Ask the Pharmacist

Q) I was just prescribed Tramacet for my bad back and was told that while it is not considered to be a narcotic, it is just as strong as codeine when it comes to killing pain. I am a little concerned as I am pretty sure I read something negative about this drug in the newspapers not so long ago. What can you tell me about it?

A) When tramadol first came onto the Canadian market back in 2005, it was really the first new pill aimed at treating pain since the influx of a wave of opioids a number of years before. There was real hope that it would be that rarest of combinations, more powerful than the current anti-inflammatories (such as Advil & Aleeve) and Tylenol minus all the drawbacks that come with prescribing narcotics (perhaps better known as opioids) for non-cancer pain. This has unfortunately turned out to be wishful thinking.

For while tramadol is not a “bad” drug, it does come with a number of potential adverse effects that closely resemble those of the narcotics we were hoping it would safely replace. Perhaps this should not have been a surprise given that it works on the same regions of the brain as better known drugs such as fentanyl, Oxycontin and Percocet, that are, of course, all opioids. That’s not to say that tramadol is not safer than these other drugs. It is a much weaker opioid than its more famous brethren so its use by Canadians has been much less problematic.

However, there have been enough “issues” with this drug that Health Canada is planning on changing how this drug can be prescribed by moving it into the “controlled substance” part of the drug registry making it harder (in theory at least) to be misused. Why it was not originally listed in this portion of the registry is a very good question as Health Canada has taken some well deserved heat for their initial decision. There have been allegations that they were influenced by heavy pressure from the manufacturers who feared that a controlled drug designation would hurt sales. Regardless of all of this, the main question is, just what do we know about tramadol.

First off, it’s known by several names and it can be either on its own or combined in a single pill with Tylenol/ acetaminophen which was first marketed as Tramacet. The drug is used strictly for pain (i.e. it has no effect on inflammation) and can be found in both short-acting (where its pain killing effects seem to last from 4 to 6 hours) and much longer-acting forms. In terms of analgesic effect (i.e. its ability to kill pain) tramadol has been as good as advertised. For most people, it is stronger than any of the anti-inflammatories or Tylenol & is in fact stronger than codeine for most.

It is a pretty effective medication for up to moderate levels of pain and as such is used commonly for post operation pain or for muscular skeletal injuries (like a significant strain/ sprain/ fracture) after a quick trip down to the emergency department for an assessment. However, it’s in the safety department that tramadol has been a bit of a disappointment. As we have hinted broadly at earlier, tramadol is a drug that can cause both addiction and dependence (the difference being that dependence means that while the patient is not taking it to get “high”, they will suffer withdrawal symptoms should they come off of the drug) and therefore has the potential to be abused.

As well, on top of the typical opioid type side effects (constipation, upset stomach, drowsiness….), tramadol had been uncommonly associated with seizures, hyponatremia (having too low a level of sodium which can cause you to feel lousy and very rarely lead to a coma) and serotonin syndrome (a nasty and potentially fatal disorder arising from an excess of serotonin in the bloodstream).

To further complicate matters, tramadol is broken down by your liver before it is eliminated from your body just like codeine is. One of these breakdown by-products is in fact “active”, meaning that it is capable of performing all of the pharmacological activities of the drug (including both the good stuff, i.e. pain killing, and the bad, i.e. depressing your ability to breathe). There is a very small segment of the population who convert tramadol to this active version extremely quickly, and it is in these people that overdoses can occur even at low to normal doses. Regrettably, there is no way to identify these individuals until such time as they are showing toxic symptoms despite taking just a single tablet.

It is for this reason that tramadol should not be prescribed to those who are least able to better deal with unnaturally high levels of this drug such as those who are pregnant, nursing or are under the age of 18. For anyone that is suspected of having an overdose to tramadol, a naloxone kit, available at just about every pharmacy, will reverse the actions of the drug just as it does with the opioids.

To sum up, tramadol is not necessarily a bad drug. When used properly, it can provide significant and prompt pain relief for a variety of aches. We just should keep our wits about us when we, or someone we care for, takes this drug. There is some potential for things to go very wrong and, as such, a little foresight can go a long way.