Be Cautious with Tramadol

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

1. 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)
2. 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.
3. Serotonin syndrome risk (Sansone 2009)
4. Hypoglycemic risk (Fournier 2015)
5. Erratic metabolism (Leppert 2011)
6. Abuse/dependence/withdrawal risk (Senay 2003)
7. Potential interaction with warfarin (Hosono 2017)

Further reading

• 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

^#7