Today’s pearl is about the unpredictable and potentially dangerous risks with tramadol.
Tramadol has a reputation for being a safe, non-opioid alternative to opioids. Nothing could be further from the truth.
Tramadol is an opioid, a synthetic one that is now schedule IV according to the DEA.
Problems with Tramadol
- It may not work very well (Sachs 2005)
- Osteoarthritis-related pain: modestly effective in placebo-controlled trials (Cepeda 2006)
- Neuropathic pain: efficacy comparable to gabapentin, TCAs, & carbamazepine (Hollingshead 2006)
- Emergency Department
- Musculoskeletal: Inferior to hydrocodone/APAP (Turturro 1998)
- Ankle sprain: tramadol/APAP equivalent to hydrocodone/APAP (Hewitt 2007)
- Seizure risk
- Some studies have not found an increased seizure risk with therapeutic doses of tramadol (Seizure Risk Associated with Tramadol Use). However, a more recent study refutes that premise (Asadi 2015), which found 22% of first-seizure patients had recent tramadol use! Be careful prescribing tramadol to patients with a seizure history or taking other medications which may lower the seizure threshold.
- Serotonin syndrome risk (Sansone 2009)
- Hypoglycemic risk (Fournier 2015)
- Erratic metabolism (Leppert 2011)
- Abuse/dependence/withdrawal risk (Senay 2003)
- Potential interaction with warfarin (Hosono 2017)
- Tramadol: When to Avoid It from Academic Life in EM
- Three Reasons Not to Prescribe Tramadol from EM PharmD
- Trama-don’t from EMCrit’s The Tox and the Hound