Tramadol is a centrally acting analgesic with a dual mechanism of action: it is a weak μ-opioid receptor agonist and also inhibits reuptake of serotonin and norepinephrine. This makes it pharmacologically distinct from “traditional” opioids, as its non-opioid activity contributes significantly to its analgesic effect. Tramadol is prescribed for moderate to moderately severe pain, especially when first-line non-opioid medicines (paracetamol, NSAIDs) are insufficient or contraindicated. It is often considered a step II analgesic on the World Health Organization (WHO) analgesic ladder, bridging between simple analgesics and stronger opioids such as morphine.
Available forms include immediate-release tablets and capsules (typically 50 mg), oral drops, oral solutions, effervescent tablets, dispersible tablets, modified-release tablets (100–200 mg), and injectable formulations (for inpatient or emergency use). The diversity of formulations allows tailoring for acute vs chronic pain settings. In most countries, tramadol is prescription-only and subject to opioid prescribing controls, though regulatory classification varies (for example, in the UK it is a controlled drug, schedule 3; in some EU countries, it remains under standard prescription law).
Because of its mixed mechanism, tramadol is associated with unique safety issues. While its μ-opioid activity means dependence and respiratory depression are possible (especially at high doses or with sedative co-use), its serotonergic activity introduces a risk of serotonin syndrome when combined with other serotonergic medicines. It also lowers seizure threshold, particularly at higher doses or in predisposed patients. These risks mean tramadol must be prescribed thoughtfully, with careful attention to dosing, comorbidities, and concomitant medicines.
Always individualise the dose, using the lowest effective dose for the shortest duration. Tramadol should not be used as “first-line” for long-term chronic pain without regular review and documented benefit.
Most side effects are dose-related. Patients should be advised to report serious symptoms immediately and avoid abrupt cessation without medical guidance.
In all cases, reassess pain and benefit regularly. Chronic prescribing should be specialist-supervised.
Key interactions include:
Always inform your clinician/pharmacist of all medicines and supplements taken, and avoid self-medicating with additional serotonergic or sedative drugs.
Overdose: Symptoms may include extreme drowsiness, pinpoint pupils, seizures, slow/shallow breathing, cardiac arrest, or collapse. This is a medical emergency — call emergency services immediately. Management often includes airway support, naloxone (opioid antagonist, though less effective for tramadol due to mixed mechanism), and treatment for seizures/serotonin syndrome.
Accidental double dose: If taken close together, monitor for drowsiness, nausea, or unusual symptoms. Skip the next dose and seek advice if unwell. Do not take extra to “catch up.”
Missed dose: Take as soon as remembered if not close to next dose. If it’s nearly time for the next dose, skip the missed one. Maintain at least 4–6 hours between immediate-release doses, or 12 hours for modified-release. Never double up.
Always read the package leaflet and follow prescriber instructions. Any concern about overdose or severe side effects requires immediate medical review.
Check expiry date regularly; discard safely after expiry.
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