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


Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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