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Tramadol Addiction

Posted on January 22, 2013 in Prescription Drug Addiction

Tramadol AddictionIn 2009 an Anti-Drug Task Force in Cairo seized a shipment of drugs containing over 2.5 million tramadol pills. That same year researchers estimated that 30% of men ages 14 to 30 years old in Cairo were addicted to tramadol, which was entering the country in large illegal shipments from China and India. Drug addiction remains an ongoing serious problem in Egypt today, especially in Cairo, where an estimated 1.4 million are drug addicted, most commonly to tramadol or heroin.

Any major drug epidemic is never about statistics, but one individual’s suffering. As one young man in Cairo said, “I would like to stop taking tramadol, because I am tired and depleted from the inside. All of my internal organs are at God’s mercy. I feel my wife will try to wake me up one day and I will not wake up.”

Tramadol has long been considered a non-addictive drug, even though it is a weak narcotic. Many countries, including the United States, do not classify it as a controlled substance. The drug is unusual in that it affects levels of serotonin, a brain chemical associated with pleasure, and therefore works something like an anti-depressant as well as a painkiller.

Within the past five years or so, drug enforcement agencies and emergency room doctors are reporting more tramadol abuse and poisonings. Tramadol is becoming more popular in the USA because it is cheap, readily available on the Internet, supposedly does not show up in urine tests, and is not a federally controlled substance. Since 2008, eight states labeled tramadol as a Schedule IV Controlled Substance. The increasing abuse of “little trammies” is probably another piece of the American epidemic to prescription pain killers.

As to whether tramadol is addictive, the Egyptian experience could be a warning to other countries throughout the world.

What Is Tramadol?

Tramadol is a weak opioid painkiller that also causes an increase in serotonin. It inhibits the reuptake of monoamine, the way MAO inhibitors like Parmate and Nardil do; but as a synthetic opiate, it also works in other nerve receptor cells to relieve pain. In that way this drug can lift mood as well as relieve pain. Tramadol is widely prescribed in the United States; the IMS Health National Prescription Audit reported 28.2 million prescriptions for it in 2009, and 22.2 million in the first nine months of 2010.

What Is the Addiction Potential Of Tramadol?

German scientists developed tramadol in the 1970s and marketed in the 1990s, so it is a relatively new drug. Its manufacturer Guenthal promoted it as a non-addictive painkiller, and as one expert put it, “It was widely prescribed over the past 40 years with limited evidence of abuse and diversion, even after generics became available.” One study found the addiction rate for pain patients to be about one in 100,000. A 2006 study of 11,352 patients who were given either Tramadol, hydrocodone, or acetaminophen products found that the addiction rates for tramadol were 2,7%; for hydrocodone, 4.9%; and for over-the-counter painkillers, 2.5%.

In 1994 the U.S. Food & Drug Administration approved tramadol as an unscheduled drug, which means doctors can prescribe freely without keeping detailed records required for addictive drugs. It remains an unscheduled drug on the federal level, but between 2005 and 2008, Arkansas, Tennessee, North Dakota and Kentucky classified it as a Schedule IV Controlled Substance. In 2011 and 2012, the states of New Mexico, Illinois, Mississippi, Wyoming, West Virginia and Oklahoma followed suit and also made it a Schedule IV, meaning it has some potential for addiction and if you are caught trafficking or possessing it without a doctor’s prescription, you face fines and jail time. Ohio and Louisiana currently classify tramadol as a chemical of concern, but not a controlled substance.

However, some research was concluding that people who use tramadol along with other addictive substances such as alcohol easily could become addicted to tramadol. In March 2012, the makers of the trademarked tramadol product Ultram –PriCara®, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.– and the U.S. Food and Drug Administration issued a warning to health care professionals that “Tramadol may be expected to have addictive effects when used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression. Tramadol has mu-opioid agonist activity. Ultram can be sought by drug abusers and people with addiction disorders and may be subject to criminal diversion. The possibility of illegal or illicit use should be considered when prescribing or dispensing Ultram in situations where the physician or pharmacist is concerned about an increased risk of misuse, abuse, or diversion. Misuse or abuse poses a significant risk to the abuser that could result in overdose and death.”

In February 2011, the U.S. Drug Enforcement Agency noted that “Because of inadequate labeling and lack of established abuse potential of tramadol, many physicians felt the drug was safe for recovering narcotic addicts and known narcotic addicts, and as a consequence, numerous reports of abuse and dependence have been received.”

What Are the Medical Uses Of Tramadol?

Doctors prescribe tramadol for moderate to moderately severe pain. It is sometimes prescribed for pain after surgery, restless leg syndrome or pain from herniated discs. Tramadol is considered to be more effective than codeine and less effective than hydrocodone for acute pain. Tramadol has been tested for use in posttraumatic stress syndrome, obsessive-compulsive disorder, and antidepressant withdrawal syndrome, and may be prescribed that way in the future.

The drug once showed promise for use in treatment for withdrawal from narcotic drugs. However, in one study of narcotic addicts who took tramadol for four weeks after stopping drugs, the researchers concluded tramadol could be used in withdrawal but not to help addicts remain drug-free because they would get addicted to tramadol.

Tramadol comes tablets, capsules, suppositories, effervescent tablets, powders, liquids, creams, gels, rectal foam, skin patches, and ampoules. The most frequent version prescribed in the United States are extended release capsules and tablets, and disintegrating tablets.

The usual dosage is 100mg once a day for the extended release version, though a doctor may increase the dosage up to 300mg per day. The 50mg tablets are taken every four to six hours with a limit of 400mg of Tramadol per day.

Does Tramadol Show Up On Drug Tests?

Tramadol can show up on specialized urine tests for two to three days after you have taken it. It can show up on police blood tests, and hair analysis tests can indicate if you used tramadol in the past. Quinine increases the concentration of tramadol in your body by 50 to 60%.

What Drugs Interact With Tramadol?

Tramadol slows down the central nervous system, so it should not be taken with any other drug that does the same thing, because you increase your risk for slowing your heart and breathing to the point of death. In general, any drug that makes you drowsy is a central nervous system depressant.

Tramadol should not be taken with alcohol, street drugs, anti-histamines, cold and allergy medicines, sedatives, tranquilizers, sleeping pills, muscle relaxants, barbiturates, drugs for seizures and/or mental illness, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase (MAO) inhibitors. Do not take tramadol with morphine, codeine or codeine cough syrups, hydrocodone, hydromorphone, oxycodone, proproxyphene, anesthetics (even ones for dental surgery), antifungal medications, Digoxin, or Demerol, or quinine. Do not take Tramadol with certain antibiotics or medications for attention deficit disorder, migraine headaches, HIV/AIDs, heart problems, cancer, or high blood pressure.

What Are The Side Effects Of Tramadol?

The most common side effects tramadol are dizziness, a spinning sensation, constipation, nervousness, lightheadedness, feeling less alert, and headaches.

Less common side effects can be seizures, hallucinations, thoughts of suicide, fever, fast heartbeat, over-reactive reflexes, nausea, vomiting, loss of coordination, diarrhea, loss of coordination, red skin rashes, and fainting. Seizures, thoughts of suicide and hallucinations are not necessarily associated with other opiate drugs.

What Are The Risks Of Taking Tramadol?

One of the main risks of tramadol is addiction, in that if you take it especially at levels not medically recommended, you will develop tolerance to the drug and need more to achieve the same effect, you will develop drug cravings and drug-seeking behaviors, and you will go into a difficult withdrawal syndrome when you try to quit using it. The risk for addition is high among those who are abusing alcohol or other drugs.

Recreational users of tramadol run two risks not associated with other narcotics: seizures and serotonin syndrome. Serotonin syndrome is a rare event that occurs when a person’s brain is flooded with serotonin after ingesting too many drugs, usually antidepressants. At first symptoms of this syndrome may appear to be not serious, even to emergency room doctors. These symptoms may include diarrhea, high blood pressure, fever, sweating, dilated pupils, anxiety and confusion, but they can eventually become more threatening and cause death.

People with addictions to Ultracet and other products that are a combination of tramadol and acetaminophen risk damage to their organs, especially their livers. If they take Ultracet in combination with alcohol, the damage is likely to occur more quickly.

A rare, life-threatening event called anaphylaxis can occur in a person who takes tramadol for the first time and is unknowingly allergic to it. Symptoms of anaphylaxis may be trouble breathing or swallowing, chest pain, hoarseness, itching, rashes, and swollen hands mouth and face. A person in anaphylaxis should be taken to an emergency room for immediate medical treatment.

Who Should Not Take Tramadol?

Tramadol should not be taken by people who have had seizures, brain or spinal infections, head injuries, brain tumors, strokes, depression, diabetes, breathing problems, and/or lung, kidney or liver diseases.

Tramadol’s manufacturer specifies the drug should not be used by people with histories of alcoholism, drug addiction or mental illness, noting that “Tramadol-related deaths have occurred in patients with previous histories of emotional disturbances or suicidal ideation or attempts as well as histories of misuse of tranquilizers, alcohol, and other CNS-active drugs.”

What Is A Tramadol Overdose?

An overdose can be a life-threatening event that occurs after you take too much tramadol or mix it with the other chemicals that depress the central nervous system. Symptoms can be seizures, difficulty breathing, irregular or slow heartbeat, shallow breathing, pale and blue lips, fingernails and skin, pinpoint pupils, and shortness of breath. Without emergency medical treatment, you can have a heart attack, enter a coma or die.

The number of people treated in U.S. emergency rooms for tramadol increased 165% between 1996 and 2002, and is probably still increasing as more Americans abuse prescription painkillers.

A seven-year study of two states found the number of tramadol poisonings decreased as much as 20% after those states made tramadol a Schedule IV Controlled Substance. However, in four states where tramadol was not controlled, tramadol poisonings increased by 14% a year.

Why Do People Abuse Tramadol?

In one study of 219 narcotic addicts, subjects told researchers they could identify feelings of euphoria and sedation after they used tramadol. One Egyptian addict described it this way, “When I take tramadol, I feel completely relaxed. I forget about my feelings and emotions. The higher the dosage, the better I feel.”

Narcotic users who post on various drug websites describe the high from 200mg of tramadol as similar to morphine or heroin. Because tramadol affects serotonin levels, it can also make people feel happier, relaxed, and less anxious. The drug is sometimes described as a gentle high and its street names of “Little trammies” and “chill pills” reflect that.

Those most likely to abuse tramadol are people in chronic pain, narcotic addicts, and healthcare professionals.

Narcotics users tend to use tramadol when their drugs of choice are not available to avoid withdrawal syndrome. Some crush the extended release tablets into a powder and then inhale it or dissolve it into a liquid for injecting. Others chew the extended release tablets to obtain full results all at once. This is a dangerous practice that can lead to death.

After a certain point, people abuse tramadol because they have become addicted to it and can’t stop.

What Is Tramadol Withdrawal Syndrome?

The tramadol withdrawal syndrome is unusual in that it can combine symptoms of classic opiate withdrawal with those associated with withdrawing from antidepressants or benzodiazepines. These symptoms are difficult or impossible to manage on your own if you stop taking this drug “cold turkey” because you can develop seizures, hallucinations, and thoughts of suicide. Some tramadol addicts are able to withdraw under a doctor’s supervision by gradually reducing the amounts they take.

Symptoms will depend on the amounts of tramadol you have been taking and how long you’ve been taking the drug, and whether you combined it with alcohol or narcotics. Acute symptoms begin 12 to 20 hours after the last dosage and can last seven days, compared to three or four for other codeine analogues.

About 90% of the people who withdraw from tramadol will have classic heroin withdrawal symptoms of flu, including fever, diarrhea, uncontrollable shaking, chills, nausea, sweating, coughing, restless legs, insomnia, tremors, muscle cramps, sneezing, runny nose, and difficulty falling asleep.

Since tramadol affects levels of serotonin in the brain, about 10% of tramadol addicts also develop hallucinations, paranoia, panic attacks, mood swings, depression, anguish, aggression, feelings of electric shock sensation in the brain and body, extreme anxiety, nightmares, confusion, thoughts of suicide, restlessness, agitation, hair standing on end, and numbness or pain in the legs, hands and arms.

Some drugs used during tramadol withdrawal can be Lorazepam and Clonidine.

One study involved a 39-year-old man with no history of drug addiction, who had been taking 600mg of tramadol a day. He described symptoms of muscle cramps, anxiety, restlessness, dysphoria (the opposite of euphoria) and complained that insects were crawling all over his body during his difficult four-day inpatient withdrawal.

What Happens In Tramadol Addiction Treatment Programs?

Tramadol addiction treatment begins with detoxification or the withdrawal in which you allow yourself to become physically free of drugs. Most tramadol addicts have been using more than one substance so their detoxification can be complicated.

The next step is dealing with psychological addiction to tramadol. The majority of people with addictions have some underlying psychiatric problem that “travels with” but did not cause the addiction. These comorbidities have to be treated as separate medical issues with their own protocols of therapy and medication. Common comorbidities are clinical depression, attention deficit disorder, panic disorder, anxiety disorder, eating disorder, bipolar disorder, and so forth.

If you enter a residential treatment center and remain there for a few months, your chances of recovering from a drug addiction will increase dramatically. Part of the reason is that you are living away from your old drug environment where certain people, places and situations trigger more drug use. You need to learn to deal with these triggers before you return to your old environment. Some people decide to remain in halfway houses or other drug-free environments for a year or more after they complete their residential treatment programs and feel stronger about avoiding relapses.

At the center of a good residential treatment program is psychotherapy and working one-on-one with a counselor. Your counselor can help you understand why you became addicted to tramadol and how you can develop a new lifestyle. Some people need to change careers or break off primary relationships in order to achieve drug-free lives. Besides one-on-one psychotherapy, you participate in group therapy, and family or couples therapy.

Other forms of therapy that have been proven helpful in tramadol addiction treatment are participating in journaling, art, music, and drama as ways of becoming more in touch with your emotions. Recovering tramadol addicts also learn relaxation techniques that they can use in place of pills, such as yoga, physical exercise, and so forth. A good residential treatment center will offer many opportunities for interesting pursuits such as parties, sightseeing, outdoor sports, and new hobbies like photography or nature watching. Treatment should not be fun, not boring, and a rare opportunity for self-exploration and growth.

When you return home, you continue to participate in support meetings in your local area and with counseling to help you remain drug-free.

How Can I Tell If I Am Addicted To Tramadol?

If you can answer yes to one or more of these questions, it is time to consult your healthcare professional or local mental health center for advice about your tramadol addiction.

  • Are you using tramadol to relieve anxiety, to relax, or for other non-medical reasons?
  • Are you taking tramadol without a prescription?
  • Are you using tramadol along with alcohol and/or other drugs?
  • Do you tell your doctor that you lost your tramadol pills in order to obtain another supply?
  • Do you use more than one doctor to get prescriptions for tramadol?
  • Do you ask your doctor for refills of tramadol even when you are not due to get a refill?
  • If you obtain tramadol by other illegal means, do you worry that you will be caught by authorities?
  • Have you ever driven a car under the influence of tramadol?
  • Do you know that tramadol is causing you certain symptoms that interfere with your performance at work or school?
  • Do your friends, family members or other loved ones criticize you for using drugs?
  • Do you take tramadol in greater amounts than your doctor prescribes?
  • Have you tried unsuccessfully in the past to quit using tramadol?
  • When you stop using tramadol, do you experience withdrawal symptoms?
  • Do you need to use more tramadol than you did in the past in order to achieve the same effects?
  • Do you feel guilty, embarrassed or ashamed about your drug use?

Sources:

Progler, Yusaf. “Drug Addiction in Gaza and the Illicit Trafficking of Tramadol,”  The Journal of Research in Medical Sciences, 2010 May-Jun; 15(3): 185–188.

Viney, Stephen. “As Drug Addiction Rises In Cairo, Experts Offer Recommendations,” Egypt Independent, May 16, 2011.

Progler, Yusaf. “Drug Addiction in Gaza and the Illicit Trafficking of Tramadol,”  The Journal of Research in Medical Sciences, 2010 May-Jun; 15(3): 185–188.

Tramadol, The Department of Justice, The Drug Enforcement Agency Office of Diversion Control,  see http://www.deadiversion.usdoj.gov/drugs_concern/tramadol.pdf

Ibid.

Progler, Yusaf. “Drug Addiction in Gaza and the Illicit Trafficking of Tramadol,”  The Journal of Research in Medical Sciences, 2010 May-Jun; 15(3): 185–188.

Lanier RK, Lofwall MR, Mintzer MZ, Bigelow GE, Strain EC. Physical dependence potential of daily tramadol dosing in humans. Psychopharmacology (Berl) 2010;211(4):457–466.

Cicero TJ, Adams EH, Geller A, et al. A post marketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Drug Alcohol Depend. 1999;57(1):7–22

Adams, EH, S. Breiner, T Cicero, A Geller, J Inciardi,  S Schnoll, E Senay, and G Woody. “A Comparison of the Abuse Liability of Tramadol, NSAIDs, and Hydrocodone  inPatients with Chronic Pain,” The Journal of Pain Management, 2006 May; 3(5); 465-476.

See the websites of individual states for the most up-to-date information.

Liu, Z, W Zhou, Z Lian, Y Mu, A Ren, J Cao and Z Cai. “Drug Dependence and Abuse Potential of Tramadol,” the National Institute on Drug Dependence, January 1999 (10(1), 52-54.

“Important Health Warning Re: Tramadol,” The U.S. Food and Drug Administration, see http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM213265.pdf

Tramadol, The Department of Justice, The Drug Enforcement Agency Office of Diversion Control,  see http://www.deadiversion.usdoj.gov/drugs_concern/tramadol.pdf

“Tramadol (Oral Route),”  The Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601787

1“Restless Leg Syndrome,” The New York Times, Health Topics, see http://www.nytimes.com/ ; and “Herniated Discs,” The New York Times, Health Topics, see http://www.nytimes.com/

Lanier RK, Lofwall MR, Mintzer MZ, Bigelow GE, Strain EC. Physical dependence potential of daily tramadol dosing in humans. Psychopharmacology (Berl) 2010;211(4):457–466.

“Tramadol (Oral Route),”  The Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601787

“Tramadol,”  Drugs.com, see http://www.drugs.com/tramadol.html

“Tramodol,” The U.S. Library of Medicine, Medline, see http://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html

“Tramadol (Oral Route),”  The Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601787

“Tramadol,” PubMed Health, The U.S. Library of Medicine, see http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000960/

“Tramodol,” The U.S. Library of Medicine, Medline, see http://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html

“Tramadol,”  Drugs.com, see http://www.drugs.com/tramadol.html

“Tramodol,” The U.S. Library of Medicine, Medline, see http://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html

“Tramadol (Oral Route),”  The Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601787

Brody, Jane. “A Mix of Medications That Can Be Lethal,”  the New York Times, February 27, 2007.

“Smaller Doses of Acetaminophen in Considered Safe,” News  from the Mayo Clinic, January 14, 2010, see http://www.mayoclinic.org/news2010-mchi/5590.html

“Tramadol,”  Drugs.com, see http://www.drugs.com/tramadol.html

“Tramadol,” PubMed Health, The U.S. Library of Medicine, see http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000960/

“Tramadol (Oral Route),”  The Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601787

“Tramadol,” PubMed Health, The U.S. Library of Medicine, see http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000960/

“What Is the Addiction Risk Associated with Tramadol?” Clinical Inquiries, the Journal of Family Practice, January 2005, Volume 54 Number One.

Spiller, HA et al. “Effect of Scheduling Tramadol As a Controlled Substance on Poison Center Exposures to Tramadol,” The Annals of Pharmacotherapy, June 2010, a Volume 44 Number Six, Pages 1016 to 1021.

Liu, Z, W Zhou, Z Lian, Y Mu, A Ren, J Cao and Z Cai. “Drug Dependence and Abuse Potential of Tramadol,” the National Institute on Drug Dependence, January 1999 (10(1), 52-54.

Progler, Yusaf. “Drug Addiction in Gaza and the Illicit Trafficking of Tramadol,”  The Journal of Research in Medical Sciences, 2010 May-Jun; 15(3): 185–188.

“Tramadol,” PubMed Health, The U.S. Library of Medicine, see http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000960/

Tramadol, The Department of Justice, The Drug Enforcement Agency Office of Diversion Control,  see http://www.deadiversion.usdoj.gov/drugs_concern/tramadol.pdf

Rashmi, Oiha (MD) and Subhash Chatia (MD). “Tramadol Dependence and the Patient with No Previous Substance History,” the Journal of Clinical Psychiatry,  2010, 12 (1).

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