Wednesday, January 18, 2012

Tramadol (Ultram) – A New Safe Painkiller?

Dr. Peter R. Coleman

When Tramadol was first approved a pain reliever, the drug company was happy to market it as a safe and non-addictive pain killer.  I was a little suspicious however, because the drug company reported that Tramadol worked on the same part of the brain (the mu opiate receptors) as Heroin and all of the other hard core, addictive narcotics.  And indeed, right from the early days, I started seeing patients who were prescribed this new “non-addictive” painkiller and they were becoming physically dependent on it.  It is still being prescribed by a lot of physicians, many of whom still think it is harmless and non-addictive.  Now we are seeing patients have a very difficult time coming off it – many patients have much worse detox symptoms than patients who are coming off of Heroin.

Last month, we had to detox a patient off very large doses of Tramadol.  He was taking about 40 pills per day – far more than the maximum of 8 pills per day, prescribed by most physicians.  It is quite surprising that he had not started having seizures, because many patients frequently have seizures if they take high doses of Tramadol.  I was very concerned about how difficult his detoxification would be coming off such high doses.  Over the years I have observed that most patients who are detoxing off Tramadol have a very difficult time.  I have seen many patients have such a difficult detoxification that they become confused, delirious, and even lose touch with all reality- they become psychotic.  I have been asked to consult on patients who have had this severe reaction.  One of the scariest things about these patients is that they can remain delirious for around 10 days.  Our patient did well.  We extended his detoxification to make it gentler on his body and we used high doses of medicines to calm his nervous system down.

The history of drug development and drug marketing has many examples of medicines, like Tramadol, that are introduced as safe and non-addictive drugs, only to find out later that they are very addictive and have serious side effects.  In the late 1800s, Sigmund Freud recommended using cocaine to help patients detoxify from Morphine - which had become quite a problem at that time.  Ironically, a short time later, physicians were recommending using Morphine to get off cocaine, which, by then, had also become a big problem!  Even Heroin was initially introduced as a safe cough medicine.  In the 1960s, Valium was introduced as a safe and non- addictive medicine for anxiety and insomnia, only to find out later that it was extremely addictive and withdrawal frequently included seizures and hallucinations.  A little later “non-addictive” Xanax (Alprazolam) was being recommended as a way to get people off Valium, and after that “non-addictive” Klonopin (Clonazepam) was being recommended as a way to get patients off Xanax!

In the world of opiates, there is a similar history of drugs being introduced as safer and non-addictive medicines, only to find out later that they are very addictive and sometimes even more difficult to detoxify off than the drug they are replacing. Darvocet was introduced and felt to be so safe that physicians were give large bottles of free samples to hand out to their patients.  Methadone was introduced as a safe alternative to heroin and other opiates.  Methadone is now used at clinics all over the country and is prescribed by many doctors as a chronic pain medicine.  I believe that Methadone has now become the number one cause of opiate overdoses in the country.  Recently Suboxone (Buprenorphine) was introduced and is being used as a substitute for other opiates.  When it was first released it was believed by many experts that Suboxone was not addictive and it would be easy for patients to stop taking.  As time has gone on, we are now aware that most patients have a very difficult time detoxifying off Suboxone.  Frequently, the withdrawal symptoms coming off Suboxone are more severe that withdrawal symptom coming off short acting opiates like OxyContin, Percocet and even Heroin.  The withdrawal symptoms coming off Suboxone go on and on, and unfortunately most patients revert back to taking their drug of choice.

So, while I applaud drug manufacturers for developing new treatments and medicines for patients, we have to be careful.  We have to recognize that some new drugs appear safe but they are not safe.  Addictive drugs all work in the same part of the brain – the Nucleus Accumbens and Ventral Tegmental area.  Addictive drugs (and alcohol) all release Dopamine in this area and it is the Dopamine that feels good and makes people want to take more of it.  If new drugs work in this same part of the brain, then they will almost certainly be addictive.  Physicians and patients both need to be careful before trying something new.

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