KEY TAKEAWAYS
Tramadol detox comprises:
How To Detox From Tramadol In A Controlled Setting
Most rehabs do not provide tapering using tramadol as part of detox.
At Abbeycare, detox is done using either suboxone or buprenorphine, subject to medical approval.
Detox Using Buprenorphine | Detox Using Suboxone | |
|---|---|---|
Method | Buprenorphine blocks opioid receptors 8 - 16 mg per day, twice per day (patient-dependent) | Similar to buprenorphine with the addition of naloxone Titration starting with 2mg/0.5 mg initially, increasing by 2 - 4mg/day |
Timeline | Doses are titrated over 7-14 days until used at maintenance | 7 to 14 days, and doses are titrated similarly to buprenorphine |
Other Medications Used | Analgesics Anticonvulsants | Analgesics for headaches Metoclopramide for nausea Anticonvulsants |
Risk Of Seizures | Low to moderate Anti-seizure medications may be required | Low to moderate Anticonvulsant medications may be required |
Suitability | History of relapse Inpatient |
Tramadol Tapering | |
|---|---|
Method | Tramadol doses are slowly lowered until 0mg tramadol/day Symptom-managed withdrawal |
Timeline | Doses are decreased by no more than 10% every 1-2 weeks Dose reductions occur 1 to 2 times per week [1] |
Other Medications Used | Analgesics Naloxone Anticonvulsants |
Risk Of Seizures | Moderate if tapered too quickly |
Suitability | Outpatient |
Tramadol Detox Physical Symptoms
Sweating
Sweating is a physiological symptom of treatment for tramadol dependence and is distinct from other opioid detox due to the dual mechanism of action between opiate binding and serotonin/norepinephrine reuptake inhibition.
Six hours into treatment, there is a 24% increase in temperature thresholds, indicating an inability to thermoregulate and subsequent cold sweats [2].
Compared to sweating during heroin detox, sweating in tramadol treatment typically occurs at night, with cycles of both hot and cold sweating, due to a -1.03 decrease in the sweating threshold [3].
Sweating occurs in protracted withdrawal (i.e. beyond 4 weeks) in those formerly using high doses (~1200mg/day) due to the continued presence of SNRIs in the bloodstream.
Unlike traditional opioid withdrawals, detoxing from tramadol causes sweating for up to 4+ weeks, particularly if slow tapering is used.
Seizures
Due to tramadol binding to inhibitory GABA receptors in the brain during active addiction, there is a sudden influx of excitation in detox, resulting in a risk of seizure within 4 hours of treatment [4].
During detox, the combined use of tramadol tapering and naloxone reduces the mortality rate from seizures by 30% compared to tapering alone [5].
Gabapentin and naloxone treated detox reduces the seizure severity scores by 67% and 62%, respectively, highlighting the need for a medicated treatment [6].
Mice exhibit seizure onset at 52 seconds into tramadol withdrawal, on average, indicating potential dangers when ceasing tramadol use without tapering or buprenorphine [7].
At Abbeycare, we use the following medications to prevent and manage seizures:
Brain Zaps
Brain zaps are a physiological symptom of treatment, resulting from rebound activity in the serotonin and norepinephrine pathways, causing the sensation of "electric shocks" in the brain.
Opioid antagonists on muscarinic receptors inhibit tramadol binding by 15%, indicating that rebound activity in the acetylcholine receptors may also be partially responsible for brain zaps [8].
8.2% of new-onset brain zaps and seizures are caused by tramadol use and subsequent withdrawal; however, the occurrence rate depends on concurrent use of SSRIs/SNRIs, as well as tricyclic antidepressants [9].
Belaise et al. (2012) report a case study describing brain zaps as zapping sensations that 'wash over the entire body' as well as 'riding a rollercoaster' [10].
40% of patients tapering or stopping SSRIs experience brain zaps for 6+ weeks; however, for tramadol dose reductions, longer-term brain zaps are avoided by not lowering doses more than 10% in one week [11].
Mild brain zaps (1-2 seconds) occur in those with former mild tramadol addiction (200+mg per day), whereas severe brain zaps (3-5 seconds) occur when healing from more severe addiction (800mg+ per day).
Tingling Sensations In Hands And Feet
Tingling in hands and feet occurs due to hyperactivity in norepinephrine pathways, similar to brain zaps in the thalamus.
Rearing behaviour occurs in mice 2 hours into treatment for tramadol dependence, following 5mg/kg of naloxone, and this typically occurs due to tingling and/or seizure activity [12].
Rearing behaviour typical of tingling feet in mice is reduced by 15.3% upon administration of nalbuphine, indicating that tingling is potentially treatable in humans and aids in detoxification [13].
Tingling hands and feet may be experienced as "pins and needles", with sensations carrying up to the forearms and shins, looking like:
Tingling in the extremities, resulting in flinching and excessive movement, may be mistaken for a sign of early seizure in withdrawal.
Manish et al. (2018) present a case study of tingling in both hands and feet following the discontinuation of paroxetine, suggesting that serotonergic pathways may also be involved in tramadol detoxification, although these symptoms resolved within one week [14].
Tramadol Detox Psychological Symptoms
Visual And Auditory Hallucinations
1 to 14% experience some form of auditory and/or visual hallucinations with dysphoria [15].
Tramadol withdrawal hallucinations look like:
Compared to tramadol, fentanyl withdrawal has an 8% lower rate of hallucinations as a primarily mu-opioid agonist, indicating SNRI activation underlies the hyperexcitability causing hallucinations [16].
2% of cases of normeperidine neurotoxicity have been found to cause hallucinations, suggesting that substance metabolites (e.g. O-desmethyltramadol for tramadol) drive hallucination onset as well as serotonin and norepinephrine rebound activity [17].
Altered mental state explains audio and visual hallucinations in 40%, though this is medically managed at Abbeycare with antipsychotics such as haloperidol [18].
Panic Attacks
When tramadol has previously been used as a sedative for self-medicating anxiety, rebound activity occurs on serotonin/norepinephrine pathways as the substance is no longer present to prevent reuptake in presynaptic membranes.
Panic attacks typically occur when tramadol wears off, 12-24 hours after the last dose.
Panic attacks are managed throughout treatment through medication management, for example, with 40mg propranolol to overcome acute situational anxiety in the short term (~7 days) [19].
Panic attacks stem from anxiety caused by withdrawal from tramadol, and are one of the three most reported symptoms in the first phase of rehabilitation; however, the degree of panic attacks varies from patient to patient [20].
To combat panic attacks in tramadol withdrawal, venlafaxine is shown to be effective in Mukau et al (2022), due to its ability to partially block norepinephrine receptors to prevent rebound anxiety [21].
Depression
Depression is a psychological symptom of tramadol withdrawal due to the immediate crash in norepinephrine and serotonin levels in the brain, as tramadol is no longer available to prevent reuptake.
Atypical opioid activity from tramadol dependency causes depression through disrupted endorphin imbalance, as depressed patients are found to have a 62% decrease in beta endorphins [22].
85.7% of tramadol users incur some symptoms of depression, with 15.9% in a depressive episode without somatic syndrome in treatment [23].
7.9% of tramadol treatment patients have mild symptoms of depression with somatic syndrome, resulting in brain fog and difficulty concentrating [24].
In 1 week, major symptoms of depression (e.g. suicidal thoughts) typically resolve, though depressive symptoms (e.g. anhedonia) may linger for 6+ months, requiring continued medical management [25].
Intrusive Thoughts
Intrusive thoughts are a psychological symptom of tramadol withdrawal due to emotional rebound that occurs in treatment, for example, "why did I ever do this to myself?", as guilt and other internal emotions become externalised.
Tramadol users, compared to combined tramadol and opioid users, have a 5% increase in intrusive thought patterns and social phobia, due to the additional action on both serotonergic and noradrenergic pathways [26].
Haddad et al. (2018) found that anti-depressant withdrawal with SNRI action similar to tramadol results in a 78% prevalence of discontinuation symptoms, including intrusive thoughts and compulsions [27].
Serotonergic and noradrenergic rebound from treatment results in a 23% decrease in REM sleep, explaining intrusive thoughts as emotions a quarter of the time to be decoupled from memories [28].
Intrusive thoughts in tramadol treatment look like:
Intrusive thoughts typically disappear within 7 to 14 days of treatment [29].
If intrusive thoughts are severe (e.g., thoughts about a risk of harm to self or others), medical intervention may be introduced through non-serotonergic antipsychotics, such as haloperidol.
Regular monitoring (5+ times per day) occurs in those with severe intrusive thoughts in treatment, and surplus psychiatric referrals are made if necessary.
Positive Indicators Of Tramadol Detox
Reduction In Seizures
When tramadol is successfully withdrawn from the body, the risk of seizure reduces by an average of 30%, as long as relapse does not occur thereafter [30].
5mg of diazepam/day has been found to prevent further seizures in one case study of a 22-year-old female undergoing tramadol treatment, indicating benzodiazepines are an effective medication in early withdrawal [31].
In cases where there is a high seizure risk (e.g. family history of epilepsy), 2mg lorazepam is found to be effective in short-term treatment [1].
Within 7-17 days of benzodiazepine treatment for tramadol dose reduction, patients are typically no longer at risk of seizures, though this depends on medical history, and continuous monitoring is required [1].
Patients formerly taking the antidepressants bupropion and clomipramine have a 0.5-12.2% reduced seizure risk when these are stopped in treatment, but depending on symptom presentation, medications may be changed instead of stopped [32].
Although not directly an anticonvulsant, citalopram doses that increase 5-HT by 80-350% have been found to protect against seizure risk within the first 72 hours of treatment [33].
The first 7 days of treatment in patients with a seizure risk can be extended to 10+ days to ensure safety when weaning off tramadol; however, buprenorphine administration may be preferred in some patients.
Reduction In Panic Attacks
If a patient experiences 3 panic attacks in a day in early treatment, this will lower to 0-1/day over 2 weeks when appropriate medications are given, such as non-SNRI tricyclic imipramine.
Avoiding caffeine reduces panic attacks by 53.9% in those with underlying panic disorder, making this a standard in treatment at Abbeycare [34].
Panic levels decrease by 53% when naloxone is administered during treatment, as measured by escape latency in rats subjected to stress [35].
Lowering 32mg/kg doses of tramadol to 16mg/kg reduces the panicolytic effect of tramadol in rats by 65%, indicating that gentle dose reduction is effective as a treatment without the need for supplementary anxiolytics [36].
In treatment, patients experiencing panic are provided with continuous medical and pastoral care to manage panic attacks, helping to lower the duration of attacks from 30 minutes to 5-10 minutes until panic is no longer experienced.
Improved Sleep Patterns
Stage N1 of sleep, or the first stage of non-rapid eye movement (non-REM) sleep in the sleep cycle, is 55% shorter following tramadol treatment, resulting in a swift transition into the deeper stages of sleep without waking up [37].
Treated patients wake up, on average, 25% less than those still in addiction, resulting in healthy, continuous sleeping patterns [37].
There is a 40% improvement on the Pittsburgh Sleep Quality Index (PSQI) in those fully withdrawn from opioids compared to those on buprenorphine therapy, indicating there are positive effects on sleep after treatment [38].
Co-occurring psychiatric sleep disorders are reduced by 46% when fully healed from tramadol addiction, though the timeline for this depends on symptom presentation and former polydrug use [37].
Sleep apnea decreases by 15% after treatment, supporting healthy sleep through adequate oxygenation and less snoring [37].
How Does Tramadol's Original Prescription Purpose Alter Detox Protocols?
Prescribed For Pain
Continuous monitoring for widespread and localised pain occurs in treatment to gauge the necessity for supplementary non-opioid pain medication.
For those formerly using tramadol for pain relief, gradually decreasing doses may be done at no more than 5% every two weeks, compared to the standard 10% recommendation, to prevent rebound pain [1].
Non-opioid medication substitutions are required in those with chronic pain, for example:
Standardised pain scales and tools are utilised in tramadol treatment to assess the frequency, duration, and intensity of pain [39]:
Unlike typical opioid withdrawal, the Clinical Opioid Withdrawal Scale is sometimes avoided in treatment for tramadol dependency because it does not encapsulate SNRI withdrawal symptoms, including brain zaps and tingling that patients report as pain.
Prescribed For Low Mood
As a serotonin reuptake inhibitor, tramadol is sometimes prescribed for low mood and depression to balance serotonergic activity on 5-HT receptors and stabilise mood.
When tramadol is taken away in treatment, rebound depression may occur, so medical professionals continuously observe the need for alternative mood stabilisers, such as:
Assessments for this population are taken daily to assess changes in behaviour and emotions compared to those not using tramadol for this purpose.
Although not standard practice in many rehab clinics, individual one-to-one therapy may begin within 7 days of treatment to ensure transparency of current mood and that needs are being communicated.
Treatment programmes change for those addicted to tramadol as a mood stabiliser by screening for co-occurring mental health disorders that explain the depressive episode, including:
Although careful monitoring for the above disorders occurs during treatment, patients with any of these conditions are typically only granted inpatient treatment when these conditions are managed.
Continuous monitoring for serotonin syndrome is also ensured, especially when transitioning to alternative antidepressants.
How Do Pre-Existing Conditions Change Tramadol Detox?
Co-occurring depression changes tramadol treatment due to concurrent use of SNRIs/SSRIs, as these induce a risk of serotonin syndrome, so doses are closely monitored and lowered if necessary.
Patients taking SSRIs for depression have a 15% increased risk of serotonin toxicity, so withdrawal from tramadol changes to incorporate slow decreasing of doses as required, sometimes 2+ weeks [40].
Patients with epilepsy require a detailed seizure risk assessment, exploring current medication and seizure triggers so these can be avoided appropriately within the critical 7-day period.
97% of those with epilepsy report that at least one of stress, sleep deprivation, and fatigue is a seizure trigger in epilepsy, changing withdrawal through [41]:
Serotonin toxicity caused by combined withdrawal from tramadol and SSRI medication causes tachycardia in 44%, so those with heart conditions require heart monitoring up to 10 times per day or as necessary [42].
Detoxing From Tramadol At Abbeycare
Tramadol detox at Abbeycare is personalised with a structured care plan that is decided upon by on-site clinicians.
Pre-admission phone calls assess the history of tramadol addiction, frequency and severity of use, as well as any other co-occurring addictions.
Upon admission, patients begin buprenorphine or suboxone treatment, subject to approval by our medical team.
Withdrawal symptoms are continuously monitored for 7 days; however, the treatment may extend at the discretion of the on-site clinicians.
All symptoms are monitored for medication side effects and efficacy, and doses are titrated and adjusted accordingly to achieve pain management, craving management, and minimal withdrawal symptoms.
Medication is administered 1 to 2 times daily (or more as needed), with health observations conducted as required.
