Tramadol and Nucynta

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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, in some states. It does have some benefit for pain relief, 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. [1]

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.

1. Leavitt, MA, PhD, “Methadone-Drug Interactions,” Pain Treatment Topics, Addiction Treatment Forum, January 2006

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8 responses to this post.

  1. Posted by Jeff on January 20, 2014 at 2:38 am

    I started my addiction in 2003. When my family sources of opiates passed away (grandparents who didn’t use the copious amounts prescribed) I used tramadol as my “suboxone” for several years starting in 2007. I was in full withdrawal and desperate to relieve it when I found an old bottle of tramadol my wife had. One pill stopped my withdrawal. The ability to get it through the Internet kept me on it for over two years until I got on actual Suboxone. Very good thing the doctor I saw was willing to treat me with sub since I’m betting I had no “real” opiates in my system when he tested me. Perhaps I did? Clearly my history included everything but heroin. Tramadol seemed to block other opiates as well. Or perhaps it just pushed my tolerance very high as I was taking over 1,000 mg a day. I never had a seizure but did have depression that I’ve never expire ended before or after the tramadol. I’m still amazed it was not made a controlled substance sooner. It did keep me from most other drugs. Not sure if that was good or bad and certainly Suboxone works much much better. I personally don’t see any difference between tramadol and Vicodin as far as withdrawal goes. Tramadol just never gave me the same high – not even close but it did keep withdrawal at bay.

    Reply

  2. Would you like to hear something super scary?
    2 months ago: My dr put me on tramadol on top of the subutex in efforts to get me to wean down off subutex. Long story short- it closed my throat on day 3. I use to not be allergic to it but now I am.

    He prescribed 50mg 4x a day, I only took 1/2 -so 25mg twice a day to see how my body would react. This small dosage closed my throat.

    Umm most all the subutex drs in Memphis are giving this to patients to wean them down from subutex. I told my dr this is a no no. That tramadol was a drug that would get me out of hydrocodone withdrawal 5 years ago and was very addicting – but I agreed to try his method, which failed for me. He says that he has had several pts successfully wean down while taking tramadol.

    I don’t want another pill, to swap for subutex- I want to get off it the right way.

    Your post is very true, and the withdrawals from 100mg ultram were worse (for me) than high doses (250-300mg) of hydrocodone. I went thru this just taking a weeks worth of ultram in efforts to get off hydrocodone. Ended back up on hydrocodone. Needless to say- it is a bad egg for addicts!

    Thank u for realizing this 🙂

    Reply

    • I tgjook my self down to 1 mig by cutting the pill in how many pieces I needed if it is two mg cut it in half if it is 8mg cut it as much as you can. You can always take more but never can take less. When there are days that it pass and I did not notice I took my pill in the morning it was time for me to get off. And that is how I did it.

      Reply

  3. Posted by kevin on January 21, 2014 at 3:13 pm

    I took ultram for a while before I knew it cause seizures in higher doses. My mom use to get them and would give them to me. I would usually take 4 to 5 to get the effect. I remember it wasn’t like taking lortab. And u had to take more. Well I started cleaning a Dr office and there was a bunch of samples laying out and there was 8 in each pk.@ 50mg a peice. U took 2 packs. I took the whole pack at work. 8 of them. A little while later I wasn’t pleased with the way I felt so I took the other 8. Got home after work. I remember feeling a little drowsy so I layer on the couch. My boyfriend was at one end I was taking up the other 2 seats laying there and my mother on the sofa. Nobody knew what I had done. I remember my mother standing over me saying OMG OMG breath kevin please breath. I also remember a deputy in the room asking if I had taken anything. And then the ambulance got there loaded me up and taken me to the hospital. I was babying my shoulder and was in so much pain. When I woke up I found out that I had a grand ma seizure and dislocated my shoulder during it. I have so many problems with my shoulder hurting now cause of it. Well later(about 8 to 10 yes later) on I was needing something and couldn’t find anything except ultra so I thought if I took less I would get what I needed and not have the seizure. I took 5 in the morning and another 5 around 2 and had another seizure with a dislocated shoulder while riding with my mom to pick my sister up in the school parking lot. It’s not worth it. Go without rather taking ultram. It’s just not worth the risk of seizures and the complications from them

    Reply

  4. Posted by Sean McKinnon on January 21, 2014 at 10:51 pm

    I have heard anecdotal reports of Tramadol causing precipitated withdrawal in methadone patients and generally advocate to other patients to make their health providers aware of this. If Tramadol causes activity at the Mu Opioid receptor the why would a patient who has only abused Tramadol not be offered MMT?

    Reply

  5. Interesting, I wonder what is the difference between a patient who has severe withdrawals from those who had none? That ought to be a study for neuroscience.
    I was on tramadol for over 3 month. I admit, I do not remember what dose. I took it every day with 600 mg. of Ibuprofen. I ran out of it short of a month ago(both of them) I took it for injuries I had on a motorcycle accident in 1978. I do not remember having any withdrawals. I thought tramadol would mimic an opiate but was not an opiate.. I also did not take it like every six hours, Usually once dose a day in the morning with the ibuprofen. Rarely did I needed to take a second dose in the afternoon. So I was taking it PRN. There were a few times that I missed a day but in the three month perhaps it happened 3 to 5 times.

    http://theworsetreatmentever.blogspot.com/‎

    Reply

  6. Posted by nicole on January 24, 2014 at 5:46 am

    Thank you for sharing i didnt know it could cause withdrawl if u take it with methadone my mom has been prescribed tramadol for eight yrs nd she swears shes not addicted to them wel im on methadone Maintenance nd i have seveR back paIn nd i take some of my moms sumtimes nd they do help but im not goin to take them anymore.its not worth my life thanks again!

    Reply

  7. Doctors prescribed the medicines that are useful to every patient. Tramadol is a painkiller that comes with powerful characteristics of antidepressants too. But once addicted, it becomes difficult to go out of it. Thus, there are many other facts to know about Tramadol, http://jrms.com.mx/blog/blog/2015/04/30/treatment-for-body-pain-facts-you-need-to-know-about-tramadol/

    Reply

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