Tramadol: Uses, How It Works, Dosage and Side Effects

Tramadol works in two different ways at the same time. The first of these is its action as an opioid medication. Tramadol attaches to opioid receptors in the nervous system in the same way that codeine and oxycodone do. However, tramadol has a weaker effect through this action.

The second way that tramadol works is that it raises the levels of the chemicals serotonin and noradrenaline in the nervous system. That is the same broad action used by a group of antidepressants, and most opioid painkillers do not do this at all. This second action is the reason tramadol has two risks that are not associated with codeine or oxycodone.

Tramadol is made in two forms and the form of the tramadol matters as much as the number on the box.

Immediate-release tramadol is available in 50mg tablets or capsules and is taken when pain is experienced.

Prolonged-release tramadol releases the tramadol over twelve or twenty four hours and is taken on a schedule instead of when the patient feels the pain. The prolonged-release form of tramadol is available in 100mg, 150mg and 200mg tablets. A 225mg tablet is supplied by some manufacturers but falls outside the normal range authorised for use in Europe.

The daily ceiling. The maximum dose for tramadol for adults is 400mg in a twenty four hour period. The dose is built up from the lowest amount that provides relief from the pain. Taking tramadol in doses over 400mg will not provide additional relief from pain but can increase the risk of experiencing a seizure.

The same dose of tramadol will not have the same effect upon every individual taking it. The tramadol has to be converted by the liver to its strongest form in order to exhibit its pain relief properties. The enzyme that performs this conversion is known as CYP2D6.

Each person's gene for this enzyme can be of various genetic makeups. Those that genetically produce little of this enzyme will experience less relief from the tramadol compared to others. Those that produce a great deal of this enzyme are at risk of experiencing the side effects of tramadol. Codeine is also converted by this same enzyme in the liver, which is why the two medicines share this pattern.

The side effects of tramadol are most commonly nausea, dizziness, dry mouth, constipation and drowsiness. The nausea and dizziness typically appear when first taking the medication and often settle after several days. The constipation will not go away on its own and should be considered prior to taking the medication. Drowsiness may affect a patient's ability to drive a car or use machinery.

Seizures. Tramadol lowers the threshold at which a seizure can happen. Seizures have been reported in people taking normal doses of tramadol as well as those taking high doses. People who have previously experienced seizures are at increased risk of developing them while taking tramadol. The risk is also increased for people taking other medications that lower the threshold for seizures, or those that raise the level of tramadol in the blood.

Serotonin syndrome. Serotonin syndrome occurs when there is too much serotonin activity in the nervous system. Symptoms include agitation, fast heartbeat, shivering, sweating, muscle twitching and confusion. Serotonin syndrome is a medical emergency. In the European Union the emergency number is 112.

Antidepressants are the interaction that matters most. Antidepressants that raise the levels of serotonin in the body include SSRIs, SNRIs, tricyclic antidepressants and MAOIs. Each of these can interact with tramadol to cause serotonin syndrome or seizures. Triptans, which are used to treat migraines, also raise the levels of serotonin in the body. Some antidepressants also block the enzyme CYP2D6, which raises the levels of tramadol in the blood.

Paxlovid, the antiviral medicine used to treat COVID-19, contains ritonavir, which also raises the levels of tramadol in the blood. Blood thinners, such as warfarin and rivaroxaban (Xarelto), can interact with tramadol. Sleeping tablets, or medicines that contain benzodiazepines, will deepen the effect of tramadol on breathing and drowsiness.

Always tell any prescriber that you are taking tramadol so they can take that into account when prescribing a new medicine to you.

Tramadol should not be given to children under twelve years of age. Deaths from slowed breathing have occurred in children taking the drug, several after they underwent surgery to remove their tonsils or adenoids, in children who converted the drug very quickly.

A further restriction covers people under eighteen years of age after those kinds of surgeries, and children with obesity, sleep apnoea or severe lung disease. That last restriction was issued by the United States Food and Drug Administration. The European Medicines Agency has not published wording similar to this restriction, so it should not be described as European guidance on the use of tramadol.

Tramadol can lead to physical dependence if taken regularly over a length of time. While physical dependence and addiction are related, they are not the same. After taking tramadol regularly, the body can adjust to the presence of the medication. If the medication is abruptly stopped, the body may experience withdrawal symptoms.

There are two parts to withdrawal from tramadol. Because tramadol acts on opioid receptors and on serotonin and noradrenaline, stopping it abruptly can produce the effects seen when an opioid is stopped and effects closer to those seen when an antidepressant is stopped. Withdrawal is managed by slowly reducing the dose of tramadol over a period of time, each step in the reduction to be taken under the care and guidance of the prescriber of the medication.