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Tramadol: Dosage & Side Effects
Tramadol is a prescription medication used to treat moderate to moderately severe pain. It is sold under the brand name Ultram in the United States, and as Ralivia, Dromodol and other names elsewhere. It is intended to work by changing the way the central nervous system responds to pain.
Tramadol is effective on two fronts: About 20 percent of its painkilling effects come from opioids, and 80 percent from ingredients that inhibit the reuptake of serotonin and norepinephrine, two chemicals in the brain associated with mood and responsiveness to pain, said Dr. Lewis Nelson, a professor of emergency medicine at New York University's Langone Medical Center.
Because tramadol has less opioid content than other addictive painkillers such as oxycodone, hydrocodone and morphine, "a lot of doctors inappropriately view this as safer," Nelson told Live Science. But tramadol carries risks: People can still abuse and overdose on tramadol because of its opioid component. Its interaction with serotonin can also affect people taking other serotoninlike drugs, such as antidepressants, he said.
However, tramadol's opioid and serotonergic effects are important because they allow tramadol to treat both pain and the psychological components of pain, he said.
Researchers first synthesized tramadol in the 1970s, and the Food and Drug Administration approved it for treatment of acute and chronic pain in 1995. The Drug Enforcement Administration identified it as a Schedule IV drug in 2014 to show that tramadol has potential for abuse.
Dosage
Tramadol is available in several forms: tablet, orally disintegrating tablet, extended-release capsule and extended-release tablet, orally disintegrating tablet and suspension. The extended-release tablets and capsules are prescribed for patients who need round-the-clock pain relief.
Safe dosage of tramadol varies based on the patient and his or her needs. For chronic pain, doctors often prescribe a low dose at first, usually after surgery. Doctors also prescribe tramadol to treat arthritis, fibromyalgia and other chronic pain conditions. According to the National Institutes of Health (NIH), the regular tablet and disintegrating tablet are usually taken with or without food every four to six hours as needed. The extended-release tablet and extended-release capsule should be taken once a day.
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Patients should not take a larger dose or take it more often or for a longer period of time than prescribed. The NIH advises that if you miss a dose, take it as soon as you remember, unless it is very close to the time for the next dose. Then, skip the missed dose and continue the regular schedule. The dosage may be increased by the doctor, but should not be increased by the patient.
It is also important not to suddenly stop taking tramadol, according to the NIH. Doing so may cause withdrawal symptoms, such as nervousness, panic, sweating, difficulty falling asleep, runny nose, chills, nausea, diarrhea and hallucinations. Your doctor will likely decrease your dose gradually.
Children younger than 12 should not take tramadol, according to 2017 rules from the Food and Drug Administration (FDA). "Our decision today was made based on the latest evidence and with this goal in mind: keeping our kids safe," Dr. Douglas Throckmorton, deputy center director for regulatory programs at the FDA's Center for Drug Evaluation and Research, said in a statement.
Side effects
As noted, tramadol can interact with drugs that affect serotonin levels, such as antidepressants, sometimes leading to serotonin syndrome, described as uncontrollable shaking, altered mental status, rigidity and high body temperature, Nelson said.
Seizures have been reported both in animals and humans taking tramadol. Seizures can happen even at recommended doses, but are more common if a person misuses or overdoses on the drug, or if tramadol interacts with another drug, especially antidepressants, according to a 2009 study published in the journal Psychiatry.
Common side effects of tramadol include:
- Abdominal problems, such as diarrhea, constipation, nausea, or stomach pain
- Depression, including feelings of sadness and discouragement
- Skin problems, such as itchiness, rash, or sweating
- General aches and pains in the muscles and joints
Some side effects are more rare than others, such as:
- Swollen joints
- Weight changes
- Severe headaches
- Falling down
- Confusion
- Severe cough
Some rare side effects warrant a call to the doctor. These include:
- Blisters under the skin
- Blood in the urine
- Chest pain
- Convulsions
- Seizures
- Darker urine
- Fainting
- Indigestion
- Numbness in the extremities
- Yellowed eyes or skin
Addiction
Tramadol is increasingly prevalent as a drug of abuse, possibly because other opioids are becoming difficult to obtain, Nelson said.
"It would be great if you could dissociate the pain-relieving part of [opioids] from the euphoria-inducing part of [opioids], but you can't," Nelson said. "They're inextricably linked."
People who use tramadol therapeutically can become addicted due to the drug's opioid component. People who abuse the drug to get high or have hallucinations can also become addicted, Nelson said. If people suddenly stop using the drug, they may experience withdrawal symptoms.
"Withdrawal is miserable," Nelson said. "So people often don't allow themselves to withdraw, by continuing to take the drug."
Overdose
Deaths from tramadol overdose have increased over the past two decades. Researchers at the Centers for Disease Control and Prevention found that the percentage of overdose deaths involving synthetic opioids, such as tramadol, have increased from 8 percent in 2010 to 18 percent in 2015.
"The continuing rise in death rates related to heroin use and synthetic opioids is of great concern," said Dr. Larissa Mooney, an assistant clinical professor of psychiatry at the University of California, Los Angeles, and director of the university's Addiction Medicine Clinic.
Because many prescribers view tramadol as a "safer" opioid than something stronger, such as morphine, patients often ignore dosage instructions or drug interaction warnings. Those abusing the drug build tolerance over time and unsafely increase their dosages so that they can continue to achieve the high.
Tramadol is designed for oral use only, and the tablets should not be crushed for the purpose of inhalation or injection. Snorting the drug increases the intensity of the effect of the drug, but brings it in large doses into the bloodstream. These large doses can cause overdose and increase the risk of adverse side effects, such as seizures. Other serious side effects of snorting tramadol include coma and breathing problems.
If you or someone you know has possibly overdosed, emergency help must be contacted at once. Signs of an overdose can include convulsions or seizures, trouble breathing, irregular breathing, pale or blue lips and skin, and pinpoint pupils in the eyes. Some patients may have decreased awareness or responsiveness to the point of loss of consciousness.
Who should not take tramadol
Patients with a history of drug or alcohol abuse, or a history of suicide attempts should not use tramadol. It should not be taken at the same time as alcohol, street drugs, narcotic pain meds, sedatives or medication used to treat mental illness, according to the Mayo Clinic.
Taking tramadol increases the risk of seizures for those with a history of seizures, a head injury, a metabolic disorder, or those taking antidepressants, muscle relaxers and narcotics. Before taking tramadol, be sure to inform your doctor if you have kidney disease, cirrhosis or other liver disease, a stomach disorder, or a history of depression and mental illness, the Mayo Clinic reports.
It should be used sparingly in the elderly, as they are more likely to have unwanted side effects such as constipation, lightheadedness, dizziness, fainting, and stomach upset, as well as age-related kidney or liver disease.
Tramadol for dogs and cats
For dogs and cats, tramadol is used often as a pain reliever for post-surgery pain or chronic conditions such as cancer or arthritis, said Dr. Greg Nelson, a veterinarian with Central Veterinary Associates, in Valley Stream, New York.
"It's usually not one of the first things we reach for, but we use it when there's a little bit more advanced pain after surgery," Nelson said.
It is also used as a cough suppressant in pets. It's most often used in dogs, though it can be used for cats as well. (The pill comes in 50-milligram capsules, and cats usually take 10 mg tablets, Nelson said. However, pet owners can ask pharmacists to make special cat-sized dosages, he said.)
Tramadol is used as an alternative or in addition to non-steroidal anti-inflammatory drugs (NSAIDs) or in conjunction with them, Nelson said. Because tramadol works differently than NSAIDs, they can be used as an alternative for pets who cannot take NSAIDs. The tablets can be given to pets with or without food, but dosage instructions from the vet must be followed. Just as in humans, if the medication has been used long term, do not abruptly stop giving it for risk of withdrawal symptoms. Work with your vet to wean your pet off of tramadol properly.
Additional reporting by Alina Bradford, Live Science Contributor.
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Laura is the managing editor at Live Science. She also runs the archaeology section and the Life's Little Mysteries series. Her work has appeared in The New York Times, Scholastic, Popular Science and Spectrum, a site on autism research. She has won multiple awards from the Society of Professional Journalists and the Washington Newspaper Publishers Association for her reporting at a weekly newspaper near Seattle. Laura holds a bachelor's degree in English literature and psychology from Washington University in St. Louis and a master's degree in science writing from NYU.