As an opioid-type analgesic, which exerts its effects through multiple receptor systems, tramadol carries a dependence producing potential.[20
] This needs to be taken into consideration when detoxifying the patient from other opioids. In three of our patients, initiation of tramadol use had begun with a prescription of tramadol for detoxification; they were not able to taper the doses of tramadol as per prescription. Experience of euphoria with tramadol was also reported. Thus, tramadol is used by opioids-dependent subjects as a substitute for the unavailable ‘harder’ drugs.
Detoxification of our patients was done largely with oral clonidine and non-steroidal anti-inflammatory drugs (NSAIDs), as reported by some,[18
] but not others who used the buprenorphine–naloxone combination and methadone for tramadol-detoxification.[21
Apart from those patients with medical disorders using tramadol;[8
] the drug has the potential for abuse by opioids-dependent subjects. Given the easy availability of tramadol from pharmacies in India and some other countries, its abuse and diversion may become a bigger challenge in the future. There is a need to effectively regulate the distribution of this medication, and apply the appropriate safeguards, to prevent diversion.
This case series adds to the growing concern about tramadol-dependence. It emphasizes the need for caution before prescribing tramadol to patients, especially those who are opioids-dependent, and to apprise the drug regulatory authorities of such occurrences, for proper scheduling and issue of warnings.