COVID 19 unveils tramadol dependence

To the Editor

Tramadol hydrochloride is a centrally acting analgesic widely prescribed for acute and chronic forms of pain due to its less abuse potential and a better safety profile in comparison to some opioids. Its analgesic potency is estimated to be one fifth to one tenth of morphine (World Health Organization, 2014). Centrally it acts on the mu receptors and peripherally inhibits serotonin and norepinephrine reuptake (Ferrari, 2014). The latter effects are likely to be an important element in analgesia but also account for some of the adverse effects of the drug. We have very few studies of patients treated with tramadol for chronic benign pain who then develop tramadol abuse, dependence and withdrawal syndrome after abrupt cessation.

We describe here a case of tramadol dependence in a healthy male with previous history of alcohol use disorder.

This 48-year-old English male teacher presented to the Emergency department during the Covid 19 lockdown for management of withdrawal from tramadol on which he had been dependent for the past 8 years. His general practitioner (GP) had prescribed tramadol for peripheral neuropathy that developed as a complication of alcohol misuse approximately 8 years prior to presentation to Alcohol and Drug service (AODS). Initially, he took up to 400 mg of tramadol tablets per day but over the next few years his daily consumption of tramadol increased to 2.4–3 g per day. He was working as an English teacher in China and lived between China and Australia each for 6 months at a stretch. He was able to procure a 6-month supply of tramadol from his GP in Australia on each return visit. While in China he managed to source a further supply from four different hospitals as well as from some of his students; however, during this lockdown, he was not able to procure his usual supply which led to his presentation.

History suggested he was never dependent or injected on any other illicit drugs.

He had history of depression in his 20s which was treated with antidepressants. With respect to family history, his grandfather was dependent on alcohol. There was no other history of illnesses or stressors in family.

Positive findings on physical examination included sweating and hand tremors. He had consumed 400 mg of tramadol 6 hours prior to his examination and around 800 mg a day before the presentation. Relevant haematological and biochemical parameters were within normal limits. He was managed in an outpatient setting with suboxone. After the initial dose of 6 mg on the first day, he developed hypertensive crisis suspected to be due to Serotonin Nor-adrenaline Reuptake Inhibitor (SNRI) discontinuation syndrome with abrupt cessation of high-dose tramadol and this was managed in the emergency department. He recovered within 12 hours and continued with outpatient management of gradual upward titration of suboxone. He was also commenced on duloxetine 30 mg for its dual action on the serotonin noradrenaline reuptake and its analgesic effect. After 5 weeks, he continued to be managed as a case of opiate dependence on suboxone 20 mg daily with a view to a gradual wean prior to returning to China.

This case highlighted the need for (1) patients must be advised to take tramadol regularly and to stop gradually, especially after long treatment periods (Freye and Levy, 2000); (2) physicians must consider the potential physical dependence when they prescribe tramadol for pain; and (3) any form of ‘dependence’ of patients taking tramadol needs to be further explored. Finally, the establishment of an evidence-based tramadol detoxification protocol would be highly desirable.