuals with a history of seizures and those who combine tramadol with antidepressants, antipsychotics, alcohol, or illicit drugs 15.
Get Help for Tramadol Addiction
Treatment for addiction to tramadol, like other opioids, begins with the process of detoxification, or detox. Professional detox centers can provide medical supervision for individuals detoxing from tramadol and give them the best chance to successfully complete the process.
They can help patients through a process of drug tapering, or slowly decreasing the dose they take over several days or weeks, to minimize the most uncomfortable symptoms of opiate withdrawal. Detox centers can also provide a safe environment for people experiencing symptoms specific to tramadol withdrawal such as hallucinations and panic attacks and keep them from putting others around them in danger.
Following detox, people recovering from tramadol dependence are strongly encouraged to complete an inpatient or outpatient drug treatment program. Rehabilitation programs can last from several weeks to several months and offer both medical and behavioral therapies to help their clients permanently break the cycle of addiction.
The cycle of addiction can be difficult, if not impossible, to stop alone. If you or a loved one is struggling with tramadol dependence, there are resources available to help. Call us today at 1-888-744-0069Who Answers? to start hearing about the solutions that are out there. We can help you find out about your options and decide what next steps make the most sense for you.
- Babalonis, S., Lofwall, M. R., Nuzzo, P. A., Siegel, A. J., & Walsh, S. L. (2013). Abuse liability and reinforcing efficacy of oral tramadol in humans. Drug Alcohol Depend, 129(1-2), 116-124. doi:10.1016/j.drugalcdep.2012.09.018
- Zacny, J. P. (2005). Profiling the subjective, psychomotor, and physiological effects of tramadol in recreational drug users. Drug Alcohol Depend, 80(2), 273-278. doi:10.1016/j.drugalcdep.2005.05.007
- Senay, E. C., Adams, E. H., Geller, A., Inciardi, J. A., Munoz, A., Schnoll, S. H., . . . Cicero, T. J. (2003). Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend, 69(3), 233-241. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12633909
- Drug Enforcement Administration. (2014). Oxycodone. Retrieved from http://www.deadiversion.usdoj.gov/drug_chem_info/oxycodone/oxycodone.pdf
- Stoops, W. W., Hatton, K. W., Lofwall, M. R., Nuzzo, P. A., & Walsh, S. L. (2010). Intravenous oxycodone, hydrocodone, and morphine in recreational opioid users: abuse potential and relative potencies. Psychopharmacology (Berl), 212(2), 193-203. doi:10.1007/s00213-010-1942-4
- Comer, S. D., Sullivan, M. A., Whittington, R. A., Vosburg, S. K., & Kowalczyk, W. J. (2008). Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology, 33(5), 1179-1191. doi:10.1038/sj.npp.1301479
- Kuehn, B. M. (2013). SAMHSA: Pain medication abuse a common path to heroin: experts say this pattern likely driving heroin resurgence. JAMA, 310(14), 1433-1434. doi:10.1001/jama.2013.278861
- Dasgupta, N., Freifeld, C., Brownstein, J. S., Menone, C. M., Surratt, H. L., Poppish, L., . . . Dart, R. C. (2013). Crowdsourcing black market prices for prescription opioids. J Med Internet Res, 15(8), e178. doi:10.2196/jmir.2810
- Cicero, T. J., Adams, E. H., Geller, A., Inciardi, J. A., Munoz, A., Schnoll, S. H., . . . Woody, G. E. (1999). A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Drug Alcohol Depend, 57(1), 7-22. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10617309
- Center for Behavioral Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed Tables. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2013/NSDUH-DetTabs2013.htm
- Bush, D. M. (2015). The CBHSQ Report: Emergency Department Visits for Adverse Reactions Involving the Pain Medication Tramadol. Retrieved from Rockville, MD: http://www.samhsa.gov/data/sites/default/files/report_1965/ShortReport-1965.html
- Administration, D. E. (2014). Tramadol. Retrieved from http://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf
- Drug Enforcement Administration. (2014). Final Rule: Placement of Tramadol Into Schedule IV. Retrieved from http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0702.htm
- Beakley, B. D., Kaye, A. M., & Kaye, A. D. (2015). Tramadol, Pharmacology, Side Effects, and Serotonin Syndrome: A Review. Pain Physician, 18(4), 395-400. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26218943
- Boostani, R., & Derakhshan, S. (2012). Tramadol induced seizure: A 3-year study. Caspian J Intern Med, 3(3), 484-487. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24009919