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Tramadol is one of the most frequently prescribed painkillers in Germany and is often perceived as a comparatively harmless, weak opioid. Many people take it without being aware of the special risks. This assessment does not do justice to the risks, however.
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Like all opioids, tramadol can cause physical and psychological dependence. This is often underestimated because tramadol is considered a weak opioid, but the addiction potential is real. The risk rises with the duration of the intake and with the height of the dose. What is tricky is that a dependence often develops gradually: the body gets used to the active substance, the same dose works more weakly over time, and the wish arises to increase the dose. Exactly this dose increase is an important warning sign that should be taken seriously. In addition, tramadol can influence the mood through the serotonin and noradrenaline effect, which strengthens the psychological bond. Therefore the principle applies to take tramadol as short and as low-dosed as possible and only under medical supervision. With chronic pain, other treatment paths are preferred when possible. Opioids such as tramadol are often not the best long-term solution for lasting, non-tumour-related pain, because the benefits and risks are less favourable here. Those who notice that they can no longer leave the medicine out or need more than prescribed should address this openly, because this is not a personal failure but a known effect of the medicine. The earlier one speaks about it, the easier it is to counteract, for example with a slow tapering or a different pain therapy.
Never stop tramadol abruptly
After a longer intake you must not stop tramadol suddenly. The body has got used to the active substance, so that an abrupt stop can trigger heavy withdrawal symptoms. Because of the dual mechanism, complaints often appear in addition to the physical opioid withdrawal symptoms, as they are known from stopping certain antidepressants. Stopping should therefore always happen slowly and according to a medical tapering plan. Speak with your medical practice before you change anything, even if you feel well and think you no longer need the medicine.
Tramadol has a withdrawal that is often heavier than one would expect from an opioid considered weak. Even if the daily dose was in the medically low range, the stopping can be unpleasant. The reason lies again in the dual mechanism. When stopping, two kinds of complaints appear at once: on the one hand the typical physical signs of an opioid withdrawal such as restlessness, sweating, shivering, muscle pain, nausea and sleep problems, on the other hand symptoms as they occur with the sudden stopping of certain antidepressants, for example inner restlessness, irritability, mood swings and a feeling of electrical sensations. This combination makes the tramadol withdrawal especially unpleasant for many. The first complaints often begin just one to two days after the last intake. Some people report sleep problems or mood swings even weeks after stopping. These delayed complaints are unpleasant but temporary and usually no reason to reach for the medicine again. With a slow, medically accompanied tapering these complaints can be eased considerably. The dose is reduced step by step, so that the body can adapt in peace, and if needed the pain therapy is adjusted.
One of the most important and at the same time most underestimated dangers of tramadol is the interaction with other substances that raise the serotonin level. Exactly this point easily gets lost in the package insert among many other notes but is especially important. Because tramadol itself acts serotonergically, the combination with certain antidepressants can lead to an oversupply of serotonin, the so-called serotonin syndrome. Especially affected are active substances from the groups of the SSRIs and SNRIs, that is many common antidepressants, as well as the MAO inhibitors. These substances are prescribed very often, which is why the combination does occur in everyday life. With MAO inhibitors the combination is considered absolutely to be avoided. Other substances such as triptans against migraine, the herbal St John's wort or further opioids can also increase the risk. Even over-the-counter preparations are therefore not automatically harmless when you take tramadol. The serotonin syndrome can be life-threatening, which is why it is so important that your medical practice and your pharmacy know all the substances you take. Many people take antidepressants and painkillers prescribed from different places, so that the danger is easily overlooked when no one has the complete overview.
Signs of a serotonin syndrome: call the emergency number immediately
If, under tramadol, especially in combination with antidepressants, restlessness, confusion, fever, heavy sweating, tremor, muscle twitching or stiff muscles, a racing heart or diarrhoea suddenly appear, a serotonin syndrome can be present. These signs can develop within hours and worsen quickly. This is a medical emergency. Immediately call the emergency number and do not take a further dose. Tell the emergency service which medications you have taken, this helps with the quick and correct treatment.
Like most opioids, tramadol can have a range of side effects. Most of them are strongest at the start of the treatment and often ease over time as the body gets used to the medicine. Common are nausea, dizziness, vomiting, constipation, dry mouth, tiredness and increased sweating. In a higher dose or together with other dampening substances such as alcohol, sedatives or sleeping pills, tramadol can slow breathing dangerously. This respiratory depression is the most important acute danger with an overdose and can be life-threatening. A special feature of tramadol is that it lowers the so-called seizure threshold and can thereby in rare cases trigger a seizure. This sets tramadol apart from many other painkillers and is often only mentioned in passing in the package insert. This risk is higher with dosages above the recommended daily amount and with the simultaneous intake of other seizure-threshold-lowering substances, which include some antidepressants. This way two risks of tramadol reinforce each other, the seizure risk and the serotonergic effect. People with epilepsy or previous seizures should discuss this medically before taking it. Those who have once reacted unusually to painkillers should also mention this, so that the practice can choose the substance and the dose appropriately.
The overview below summarises the most important points. It does not replace the conversation with the doctor and the package insert but helps you to keep the most important things in view and to ask targeted questions.
| Topic | The most important in brief |
|---|---|
| Substance group | Opioid with additional effect on serotonin and noradrenaline |
| Use | Moderate to strong pain, for as short a time as possible |
| Dependence | Possible, especially with longer intake |
| Stopping | Never abruptly, always taper with medical guidance |
| Important interaction | Antidepressants (SSRIs, SNRIs, MAO inhibitors): serotonin syndrome |
Tell your practice and pharmacy what you take
So that tramadol works safely, your medical practice and your pharmacy must know which other medications you take, including over-the-counter remedies and herbal preparations such as St John's wort. This way dangerous interactions can be avoided. Never change the dose on your own and do not stop the medicine without consultation. An up-to-date medication plan that you take to every appointment is very helpful for this. For questions about the intake, your pharmacy is a good first point of contact.
Especially with an opioid like tramadol it is important to have all remedies in view. brite helps you manage your medications, be reminded of the intake and get hints about possible interactions, for example with antidepressants. This way you have a complete list at hand at the next appointment.
The bottom line is that tramadol is an effective painkiller that does good service when used correctly but that must be treated with respect. Used correctly, that is short, low-dosed and under medical guidance, it is a useful remedy against strong pain. The description as a weak opioid plays down the actual risks. Those who know the most important points, that is the dependence potential, the need for slow stopping and the dangerous interaction with antidepressants, can use tramadol safely together with the medical practice. Knowing about this does not take away the benefit but makes the use safer. With pain that keeps making tramadol necessary, for example with back pain or osteoarthritis, the conversation about a long-term, as far as possible opioid-sparing pain therapy is worthwhile. This can include exercise, physiotherapy, other painkillers and non-drug methods that replace or complement the opioid in the long run.
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This article is for general information and does not replace medical advice, diagnosis or treatment. Never change the intake of tramadol on your own and do not stop it without medical guidance. With signs of a serotonin syndrome or shortness of breath, immediately call the emergency number.
