Tramadol and Nucynta: new problems?

Tramadol, the generic for the brand name Ultram, is a messy drug. It’s a pain reliever that has actions on several types of brain receptors: the mu opioid, serotonin, norepinephrine, NMDA, and other receptors.

Because it stimulates the mu opioid receptors, it can cause feelings of pleasure as well as pain relief. Tramadol is far less active at the mu opioid receptors than its metabolite, and it takes time for the tramadol to be metabolized in the liver to its first metabolite. Because of this delay, some experts thought it wouldn’t appeal to addicts, who prefer an immediate high. Overall this is probably true, and tramadol has a much lower rate of addiction than other opioids, but it still causes addiction in some patients.

Some of tramadol’s pain relieving properties may also be produced by its actions on serotonin and norepinephrine receptors, since tramadol’s pain relieving capability is only partially reversed by a pure opioid antagonist like naloxone.

When this medication was first released, it wasn’t a controlled substance. That is, the DEA didn’t control it strictly like medications that can cause addiction. Now, it’s a Schedule IV drug, thought to have benefit but also some risk of addiction, though lower than that of hydrocodone, for example.

Tramadol is usually dosed in 50mg pills, one or two every six hours, giving the maximum dose of 400mg per day. Recreational use of this medication (to get high) is dangerous, since it causes seizures at doses higher than 400mg. In susceptible patients, it can even cause seizures at lower prescribed doses.

I’ve seen patients in tramadol withdrawal who were so sick it frightened me. This drug can produce a severe withdrawal. If a patient taking high doses stops taking tramadol suddenly, some patients have opioid withdrawal symptoms like sweating, nausea, diarrhea, high blood pressure and heart rate, and severe muscle and joint pains. The sickest patient I’ve ever seen in opioid withdrawal had been using only tramadol, in doses of around 600mg per day. She had fever to 103 degrees, and dehydration from the diarrhea and vomiting. That patient needed hospitalization.

Besides the opioid-withdrawal symptoms, some of these patients also have withdrawal symptoms similar to those seen when certain serotonin-affecting antidepressants, like Paxil and Celexa, are stopped suddenly. They can have fairly severe anxiety, depression, mood swings, and restlessness. Many times they have weird sensory experiences, often called “brain zaps,” or the sensation of electric shocks throughout the body. They can have seizures during this withdrawal.

If the patient had only physical dependency and no addiction, the dose of tramadol can usually be tapered slowly over a few weeks to months, as an outpatient. But if the patient has not only physical dependency but also the disease of addiction, the obsession and craving for the medication will usually prevent a successful outpatient taper, unless a dependable non-addict holds the pill bottle, and dispenses it as prescribed.

Traditional treatment for tramadol addiction starts with detoxification. As above, that can rarely be done as an outpatient, so medical inpatient detoxification admissions for five to seven days can be helpful. However, since tramadol acts so much like an opioid, patients ready to leave detox probably need to go on to an inpatient residential treatment center for at least thirty days.  Intensive outpatient treatment probably isn’t enough support for these addicts. But that’s only my opinion, since I haven’t found any studies describing success rates with tramadol addicts.

Opioid maintenance medications like methadone and buprenorphine do stop the opioid-type withdrawal symptoms from tramadol, but there’s no information about the use of maintenance medications in these patients. Most doctors working in clinics won’t start a patient on maintenance medications unless the patient is also using other opioids.

Often, methadone patients at the opioid treatment centers where I work are given tramadol by their primary care doctors who think it’s a low risk medication for opioid addicts. It probably is lower in its risk for abuse, but it can cause withdrawal in patients on stable, blocking doses of methadone.

Tramadol is a synthetic, pared-down version of codeine. Interestingly, a structurally similar medication, tapentadol, has just been released, and is now being sold under the brand name Nucynta. That medication is a schedule II drug, presumably because of a higher abuse potential than we’ve seen with tramadol. Tapentadol stimulates opioid mu receptors, and also acts as a norepinephrine re-uptake inhibitor, like some antidepressants.

I saw my first patient who was addicted to Nucynta earlier this year. He had a history of opioid addiction in the past, had successfully tapered off methadone maintenance, but became re-addicted to opioids during a bout of back pain. He couldn’t stop taking Nucynta without abusing other illicit opioids to ease his withdrawal symptoms. Because he was using other opioids, I did admit him to methadone maintenance and he continues to do well on our program.

The bottom line is this: if you are in recovery from addiction (alcohol or drugs, this medication should be used with caution. Let your doctor know that you’re in recovery from addiction. If you must take a potentially addicting medication, talk to your sponsor and your support network. Go to extra meetings. Let a dependable non-addict hold the pill bottle and dispense as prescribed. If you have to take the medication for more than a few weeks, have your doctor taper your dose instead of stopping suddenly.

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12 responses to this post.

  1. Excellent post. My clinical experience abundantly confirms that this is habit forming. Actually its a very interesting story, how it came to be discovered that this medication was reinforcing…it emerged during a physicians health program monitoring study! Great work with the blog; keep it up.

    Reply

    • Posted by Dr Steve on December 7, 2014 at 3:09 pm

      Yes, it is addictive, based on users’ posts around the net. I’m wondering if anyone has any experience, observation, or opinion on weaning off Tramadol through the use of the supplement 5-HTP as a transitional replacement. Being the precursor to serotonin, (and tryptophan), is it possible that 5-HTP could increase serotonin in a way that mimics Tramadol’s SRI (serotonin re-uptake inhibitor) action.

      Reply

  2. This blog post is very interesting and informative. I at one time was addicted to both opiates and benzos. I had more of a mental addiction than a physical addiction, meaning, I thought I needed the pills more than I actually did. I also used the meds to numb my feelings. I have Chiari Malformation and had brain surgery consisting of a craniectomy, laminectomy, and duraplasy back in 2007. I was still having a lot of neck pain from surgery a year later and my Dr. gave me Lortab 7.5/500 mg for my pain. It helped for a while, but eventually my body built a tolerance to it and I was taking way more than I was prescribed. When I tried to tell my Dr. that it was no longer working and I was having to take more than prescribed to get any relief, he doubled my dose, instead of changing my medication. The same thing happened with Xanax. There were days that I was taking up to 15-20 Lortabs and 6-10 Xanax. I have a history of severe depression with several suicide attempts and these Dr.’s were giving me 120 Lortabs and 90 Xanax a month with 6 refills! I ended up getting into legal trouble because of these meds and luckily part of my sentence was to go to a 30 day rehab program. Though getting into trouble sucked, I think it saved my life! That was one of the best things I have ever done for myself, besides join the military! I am happy to say that I have been opiate/benzo free since Oct. 26, 2010!! Yay for me!! 🙂

    Earlier this year I was prescribed Tramadol for my pain (I DID notify my Dr. of my past) and have not had a problem with it, sometimes it helps with my pain and sometimes it doesn’t. I am prescribed the max dose (400 mg) but I don’t always have to take that much. I base my dose it on the level/length of my pain. Within the first week or two of taking Tramadol I did notice a “high” feeling, but that went away relatively quickly. I do not foresee the Tramadol being a problem for me, but I am scared of the withdrawals if I have to stop taking it for some reason. (Sorry for the long comment)

    I have enjoyed reading through your blog, as a lot of the information pertains to something I have been through! Keep up the good work and please take a moment to check out my blog! 🙂 http://www.chiarisux.wordpress.com

    Reply

    • I’m happy to hear of your success.
      As long as you don’t start to accelerate your dose of tramadol it sounds like you’ll be OK. But if you stop it, I’d do a taper over several months. If you aren’t taking it obsessively and compulsively you should be able to do that, if/when needed.

      Reply

  3. Posted by Fred G Sanford on March 29, 2013 at 5:32 pm

    Interesting info here. I’m a CP patient that has been taking Tramadol as prescribed for several years. I am considering changing to Nucynta. Do I still need to taper the Tramadol down, can these 2 drugs be taken together safely? Will the Nucynta help with the effects of discontinuing the Tramadol?

    Reply

    • Obviously I can’t give you medical advice – please do what your doctor directs. However, I can tell you these two medications are similar, so I doubt your doc will want you to take them together. Nucynta also has an opioid-like effect in some people, so if you switch from one to the other I don’t know that you would have any withdrawal…but like I said, follow your doc’s directions.

      Reply

  4. Posted by nigma1 on May 14, 2014 at 8:43 pm

    Very interesting review. There are not many sites that shows this side of Tramadol. Tramadol can be very dangerous if it is not taken carefully. I have a blog dedicated to Tramadol. It has useful information about its Side Effects and Drug Interactions that is very important to know very even considering taking Tramadol. Check it out and give your opinion! http://everthingtramadol.wordpress.com/

    Reply

  5. Posted by Daniel Del Plato on February 7, 2015 at 7:48 pm

    I have been on nucynta for 6yrs due to a dysfunctional S1 joint and lower back injury. Due to the insurance failure to refill I ran out a week ago. I have had the runs, loss of appetite, unable to sleep, headaches, intolerable pain through out my body, depression and anxiety. People are telling me to go to detox but I refuse. It seeem it’s really hitting me mentally!

    Reply

  6. Posted by Robert on February 28, 2017 at 9:19 am

    I was addicted to Tramadol for 8+ years, 25-30 of the 50mg tabs per day for most of those years, this is by far the worst drug I’ve ever had to withdrawl from. Once past the acute withdrawal, you then have months of PAW’s to go through and the insomnia seems to never end. I had a crushed vertebrae in 2005 and ended up addicted to Oxy’s and that withdrawal was nothing compared to that of Tramadol.

    Reply

  7. Posted by Ryan on June 11, 2017 at 2:41 pm

    Hello,

    I was wondering if any new withdrawal information has come out since this blog has been written regarding Nucynta? I have been suffering with daily migraines for the past almost 4 years and they do seem to help at least a little. I have tried everything under the sun including hospitalization to try to breal this migraine chain.

    I have never been addicted to anything, but im sure Ive been considered depended on things for taking meds soo long. Anyways, I took Tramadol for a few years, and was taking Ativan at the same time. I never abused these, but I was on max dose Tramadol and maybe 2 mg a day Ativan. My doctor asked me to quit both cold turkey to make sure I wasnt getting just rebound headaches. What a nightmare withdrawal! I couldnt tell what was causing the symptoms because I have heard Ativan had nasty withdrawals too (if you want detail on symptoms then feel free to ask). I sucessfully got off both, and the doctor said congrats when I told him while he had a surprised face (this bothered me a little).

    Now I am onto Nucynta, which helps even a little more than Tramadol. I am curious what to expect when I eventually stop. Hopefully this doctor is a little more sympathetic, but I almost believe cold turkey is much much better than taper. As long as is deemed safe to do. Its like stripping the bandaid quickly. Im kind of scared to feel like I did during my lasy withdrawal though. It wont be long until im max dose on this too so better prepare now. Thankfully I am strong willed and dont fall into addiction, but opioid withdrawal doesnt discriminate I can imagine (I dont mean addicts arent strong willed by any means. Im just saying I have had every opportunity to abuse amd havent). Thanks, and im really sorry about the long post.

    Reply

  8. Hello,

    I noticed you are using one of my cartoons in the opening of this article.

    I’m honored that you decided to use my work on your site, and I’m glad that the cartoon helped you to illustrate your article. I was wondering if you wouldn’t mind adding an attribution link back to my website: https://humoresquecartoons.com as a caption to the cartoon or in the article content? It would be much appreciated.

    Thank you for your time and consideration!

    Reply

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