America is undergoing a massive opioid anxiety attack. It has been called an epidemic by lawmakers and the media. While many people used opioids responsibly for chronic pain, there has been substantial abuse and way too many deaths. As a result of scary headlines and DEA crackdowns, many physicians have become understandably fearful about prescribing drugs like hydrocodone (Lortab, Norco, Vicodin) or oxycodone (OxyContin). Instead, doctors are turning to different kinds of pain relievers. But one commonly prescribed drug for pain is not benign. Tramadol (Ultram) side effects can be quite serious. This reader shares a poignant story:
A Tramadol Tale of Woe and Intrgue:
Q. Last February my 84-year-old mother had pain in her lower back due to a car accident. The doctor prescribed tramadol (Ultram). She took it for several months. It helped with the pain, but we did not realize that the problems she had were side effects that the drug was causing.
The most serious one was shortness of breath. The doctor prescribed an inhaler, and was about to refer her to a pulmonologist. Other adverse reactions included confusion, lack of appetite, depression, anxiety and very high blood pressure (we took her to the emergency room in April for blood pressure of over 200 with shortness of breath).
They did not find anything, but prescribed more blood pressure medicine. Around July she stopped taking the tramadol and she soon realized that she was no longer short of breath. Gradually she was back to her old self, with purpose, less anxiety, and able to breath well.
Perhaps the doctor should have realized that the shortness of breath was due to the tramadol. Perhaps I should have read the sheet that came with the medicine. I wonder if any other patients have had a similar experience.
How Does Tramadol Work?
A. Tramadol (brand names Ultram & Ultracet) is a very complicated medication that was first approved by the FDA in 1995. It is a moderately powerful prescription pain reliever that has some “weak” opioid activity. That means it acts a bit like a narcotic.
It was supposed to be safer than most pain relievers, which is why it is not categorized as a “controlled” substance (the way Vicodin, OxyContin or hydrocodone are). Doctors could prescribe Ultram without using a DEA (Drug Enforcement Agency) number. That reassured many health professionals. The DEA would not come after them the way it might if they were prescribing oxycodone.
Tramadol Was Not Supposed to be “Addicting”
In the early days there was a belief that tramadol was much less likely to cause dependence than most other narcotic-like analgesics. In other words, there was not supposed to be an abuse potential (doctorspeak for the drug was generally considered non addicting). In theory, this pain reliever was supposed to have a low likelihood for producing withdrawal symptoms upon discontinuation, especially when compared to narcotics like hydrocodone or oxycodone.
A Little-Known Tramadol Effect:
We suspect that most health professionals do not truly understand the pharmacology of tramadol. They know that the DEA won’t spank them for prescribing it. They know it is not as potent as hydrocodone or oxycodone.
But do they know that tramadol also affects neurochemicals such as serotonin and norepinephrine? That means the drug behaves a little like antidepressants such as Zoloft (sertraline, which is an SSRI or selective serotonin reuptake inhibitor) or Effexor (venlafaxine an SNRI) in the brain. Tramadol has not been approved to treat depression, however. More on this effect (and its complications) in a moment.
The problem with theories is that they don’t always work out the way they are supposed to. In the case of tramadol, there are a number of side effects and complications that were not necessarily anticipated.
Tramadol (Ultram) Side Effects:
• Dizziness, unsteadiness, vertigo, coordination difficulties
• Nausea, vomiting
• Abdominal pain, indigestion, diarrhea
• Sleepiness, drowsiness, fatigue,
• Itching, skin rash (could be life threatening!)
• Dry mouth
• Anxiety, confusion, nervousness, cognitive dysfunction
• Respiratory depression, breathing difficulties (shortness of breath)
• Suicidal thoughts
• Low blood pressure on standing, hypertension, irregular heart rhythms
• Serotonin syndrome
Responding to Our Reader’s Concerns:
Your mother’s side effects including her breathing difficulties, confusion, lack of appetite, hypertensive episode and depression could all have been tied to tramadol. The drug can trigger something called serotonin syndrome, especially in combination with certain other medications. You can read more about serotonin syndrome at this link. It can be potentially life threatening.
Tramadol and Older People:
The Swedish National Board of Health and Welfare has included tramadol in its list of drugs to (BMC Pharmacology and Toxicology, October 25, 2017):
“avoid unless special reason for prescription.”
The Swedish researchers consider tramadol a “potentially inappropriate medication” in older people, especially if they are identified with “intellectual disability.” In other words, if someone is confused, they may become more confused while taking a drug like tramadol (see anticholinergic effects below).
Similar Stories from Readers:
“My doctor (and the orthopedist to whom I was referred for severe hip pain) prescribed Tramadol for recurring pain. I was nauseated, dizzy, had hot flashes, and many of the other side effects this supposedly safe drug causes.
“When I tried to stop I went through what I can only describe as withdrawal. It lasted for about 48 hours. When it was over it felt like coming out from under a cloud. This from a patient like me who is careful in her use of medications.”
Mac in South Carolina shared this:
“I took tramadol for a brief time for back pain. I tried it on three different occasions. I experienced extreme vertigo, nausea, diarrhea, and a migraine-like headache with just one dose each of those times. I had to hold on to the wall to get myself to the bathroom without falling down and could not tolerate bright light. This lasted for days.”
C.S. In Florida was also sensitive to tramadol (Ultram) side effects:
“I was prescribed tramadol for pain. After only 3 doses I experienced nausea, severe vomiting, headache, tingling in both arms and disorientation. I feared I was having a stroke and went to the emergency room. A CT scan revealed no stroke.
“I would never take this medication again. When I go to see any doctor I list tramadol in the ‘allergic to’ section of medical forms so I am not prescribed it again.”
Tramadol and Anticholinergic Activity:
Very few physicians realize that tramadol also has anticholinergic (AC) activity. That means it interferes with the action of the crucial brain chemical acetylcholine. This might explain why the woman who contacted us described her mother’s “confusion” as a possible complication of tramadol.
Learn more about the impact of anticholinergic drugs at this link:
Tramadol has weak AC activity. But if someone were taking other drugs that also have this effect, the total AC burden could become problematic. This is especially true for older people. Here is a link to more information on drugs with anticholinergic activity.
Tramadol (Ultram) Side Effects & Withdrawal
Perhaps the most disturbing and unanticipated problem with tramadol is withdrawal. Even though most health professionals thought the drug would not trigger this problem, we now know that it not only happens but can be disastrous.
In addition to the narcotic-like action of tramadol, the drug also behaves a bit like antidepressants such as paroxetine, sertraline or venlafaxine. At the time it was approved, the FDA may not have realized that when such drugs are stopped suddenly, people can experience very unpleasant withdrawal symptoms.
This dual action (the narcotic-like effect and the serotonin “discontinuation syndrome”) can lead to some terrible symptoms. Patients are not always warned about this problem.
Tramadol Withdrawal Symptoms:
• Anxiety, mood swings, irritability
• Brain zaps (shock-like sensations), tingling
• Sweating, chills, goose bumps, shivering
• Insomnia, sleeping difficulties, nightmares
• Flu-like symptoms
• Nausea, vomiting, diarrhea, loss of appetite
• Hallucinations, unusual thoughts
Here are just a few of the many stories we have received about this complication:
Keiko clearly experienced withdrawal after stopping tramadol:
“I had surgery on my shoulder for a partial rotator cuff tear and manipulation of my frozen shoulder at the same time. The doctor ordered for PT to begin very next day. I was taking tramadol, but starting to feel strange so I stopped taking it abruptly.
“By midnight I was having cold chills and the sweats all night long. By the next morning I was vomiting. In addition to sweating profusely and cold chills I had severe anxiety. I was ended up in ER that afternoon. Apparently, I was having withrawal from tramadol. It was a horrible experience. I do not want to ever experience the “withdrawal” symptoms again.”
Lorraine reports that tramadol withdrawal was awful:
“I took tramadol for just over 30 days prior to having a hip replacement. I then took the pills for a week after surgery. Then I stopped.
“The withdrawal for me was worse than recovery from the surgery. I had flu like symptoms and was depressed (something I had never experienced). It took about 3 weeks to feel somewhat normal. I would never take this drug again!”
Anonymous in Pennsylvania:
“Contrary to what doctors may say, this drug is very addictive. Use it sparingly and carefully. There is a small percentage of people who seem to be able to stop this drug cold turkey and not experience withdrawal. They are very lucky.
“More and more it’s becoming recognized that tramadol is an addictive drug and causes terrible withdrawal for many. The worst of it will last anywhere from 2 days to 2 weeks and then, depending on how long you’ve been taking the drug, you may continue to experience withdrawal symptoms for months afterward.
“I can’t even begin to explain how bad the withdrawal is. If you look it up, you will find numerous reports and testimonials from others who are trying to get off this drug and can’t because the withdrawal is so bad. Others can vouch for the hellaciousness of it.
“For me the worst physical symptom was constant restless legs. Emotionally, I was extremely depressed and had zero energy. Just lifting my arm felt like a huge effort. Going up and down the stairs put me out of breath. My internal thermostat was totally out of whack. I was hot one minute, and cold the next. My hair and clothes would get drenched from night sweats.
“The list goes on and on. I don’t EVER want to go through that kind of withdrawal again. I’m not saying don’t take this drug. But do be careful and try to stay on it for only as short a length of time as possible. Oh, I should also note I had a seizure while withdrawing from tramadol, which is not uncommon when coming off this drug.”
Generic Tramadol Issues:
In addition to the side effects and withdrawal symptoms associated with sudden discontinuation of tramadol, there is also the generic drug concern. We have heard from a number of people that not all generic versions of tramadol are created equal:
P.J.B. reported the following:
“I was taking the generic version of Ultram (tramadol) for several years when my pharmacy suddenly changed manufacturers (and did not point it out to me before I left the pharmacy with it).
“I gave them the benefit of the doubt, but within 24 hours of taking the other generic, I knew something was terribly wrong. All of my pain symptoms returned overnight, accompanied by extreme anxiety.
“I had to jump through hoops with the pharmacy but managed to get my doctor to write the script as DAW [dispense as written] and within an hour of taking the ‘Ultram,’ I felt completely different. The anxiety disappeared along with the lower back and leg pain.”
Jim also had generic drug trouble:
“When my doctor prescribed Ultram for my neurologic pain, it worked. I was nearly pain free for a few hours. When the pharmacy changed to the generic tramadol I never had total pain relief for any length of time.”
The People’s Pharmacy Perspective on tramadol:
Some people do well with tramadol. It this drug relieves their pain without side effects we are delighted. Others, however, may get modest pain relief and suffer symptoms such as dizziness, nausea and confusion. Older people may be especially vulnerable to such complications. Here is our bottom line:
• Tramadol can ease pain somewhat, but has a number of serious side effects (see above)
• Tramadol should not be discontinued abruptly. It can trigger terrible withdrawal symptoms for some people.
• The FDA has not provided physicians with clear guidelines on how to help patients phase off such drugs. We frequently see recommendations like “gradual withdrawal,” but no one bothers to provide clear instructions about what that really means.
• Do not assume that all generic tramadol formulations are identical to Ultram or each other.
If you experience any side effects, withdrawal symptoms or complications with a generic version of tramadol, contact your physician and pharmacist and request the help you deserve. Let your doctor know if tramadol is causing symptoms such as dizziness, nausea, drowsiness, dry mouth, insomnia or confusion.
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