As a prescription opioid drug with antidepressant properties, tramadol is a pain reliever first that also serves to dispel anxiety. Opioid drugs act on opioid receptors in the brain, therefore blocking pain and promoting calm. When the opioid receptors are filled, some of the pleasure-inducing neurotransmitters like dopamine remain in the system longer, producing a euphoric effect.
Tramadol also interferes with the reuptake of both norepinephrine and serotonin, the journal Psychiatry publishes, and this feature is more like an antidepressant medication than a painkiller. Tramadol’s action on all three of these neurotransmitters can cause a dependence on the drug to form after prolonged regular use or abuse.
Dependence occurs when the body expects the drug to continue to produce and move these chemical messengers around the brain in its normal manner and ceases to function the same way without it. Individuals may develop a tolerance to the drug and need to take more and more tramadol to keep feeling its effects, which can increase the odds of creating dependence.
On the labeling information for one of tramadol’s brand-name products, Ultracet, the US Food and Drug Administration (FDA) warns people of the dependence probability with extended use of tramadol even through licit means. Abuse of tramadol may increase dependence more quickly. Once dependence on tramadol is established, it is not recommended to stop taking the drug suddenly, as it can induce opioid withdrawal syndrome.
Symptoms of Tramadol Withdrawal
Tramadol, as with other opioid drugs, can have an intense withdrawal syndrome that likely manifests as soon as the drug wears off. The half-life of tramadol is about 6-7 hours, according to the FDA, and it may be longer for extended-release formations. This means that withdrawal may start in as little as 6 hours or as long as 12 hours after the last dose of the drug.
Early opioid withdrawal usually includes agitation, muscle aches, runny nose, sweating, yawning, anxiety, and tearing up. Withdrawal symptoms may peak within a day or two. Later withdrawal symptoms may include stomach cramps, nausea and vomiting, diarrhea, goosebumps, high blood pressure, irregular heart rate, fast breathing, restlessness, trouble feeling pleasure and/or depression, and drug cravings. These symptoms usually taper off within a week or so.
The Drug Enforcement Administration (DEA) reports that 90 percent of the time, tramadol withdrawal follows typical opioid withdrawal; however, in the other 10 percent, it is atypical. In these cases, withdrawal symptoms may include hallucinations, paranoia, panic attacks, confusion, numbness and/or tingling in the extremities, and severe anxiety.
Factors Impacting the Tramadol Withdrawal Timeline
The level of dependency someone has to a drug is also influenced by personal factors, such as how long they have been taking it. The longer a person takes tramadol, the more dependent they may become on the drug. The amount of tramadol taken with each dose will also impact how dependent a person may be on it as will the method in which it is taken. For example, crushing Ultracet, Ultram, Ultram ER, Ryzolt, Rybix ODT, and ConZip (all brand-name formulations of tramadol) and then snorting, smoking or injecting the resulting powder can increase dependency.
While one can become dependent on tramadol when taking it legitimately for a medicinal purpose, especially when taking it for several weeks or months, the World Health Organization (WHO) reports that individuals who abuse it are likely develop dependence more often, and perhaps more rapidly, than those who don’t abuse the drug. The more dependent a person is on tramadol, the longer and more significant the withdrawal syndrome may be. The National Survey on Drug Use and Health (NSDUH) estimated that close to 2 million people in the United States (who were at least 12 years old) suffered from a prescription opioid painkiller use disorder in 2014.
Tramadol dependence and withdrawal can also be impacted by taking other drugs or drinking alcohol. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) CBHSQ (Center for Behavioral Health Statistics and Quality) Report, in ED visits involving the nonmedical use of tramadol in the year 2011, more than 70 percent of the time another drug was involved as well. In more than half of the ED visits involving tramadol, at least two other drugs were involved. Polydrug, or more than one drug at time, abuse can potentially lengthen withdrawal and may increase the possible side effects.
Both biological and environmental aspects also play a role in dependency and may have some influence on the withdrawal timeline. Family and personal history of addiction may increase the level of dependency and therefore may extend the withdrawal process. WHO states that individuals who have a history of substance abuse may be more likely to be dependent on tramadol.
Withdrawal may also be influenced by the presence of a co-occurring medical or mental health disorder. The National Alliance on Mental Illness (NAMI) states that roughly half of the people who abuse drugs also suffer from mental illness, and around half of those battling a serious mental illness also abuse drugs. Co-occurring disorders are treated as dual-diagnosis disorders, and certain medications and therapy techniques are necessary to minimize withdrawal and work toward recovery. Environmental factors, like the lack of a strong support system at home, history of trauma or abuse, and high levels of stress, can also potentially play a role in the duration and severity of withdrawal.
Medical Detox
Detox is the removal of toxins like tramadol from the bloodstream. Since tramadol can have some potentially significant withdrawal symptoms, individuals should not ever try to just stop taking the drug suddenly, without the help of a trained professional, like a medical, mental health, or substance abuse treatment provider. Medical detox is considered the safest and smoothest method of detox in that it often includes the use of medications to ease withdrawal symptoms.
During medical detox, individuals are monitored and cared for around the clock for a period of 5-7 days until the bulk of the withdrawal symptoms have peaked and are waning. Users can slowly wean off, or taper off, tramadol during medical detox to avoid intense withdrawal symptoms. Opioid substitution medications may be useful. These medications, such as methadone or buprenorphine, can replace tramadol at lower doses that are given less frequently. These drugs keep the opioid receptors activated, be it at a lower level, to keep withdrawal from starting. Dosages can then be slowly lowered until the medications are no longer needed.
Other medications that cater to specific symptoms of withdrawal may also be beneficial during medical detox. Anti-nausea or gastrointestinal medications may help with some of the flu-like symptoms. Benzodiazepine seizure and anti-anxiety medications like lorazepam (Ativan) may be helpful with the anxiety, tremors, and restlessness that tramadol withdrawal may bring about. Some antidepressant medications, like mirtazapine, and the blood pressure medicine clonidine may be used off-label to help with the autonomic nervous system response that occurs during opioid withdrawal (heightened blood pressure, heart rate, respiration, and body temperature). Lorazepam may also be helpful during tramadol detox to reduce withdrawal symptoms, as published by the Primary Care Companion to the Journal of Clinical Psychiatry.
While specific timelines vary from person to person, treatment providers can give individuals a better idea of their specific withdrawal timeline at intake. Tramadol withdrawal is best managed with medical detox, which can help to minimize the severity and duration of the withdrawal symptoms and prevent relapse.