Drugs and Chemicals of
Concern > Tramadol
TRAMADOL
(Trade Names: Ultram®, Ultracet®)
September 200 8
DEA/OD/ODE
Introduction:
Tramadol was approved for marketing as a
noncontrolled analgesic in 1995 under the trade name of Ultram®.
Although the company initially claimed that this substance
produced only very weak narcotic effects, recent data
demonstrate that opioid activity is the overriding contributor
to the drug’s pharmacological activity. Because of inadequate
product labeling and lack of established abuse potential, many
physicians felt this drug was safe to prescribe to recovering
narcotic addicts and to known narcotic abusers. As a
consequence, numerous reports of abuse and dependence have been
received.
Licit Uses:
Tramadol is approved for the treatment of
moderate to moderately severe pain in adults. Although the
Department of Health and Human Services has not recommended the
scheduling of this substance in the Controlled Substances Act
(CSA), a requirement necessary for DEA to place a substance
under control, the Food and Drug Administration (FDA) has
required the manufacturer of Ultram® to inform physicians about
recent abuse data. The approved labeling has been modified on
three separate occasions to include new information under the
"Drug Abuse and Dependence" section. The labeling
currently contains the following language:
"ULTRAM may induce psychic and
physical dependence of the morphine-type (µ-opioid).
Dependence and abuse, including drug-seeking behavior and
taking illicit actions to obtain the drug are not limited to
those patients with prior history of opioid dependence. The
risk in patients with substance abuse has been observed to be
higher. ULTRAM is associated with craving and tolerance
development. Withdrawal symptoms may occur if ULTRAM is
discontinued abruptly."
Chemistry/Pharmacology:
Tramadol is a novel analgesic having both
opiate agonist activity and monoamine reuptake inhibition that
contribute to its analgesic efficacy. Opioid activity is due to
both the parent compound and the more active O-desmethylated
metabolite. Tramadol acts on the monoamine reuptake systems by
inhibiting the reuptake into nerve terminals of both
norepinephrine and serotonin. Apart from analgesia, tramadol may
produce a number of symptoms including dizziness, somnolence,
nausea, and constipation similar to other opioids. High doses of
tramadol, often in combination monoamine oxidase (MAO)
inhibitors or serotonin-selective reuptake inhibitors (SSRIs),
have been associated with a serotonin syndrome consisting of
convulsions, hyperthermia, muscle rigidity and pain.
Tramadol is well absorbed orally. It can
be administered in 50 to 100 mg tablets as needed for pain
relief every 4 to 6 hours, not to exceed 400 mg/day. Seizures
have occurred in patients taking recommended doses but are more
likely at high doses associated with abuse of this medication.
Tolerance, dependence and addiction to tramadol have been
demonstrated. Abrupt cessation from tramadol has been associated
with two types of withdrawal syndromes. One is typical of opioid
drugs with flu-like symptoms, restlessness and drug craving.
This type of withdrawal syndrome is encountered in about 90
percent of cases of withdrawal from tramadol. Another withdrawal
syndrome (encountered in about 10 percent of cases of tramadol
withdrawal) is atypical of opioids and is associated with
hallucinations, paranoia, extreme anxiety, panic attacks,
confusion, and numbness and tingling in the extremities.
Abuse and Diversion:
According to the System to Retrieve Drug
Evidence (STRIDE), a federal database for the seized drugs
analyzed by DEA forensic laboratories, there were 13 drug items
of tramadol from 11 different cases in 2007. These items
included 3,639 tablets, 157 capsules and 20.5 grams of powder.
According to the National Forensic Laboratory System (NFLIS),
state and local forensic laboratories analyzed 776 exhibits of
tramadol in 2007.
MedWatch is a FDA database of adverse
events of case reports voluntarily submitted to the FDA. From
initial marketing in 1995 through September 2004, the FDA
received 766 case reports of tramadol abuse and 482 cases of
withdrawal associated with tramadol. It is most commonly abused
by narcotic addicts, chronic pain patients, and health
professionals.
Controlled Status:
Tramadol is currently not controlled under
the CSA.
Comments and additional information are welcomed by the
Drug and Chemical Evaluation Section, FAX 202-353-1263 or telephone
202-307-7183.
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