Tramadol is a centrally acting synthetic opioid analgesic used to manage moderate to moderately severe pain. It has a unique dual mechanism of action that makes it different from traditional opioids, working as both an opioid receptor agonist and a serotonin-norepinephrine reuptake inhibitor (SNRI).
Generic names: Tramadol
Brand names: Ultram, ConZip, Rybix ODT, Ryzolt, Ultram ER
Pharmacologic class: Synthetic opioid analgesic
Therapeutic class: Analgesic, narcotic
Mechanism of action: Tramadol works through two mechanisms: it binds to μ-opioid receptors and inhibits the reuptake of serotonin and norepinephrine in the central nervous system, providing pain relief through multiple pathways.
Indications for use: Management of moderate to moderately severe pain in adults, chronic pain conditions, post-operative pain, and cancer-related pain.
Precautions and contraindications:
- History of substance abuse
- Respiratory depression
- Acute intoxication with alcohol, hypnotics, centrally acting analgesics, or psychotropic drugs
- Pregnancy (Category C)
- Severe renal or hepatic impairment
- Children under 12 years of age
- History of seizures or at risk for seizures
Drug Interactions
- MAO inhibitors (must discontinue 14 days before starting tramadol)
- SSRIs, SNRIs, and tricyclic antidepressants (increased risk of seizures and serotonin syndrome)
- Other CNS depressants, including alcohol
- Carbamazepine (decreased effectiveness of tramadol)
- CYP2D6 inhibitors
- Warfarin (increased INR)
Adverse Effects
- Dizziness and vertigo
- Nausea and vomiting
- Constipation
- Headache
- Somnolence
- Pruritus
- Respiratory depression
- Serotonin syndrome
- Seizures
- Physical and psychological dependence
Administration Considerations
Available preparations: Immediate-release tablets, extended-release tablets, capsules, orally disintegrating tablets
Dosages:
- Immediate-release: 50-100 mg every 4-6 hours (maximum 400 mg/day)
- Extended-release: Initial 100 mg once daily, may increase by 100 mg every 5 days (maximum 300 mg/day)
Routes and Timing:
- Oral immediate-release: Onset 1 hour, peak 2-3 hours, duration 4-6 hours
- Extended-release: Peak 4-6 hours, duration 24 hours
Nursing Considerations for Tramadol
Related Nursing Diagnoses
- Acute pain
- Chronic pain
- Risk for respiratory depression
- Risk for falls
- Risk for injury related to CNS effects
- Risk for substance dependence
Nursing Assessment
- Perform comprehensive pain assessment, including location, intensity, quality, and duration.
- Assess vital signs, particularly respiratory rate and depth.
- Review the patient’s complete medication history, especially for medications that may interact with tramadol.
- Screen for history of substance abuse, seizures, head injury, or depression.
- Assess renal and hepatic function through laboratory values.
Nursing Interventions
- Monitor pain relief effectiveness using appropriate pain scales.
- Assess for signs of respiratory depression, particularly during initiation and dose increases.
- Implement fall precautions due to CNS effects.
- Monitor for signs of serotonin syndrome: agitation, hallucinations, rapid heart rate, fever, and muscle stiffness.
- Watch for signs of dependence or tolerance.
- Keep naloxone readily available for potential overdose.
Patient Teaching Associated with Tramadol
- Take medication exactly as prescribed. Do not crush, break, or chew extended-release formulations.
- Report any unusual symptoms, particularly mental status changes, severe dizziness, or difficulty breathing.
- Avoid alcohol and other CNS depressants while taking tramadol.
- Rise slowly from sitting or lying positions to prevent orthostatic hypotension.
- Do not drive or operate machinery until the effects of medication are known.
- Never share medication with others, and keep it secured away from children.
- Be aware of signs of withdrawal and avoid abrupt discontinuation.
- Maintain adequate fluid intake and dietary fiber to prevent constipation.
Note: This is not an all-inclusive list of possible drug interactions, adverse effects, precautions, nursing considerations, or patient instructions. Please consult with a pharmacist for complete information.
References
- Miotto K, Cho AK, Khalil MA, Blanco K, Sasaki JD, Rawson R. Trends in Tramadol: Pharmacology, Metabolism, and Misuse. Anesth Analg. 2017;124(1):44-51. doi:10.1213/ANE.0000000000001683
- Vazzana M, Andreani T, Fangueiro J, et al. Tramadol hydrochloride: pharmacokinetics, pharmacodynamics, adverse side effects, co-administration of drugs and new drug delivery systems. Biomed Pharmacother. 2015;70:234-238. doi:10.1016/j.biopha.2015.01.022
- Hassamal S, Miotto K, Dale W, Danovitch I. Tramadol: Understanding the Risk of Serotonin Syndrome and Seizures. Am J Med. 2018;131(11):1382.e1-1382.e6.
- Stamer UM, Musshoff F, Stuber F, et al. Concentrations of Tramadol and O-desmethyltramadol Enantiomers in Different CYP2D6 Genotypes. Clin Pharmacol Ther. 2016;100(4):367-373.
