The earlier you seek help, the better the outcome may be. Although respiratory depression and constipation are less common with Tramadol, even amongst other opioids, it can occur, in particular, after overdose and with impaired renal function.
Unlike other opioids, Tramadol abuse is not usually associated with the development of tolerance, physical dependence or psychological addiction. There is an increase in the risk of seizures where epilepsy is prevalent. Based on the severity of the overdose, a user can be at risk of long-term organ damage. To diagnose a possible overdose, look for these signs:.
Death does have the chance of occurring in the first hour of overdose so proper procedures must be followed. Simply not exceeding the dosage recommended by the physician puts a patient at a lower risk for overdose.
Another precaution to take in decreasing the risk of Tramadol overdose is to avoid taking Tramadol when also taking large doses of the following.
This is not a complete list so it should be discussed with a medical professional. If you suspect or have observed an overdose, there are a few things to avoid. Only if it is impossible for emergency crews to get to the location of the overdose, an overdose patient should not be taken by someone to the E. They should also not try to induce vomiting. They should also try to prevent the person who overdosed from moving around, which may accelerate the speed at which the Tramadol enters the blood stream.
Unless emergency crews suggest, do not give the person who has overdosed anything to eat or drink. A Tramadol overdose may be treated with a drug to counteract the effects. Other Tramadol treatments may include induced vomiting, pumping of the stomach and close monitoring of the breathing and heart rates. If you think you or a loved one is overdosing on tramadol, take them to the emergency room where they can get their stomach pumped or possibly a different medication to neutralize the effects.
Tramadol is a highly dependent drug. Often, tramadol addictions happen accidentally by patients unknowingly abusing their prescribed medication. Anyone who takes tramadol is at risk for potential dependence, addiction, and overdose. However, those who abuse this narcotic medication will be at an increased risk. Tramadol is often prescribed due to its dual benefits of being able to treat pain while being less addictive.
However, tramadol can still be habit-forming. People who take this drug over long periods can become physically dependent on the drug, which could cause a person to take large or frequent doses. Over time, the body becomes accustomed to having high amounts of the drug in order to function normally. If a person suddenly stops or decreases their use, the body may display symptoms of opioid withdrawal. These symptoms can be extremely uncomfortable, including nausea, sweating, and muscle cramps.
To avoid withdrawal symptoms, some people may take higher doses of tramadol than prescribed. People who suffer from mental health conditions are at an increased risk for opioid abuse and overdose. When a person has symptoms of depression, bipolar disorder, or another mental health condition, they may take large amounts of tramadol to relieve the symptoms. Additionally, people who struggle with polysubstance abuse may mix tramadol with other drugs. This raises the risk of overdose. Those who suffer from these conditions can benefit from learning safer coping mechanisms, such as mindfulness.
Although opioid overdose rates are climbing, tramadol abuse and overdose is a preventable and treatable condition. When people have access to effective addiction treatment, it reduces the chance of experiencing a tramadol overdose. At Vertava Health, we provide inpatient treatment programs with services like on-site medical detox and dialectical behavioral therapy DBT.
People who suffer from substance abuse, as well as mental health conditions, can benefit from medication-assisted treatment and creative arts therapy. To learn more about preventing tramadol abuse and overdose, or to find a rehab program near you, reach out to one of our treatment specialists today. This page does not provide medical advice.
SS has been reported after concurrent use of tramadol with serotonin reuptake inhibitors SSRIs , venlafaxine, atypical antipsychotics, fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine, moclobemide, clomipramine, mirtazapine, and tricyclic antidepressants [ 5 , 7 , 53 , 97 , ].
In patients who develop lethargy, hypotension, hypoxia, agitation, tachycardia, hypertension, confusion, hyperthermia, or hyper-reflexia, diagnosis of SS should be borne in mind [ 7 , , ]. Treatment is conservative and includes cessation of the culpable medication as well as administration of the antiserotonergics ciproheptadine, metisergide, propranolol, and chlorpromazine. Clinical manifestations recover within 24 hours except in those who have consumed medications with longer half-lives [ 5 , 53 , 97 ].
Pretreatment with chlordiazepoxide may prevent tramadol-induced SS [ 48 ]. Opioids metabolized by CYP including tramadol may induce many drug-drug interactions [ ]. In an Australian study, unwanted drug interactions were evaluated in patients who consumed antidepressants.
As previously clarified, tramadol is similar to venlafaxine in structure and is believed to have antidepressant effects. Venlafaxine can even cause false positive results for tramadol in urine tests [ 5 ]. Co-administration of tramadol and antidepressants especially TCAs, SSRIs, venlafaxine, bupropion, and phenothiazines should be performed cautiously because of the increased risk of seizure [ 6 , 25 , 72 ].
Concurrent administration of tramadol and NSAIDs can result in gastrointestinal hemorrhages due to severe platelet inhibition [ ]. Fatal toxicities have been reported after tramadol-TCA overdoses [ ]. It has been shown that tramadol-related mortality is more common after co-ingestion of benzodiazepines [ 8 , 26 ]. Tramadol can also interact with antitumor medications. For instance, tramadol decreases the efficacy of cisplatin by affecting gap junctions [ ]. In a case report, combination of paroxetine, dosulepin, and tramadol caused hallucination which improved after cessation of the medications [ ].
Fatalities have been reported after tramadol overdose or its co-ingestion with other medications. In most cases, death occurred after ingestion of high doses within 24 hours post-ingestion with really high blood levels [ 70 ].
Blood levels of tramadol have been between 0. The most common mechanisms of death after tramadol overdose are cardio-respiratory depression, resistant shock, asystole, and liver failure [ ]. Apnea may increase the risk of tramadol intoxication-related deaths [ 45 ]. Fatal toxicity of tramadol has been reported after co-administration of other medications including propranolol, trazodone, ethanol, and especially CNS depressants including benzodiazepines, barbiturates, and serotonergic drugs [ 88 ].
In fatal cases of tramadol, femoral blood samples are the best since they have the least redistribution changes after death [ ]. Tramadol may remain undetected in muscle samples after death due to its overdose [ ]. Mannocchi and assistants reported a case of death due to tramadol and propofol due to advanced severe dyspnea [ ].
A report showed nine deaths due to consumption of krypton a plant material containing ODT and mitragynine in whom the concentration of ODT was between 0. Another study reported death due o tramadol because of respiratory depression accompanying GABA A and GABA B1 alpha1 over-expression in the ambiguus nucleus and medulla oblongata solitary.
Table 3 [ ]. Accidental ingestion of tramadol is well tolerated by children [ 50 , 71 , ]. Side effects of tramadol seem to be more common but milder in children. Vomiting is especially common in them [ ]. Riedel and Stockhausen reported that tramadol could cross the blood brain barrier BBB in children and suppress the brain [ ]. Rectal administration of tramadol resulted in severe CNS depression in a 5-week-old infant which was explained to be due to the decreased kinetic elimination and increased permeability of the BBB [ 51 ].
Mazor et al. Short-term use of tramadol in lactating mother is not dangerous [ ] and the risk of neonatal dependency is low. Tramadol can cause SS without the effect of any other medication while in the adults the risk is increased if a SSRI is also taken [ 40 ].
In an 8-month-old infant with SS, the cause of hospital presentation was epistaxis. Sinus tachycardia, hyperthermia, hypertension, agitation, drowsiness, and hyper-reflexia of the lower extremities occurred within the first 24 hours after ingestion of mg of tramadol. Neurologic and cardiovascular effects recovered in two days.
The infant was discharged after five days in good condition [ ]. Treatment should focus on conservative approaches including maintenance of airway, breathing, and circulation, oxygen therapy, fluid resuscitation, and diazepam administration to control agitation and seizure [ 6 , 14 , 36 ].
Patients should be monitored for increased CPK and possible acute renal failure that may happen within the next two days [ 6 , 14 ]. Hemodialysis should be considered in cases with acute renal failure and severe creatinine increase [ 14 ].
They may need intubation and ICU admission. Gastrointestinal decontamination should be performed in the patients who have referred within the first two hours post-ingestion and have no contraindications [ 8 , 49 , 50 ].
In severe toxicities due to ingestion of large amounts of sustained-release drug, multiple dose activated charcoal should be considered if no contraindication exists [ 6 , ]. In cases with resistant shock or asystole, extracorporeal methods may be needed [ 6 , 35 ]. Treatment of liver failure is conservative, as well, and urgent liver transplantation is not feasible in many cases [ 18 ]. In severe cases who have not even seized, experimental therapy with diazepam can be performed which can be of help in mild undiagnosed SS [ 6 , 44 ].
Treatment of SS in also conservative and includes withdrawal of the culpable drug and external cooling. In a clinical study on patients, naloxone administration could induce seizure in tramadol-intoxicated patients [ 75 ].
Therefore, naloxone should not routinely be administered to treat decreased level of consciousness in tramadol toxicity unless respiratory depression has developed [ 21 , 45 ]. Seizures due to tramadol do not respond to naloxone but improve with administration of benzodiazepines. Naloxone can be considered for treatment of post-seizure complaints [ ]. Shadnia et al suggested that because of the low risk of multiple seizures in tramadol toxicity, anticonvulsant treatment should not be routinely given even in those with initial seizures [ 52 ].
Stoops et al evaluated naltrexone and showed that it could reverse the opioid-induced effects such as miosis; but, increased the serotonergic and adrenergic effects such as mydriasis [ 56 ]. Intravenous lipid emulsion ILE can reduce mortality due to acute toxicity of tramadol in rabbits, but increasing the ILE dose may cause reverse effects.
In a study on 30 rabbis, ILE reduced tramadol-induced tachycardia when administered within 30 minutes of poisoning and showed positive effects on normalizing mean arterial pressure and diastolic blood pressure but it did not have major effect on systolic blood pressure.
Intralipid also prevented tramadol-related seizures in low doses and reduced the frequency of increased CPK with higher doses [ ]. Although tramadol has less side effects, addicting capacity, and respiratory depression power in comparison with other opioids, many cases of dependency, abuse, intentional overdose, or poisoning have been reported following its use [ 20 , 27 , 48 , 56 , 70 , , , ].
Tramadol withdrawal lasts longer compared with other opioids [ ]. Where ultrarapid metabolizers are high in number, people are expected to have a higher risk of dependency to tramadol [ ].
Tramadol is as potent as heroin to cause euphoria [ 2 , 55 , ]. Withdrawal occurs after rapid abrupt discontinuation of tramadol with clinical manifestations including abdominal cramps, anxiety, skeletal pain, depression, diarrhea, goose flesh, insomnia, lacrimation, nausea, restlessness, rhinorrhea, and sweating. The manifestations may sometimes be atypical and include hallucination, paranoia, panic attack, confusion, and atypical sensational experiences such as paresthesia, itching, tingling, delusion, depersonalization, derealization, and tinnitus [ 22 , 55 ].
Tramadol dependency happens faster in those who abuse it with other analgesics or ethanol [ 55 ]. Clinical therapeutic doses of tramadol may affect psychomotor and physiologic capacities of the patients who recreationally abuse it [ ].
Tramadol abuse in pregnancy may cause preterm labor and withdrawal manifestations in the newborn baby depending on the age of pregnancy, time elapsed since the beginning of tramadol use, dose of tramadol, CYP D2 polymorphism, development of the liver conjugation, and renal function of both mother and baby.
Attempts have been performed to treat this syndrome in neonates using clonidine alone or in combination with the thin opioid tinctures, chloral hydrate, benzodiazepines, and methadone [ 55 ]. In a study on patients with chronic non-cancer pain, it was shown that the frequency of abuse and dependency on tramadol and NSAIDs were the same and significantly less than hydrocodone [ ]. It is less dangerous to the organs in comparison with selective and nonselective NSAIDs and very powerful in the treatment of chronic pains [ ].
Tramadol can also be used in moderate to severe toothaches alone or in combination with acetaminophen or codeine [ , ]. In opioid-addicted patients, tramadol can be used for the treatment of withdrawal pain [ 68 ]. Tramadol in combination with paracetamol has a fair efficacy, immunity, and acceptance rate by the patients without development of dependency syndrome [ , , ]. Complications can be decreased by adding tramadol to the controlled medications [ ].
Monitoring of the liver function especially when the maximum daily doses are given is mandatory. Also, because of drug-drug interactions and differences in the individual metabolism and the chance of dependency, tramadol administration should be controlled by the treating physician.
If the patient is an opioid-addict, tramadol should not be administered unless absolutely indicated [ , ]. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers.
Login to your personal dashboard for more detailed statistics on your publications. Edited by Ana Cristina Andreazza. Edited by Theophile Theophanides. We are IntechOpen, the world's leading publisher of Open Access books. Built by scientists, for scientists. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. Downloaded: Introduction Poisoning is one of the leading causes of mortality and morbidity in many countries.
Table 1. Studies on tramadol-induced seizures. Carcinogenic effects In long-term studies on rats and mice, no tramadol-attributed carcinogenic changes were detected. Biochemical findings of tramadol Bleeding time BT , clotting time CT , prothrombin time, partial thromboplastin time, and body temperature were not affected by tramadol [ 17 ]. Table 2. Studies on patients with tramadol poisoning. Serotonin syndrome Serotonin syndrome SS is a potentially fatal syndrome due to increased synthesis, decreased metabolism, increased release, and reuptake inhibition of serotonin or direct agonism at the serotonin receptors [ 5 , 53 ].
Three key clinical features of this syndrome include: Neuromuscular hyperactivity tremor, clonus, myoclonus, hyper-reflexia, stiffness, impaired coordination. Drug interactions Opioids metabolized by CYP including tramadol may induce many drug-drug interactions [ ]. Tramadol-related mortalities Fatalities have been reported after tramadol overdose or its co-ingestion with other medications.
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