Expert: Jacqui - 3/29/2011

Question
QUESTION: Hi Jacqui,
First, let me thank you for all the wonderful help you have given me and so many others in the past. The non-judgemental, accurate advice you give to us is vital and cannot be found anywhere else...I have looked for a long time. You are so important and I thank you.

I have a very addictive personality and have just recently been through withdrawal from hydrocodone. That is completely over with.. My friend gave me Tramadol, or Ultram, for pain and it stopped the pain without giving me the high that opiates do, which I did not want since I had just gone through that hamster wheel. It worked so well I went to my own doctor who I suspect has figured out my addiction problem, but I am not sure. He gave me a prescription for Tramadol. I am not sure how much I have taken. I know my friend got the prescription filled the end of February so it has been going on no longer than that. I would guess I took one 50mg a day for about a week to 2 weeks, then for the past 2-3 weeks at most I have taken 2 pills some days, 3 pills other days. Well guess what...they lied! This stuff gives me quick and fierce withdrawals HOURS after I don't take it and now I have read that you can have seizures and hallucinations if you go off too fast! This is criminal! For both mine and my friend's doctors to tell us this is a safe, non-addictive drug...after reading up on it for days on the Internet and listening to other's stories, this is a crime, this stuff is dangerous to get off of, whereas the hydrocodone was simply extremely unpleasant.
Nowhere online can I find a decent taper schedule. I see them ranging from reductions every 4 days to every 2 months. I have a limited supply and would like to keep some around for when I do get the headache and need one so I don't want to use them all up. I have about 40. Can you suggest a taper schedule? I do not have to be withdrawal symptom free, I can handle a bit of discomfort, but I do not want to be incapacitated and want to avoid the seizure and hallucinations completely. I hope you can help. I realize you are not a doctor so whatever advice you give me I realize is simply your opinion and you are not responsible for anything I do or anything that happens to me (read that lawyers, she is not responsible!)

Thank you for anything you can tell me.

Paula

ANSWER: Hey Paula,

mmmm ... yep the old "tramadol isn't addictive", they said the same thing about zolpidem, and way back in the day they said the same thing about diazepam.  You might be interested to know that when diacetylmorphine was synthesised over a hundred years ago, they said that wasn't addictive and they thought it was such a heroic medication they called it "heroin".

Anyway, none of that helps you now though unfortunately.  

Of course I am going to start this by saying I am not a medical practitioner, so this is my opinion and definately does not constitute medical advice.  I would strongly recommend you make contact with a medical practitioner about withdrawing off this medication.  However, I do understand that the medical system in the US is pretty deficient and that there is huge judgement against drug users across the health sector (I recently wrote a thesis on this and the results were pretty awful).  

Now, there are a few things that may impact on your situation.  Firstly, are you on Ultram ER.  If so, you are on an extended release medication and the tablet can't be broken as it affects the 'slow release' nature of it.  Unfortunately, the anecdotal information I have about slow release meds is that they take longer to withdraw off and the withdrawals start longer after the last dose.  I note that Ultram ER comes in 50mg tabs so dropping down is going to in bigger steps (which is a shame).  Also, as you have previously had a physical dependence on opiates, it is likely that you are kind of 'primed' for dependence.  I know that sounds silly, but often after people have used opiates for years then stop, if they use only two or three days in a row again, they will often go through withdrawals.  I have no idea why this occurs, but guess it could be related to the opiate receptors keeping some kind of "memory" of the drug.  There may also be a psychological aspect.  Finally, before I suggest a 'taper' can you get tabs that are in smaller doses?  This will make tapering easier.  

If you are taking three a day, I would perhaps try to drop to two tabs for a week, then try one a day for a week.  Depending how you feel, you could try taking one every second day for the week following.  Alternatively, codeine tabs come in much smaller doses - these are available over the counter in Australia (in doses of 10mg or less) but not sure about the US.  If that is possible, you could try switching to a low dose codeine and taking that for a week after you drop from one tab a day (instead of doing the second daily Tramadol).

Hey Paula I am really sorry I can't help too much with this one.  Unfortunately, these long acting tablet formulations make it really difficult to cut down in small doses.  However, if you aren't on the long acting ones, you do have the option to break them (I think).  In this case, I would suggest going from 2 tabs for 5 days, then 1.5 tabs for 5 days, 1 tab for 5 days, .5 tab for 5 days, then if you want to be really careful, .25 tab a day.  

As I always say, when you are withdrawing off opiates, you need to be kind to yourself.  Avoid alcohol as it will make you feel worse (unless you are dependent on alcohol and if that is the case, you definately would need to see a doctor for the tramadol withdrawal as alcohol withdrawal can cause seizures and other serious side effects - Actually, now I think about it, if you are on any other meds, it will complicate this, so what I have suggested may not be appropriate).  Also, you need to eat well, and use "sleep hygeine" methods - (google these - I know things like 'progressive muscle relaxation' sound a bit wishy washy, but they are proven to work and have so side effects), and get sunlight and at least some light exercise.  You will probably not feel like exercising at all, but just a light walk around the block will be helpful.  Exercise gets the body's natural endorphins working and can also make you more likely to sleep better at night.

Finally, if you choose not to get medical advice before doing this, and for some reason you have serious side effects, you need to get to a doctor urgently.  I know that the judgement from some doctors can be awful, but it is better than suffering a seizure and god knows what afterwards.  

Good luck and please don't hesitate to contact me again.  

Jacqui

Ps.  I forgot one more thing - don't hate yourself.  Humans take drugs, they have for thousands of years, it is nothing to be ashamed off.  

---------- FOLLOW-UP ----------

QUESTION: Thanks Jacqui!
I agree with you completely, humans take drugs, always have and always will. Simply the fact that we are aware of our own mortality should be excuse enough, what a burden nature gave us with that one! lol.

Codeine is not available here in the US. They say it is but you cannot find a pharmacist willing to give it out. There is a big push now in the US to get doctors to stop using opiates at all. I had a friend recently who tore a ligament in his knee, writing in pain, and they gave him what amounts to prescriptions strength aspirin. Incredible! Oh and I really enjoyed your "heroin" story, very interestingly. You should write a book, you really should.

Anyway, I am not on the long acting Tramadol, thank goodness. I am not really concerned about the opiate withdrawal aspect of this, I have done that before and, though unpleasant, it is not really dangerous. What I am concerned about is the SSRI part of this drug. They did not TELL me there was an SSRI in this or I would never have taken it. I am pretty sure this is what makes withdrawal dangerous. If you were to advise a person regarding an SSRI taper, do you still feel that the 5 day taper you gave me is reasonable? (meaning it will probably keep the seizures away?). That is really my main concern, the seizures.
And I do believe you are right about the brain's opiate receptors having a memory. It seems no matter how long I ma off them, if I take prescription cough medicine when sick (which is 5mg hydrocodone per dose in the US) I will have withdrawal after about 5 days use...crazy!
Anyway, thank you again and please let me know if you think the 5 days is safe. I have not been on them that long either and hopefully that makes a difference, I just know nothing about SSRIs and cant find a whole lot of info.

Answer
Hey Paula,

Yep tramadol has a similar action to some anti-depressants, in that it is has a SNRI type activity (serotonin norepinephine receptor inhibitor) - in the US, norephinephine is known as noradrenaline.  Cessation of SNRIs and SSRIs can result in what is referred to as a "discontinuation syndrome" which is technically different from a withdrawal (although this is semantics in some way).  Discontinuation syndrome for SNRIs and SSRIs often causes a weird feeling of dizziness (like you have stood up to quickly, but happening at random) and mood symptoms.  I have never heard of anyone having seizures from withdrawal from an SNRI or SSRI but that doesn't mean it can't happen.  Withdrawal off them is the same principle, do it slowly and if this is the case, you shouldn't have any symptoms at all.

I have just done a quick lit search on a scientific database and found the following about tramadol withdrawal - I have copied a few of the abstract below for you to review.  If you would like the full articles, let me know and I can email them to you (I will of course need an email address!)


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Physical dependence on UltramŽ (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur

SENAY et al. 2003

In 1994, the Drug Abuse Advisory Committee (DAAC) of the Food and Drug Administration (FDA) concluded that UltramŽ (tramadol hydrochloride) could be marketed as an analgesic drug without scheduling under the Controlled Substances Act based upon extensive pre-clinical, clinical and European epidemiological data. However, to guard against unexpectedly high levels of abuse in the United States, the DAAC recommended that an independent steering committee (ISC) be appointed to proactively monitor abuse/dependence. In the event that high rates of abuse were found, this ISC was given the authority to immediately recommend to the FDA that UltramŽ be scheduled. In the course of the surveillance project, the ISC received reports of withdrawal following abrupt discontinuation of UltramŽ and in some instances, following dose reductions. In most cases, the withdrawal symptoms consisted of classical opioid withdrawal, but in some cases were accompanied by withdrawal symptoms not normally observed in opiate withdrawal, such as hallucinations, paranoia, extreme anxiety, panic attacks, confusion and unusual sensory experiences such as numbness and tingling in one or more extremities. Withdrawal symptoms of either type were one of the more prevalent adverse events associated with chronic UltramŽ use, comprising nearly 40% of all adverse events reported with UltramŽ. Most of these consisted of typical opiate withdrawal symptoms, but 1 in 8 cases presented as atypical. These results indicate that physicians and other healthcare professionals need to be aware of the potential of UltramŽ to induce withdrawal of the classical opioid type, and that atypical withdrawal may also occur.
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Physical dependence potential of daily tramadol dosing in humans

Lanier et al. (2010)

Tramadol is an atypical, mixed-mechanism analgesic involving both opioid and catecholamine processes that appears to have low abuse potential and may be useful as a treatment for opioid dependence. The current study assessed the level of physical dependence and opioid blockade efficacy produced by daily maintenance on oral tramadol. Methods: Nine residential opioid-dependent adults were maintained on two doses of daily oral tramadol (200 and 800 mg) for approximately 4-week intervals in a randomized, double-blind, crossover design. The acute effects of intramuscular placebo, naloxone (0.25, 0.5, and 1.0 mg), and hydromorphone (1.5, 3.0, and 6.0 mg) were tested under double-blind, randomized conditions. Outcomes included observer- and subject-rated measures and physiologic indices. Challenge doses of naloxone resulted in significantly higher mean peak withdrawal scores compared to placebo. Withdrawal intensity from naloxone was generally greater during 800 versus 200 mg/day tramadol maintenance. Mean peak ratings of agonist effects were elevated at higher hydromorphone challenge doses, but did not differ significantly between tramadol doses. Physiologic measures were generally affected by challenge conditions in a dose-dependent manner, with few differences between tramadol maintenance dose conditions. Conclusions:  Chronic tramadol administration produces dose-related opioid physical dependence, without producing dose-related attenuation of agonist challenge effects. Tramadol may be a useful treatment for patients with low levels of opioid dependence or as a treatment for withdrawal during opioid detoxification, but does not appear to be effective as a maintenance medication due to a lack of opioid cross-tolerance.
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Paula there are also a bunch of case reports in a journal named "Reactions Weekly" that reports on drug reactions, however they don't have abstracts.  The danger in reading about all of the reports in that journal would be that they would only be the adverse reports and not the ones where there were no problems (people don't find 'no problems' very interesting!)  Either way, it sounds like while seizures are reported, they are very rare.  If you are on non-slow release tabs, I would slow down your reduction even more by cutting the pills (can you get a pill cutter, they sell them in pharmacies in Australia, not sure about US).  If you can do this, I would try dropping about a quarter of a tablet once a week (if you have enough), alternatively you could drop half a tab once a week which might leave you with a few.

Let me know how you go!

Stay safe,

Jacqui