Jackie’s 84 year old mother had been diagnosed with spinal stenosis and was taking opiates for years. As the opiate epidemic dominated the news cycles day after day, she became quite concerned with her mother, especially given the fact that she was getting older and Jackie knew her body did not work as well as it did when she was younger. She took these concerns to her mother’s nurse practioner.
“We had a long conversation about the pain medications she was on and he felt that the best thing to do would bring down her dosage of oxycodone and switch her to Tramadol,” Jackie said. “He stated that it is a non-narcotic and they are using that now in many cases to avoid the problems with opiates.”
Jackie stated that things did not go well. “She began to act differently, and I became concerned. The initial dosage was to take the medicine twice a day. I called the doctor’s office back and was told that some of the behavior I was seeing could be the result of coming off the narcotic and to just keep an eye on her, which I did. But things got worse."
According to Jackie, her mother “became very jittery, confused and unsteady
on her feet. When I called the office again, I was told to give her the Tramadol once a day instead of twice, and by doing this her pain got worse and she slept all day and was awake all night. Within a couple of days, she started with shortness of breath, anxiety, wouldn’t eat, and very high blood pressure – this landed her in the ER.”
“When I told the emergency room doctor what had happened and the fact that the nurse practioner said Tramadol was not a narcotic and safer than the opiate she was on, he told me that was wrong, that this medication is an addictive narcotic. I wish I had known that,” said Jackie.
Tramadol was first introduced in the United States in 1995 under the brand name Ultram and was initially marketed as a safer non-controlled analgesic with less potential for abuse than traditional opioids. Tramadol has become the second most commonly prescribed narcotic-type analgesic, ranking behind only hydrocodone/acetaminophen products.
Tramadol is in a group of drugs called opiate agonists. It is used to treat moderate to severe pain by changing the way the body senses pain. It binds to opioid receptors, decreasing the body's ability to feel pain. It is similar to morphine in the way it works but is about one-tenth as potent – but it still carries the risks associated with opioids and some that are not associated with opioids.
Like other opioids, Tramadol can produce physical dependence with severe flu-like withdrawal symptoms. In addition, withdrawal from Tramadol can produce seizures which are not usually experienced as a consequence of opioid withdrawal.
The mistake made by the nurse practioner when speaking with Jackie is understandable. For many years, Tramadol was widely prescribed by doctors as the “safer” alternative to narcotics for pain. The difference between narcotics and opioids is subtle and usually comes down to a legal definition. A narcotic is sometimes mistakenly used to refer to illicit drugs. In reality, a narcotic is a drug that relieves pain.
Narcotics are the same thing as opiates and opioids. Drugs like hydrocodone
and oxycodone can be described as prescription narcotics, or opioids. Heroin is also considered a narcotic because it acts on the same receptors in the brain and causes the same effects as prescription opioids. Narcotics, opiates, and opioids are all drugs that reduce the intensity of pain signals reaching the brain. They all affect certain areas of the brain that control emotion, which is how they’re able to reduce pain sensations. The only difference between opiates and opioids is that opiates are naturally-derived, while opioids are man-made.
But because of this subtle difference and the potency, the Drug Enforcement Agency didn’t classify Tramadol as a controlled substance, because the FDA believed it had a low potential for abuse. Though concerns had surfaced about the abuse potential of the drug, the FDA continued to leave it as an unscheduled medication.
Unfortunately, this made Tramadol a particularly dangerous drug — because it is, in fact, highly addictive and prone to abuse. But because it was easier to obtain and physicians had less concerns about the drug, it was more widely prescribed. Over the years, as often happens, a difference between clinical trials and the real world started to emerge.
Emergency rooms began to report a growing number of overdoses related to Tramadol and prescription numbers soared when the drug went off patent and became available as a generic a little less than a decade ago. Just five years after the generic was introduced, prescriptions for the medication doubled and it continues to grow given the opiate crisis and the need for an alternative.
In August 2014, when it became apparent that Tramadol abuse was now a serious problem the Drug Enforcement Agency (DEA) officially made all Tramadol containing products a schedule IV drug. In October of that year, the DEA took additional steps to help curb prescription drug abuse by rescheduling all hydrocodone containing products as schedule II controlled substances. As a result, the number of oral nonscheduled II analgesics available is limited to Tramadol and codeine containing products.
According to the Wall Street Journal, Tramadol abuse has spread around the
globe. African nations of Cameroon and Nigeria are experiencing horrific problems with the drug among older adults and in Ireland, recreational use has resulted in a spike of overdoses. Even in the Middle East, Egypt has reported that Tramadol has become the “daily helpers” for the poor and middle class, much like the Valium epidemic of the 1960s here in the United States.
Still, widespread Tramadol abuse in this country did not become a problem with the availability of other opioids that were more powerful and not much more expensive. Then came the opioid epidemic and the crackdown on the number of prescriptions being written for pain medications. And this is where the Tramadol issue started coming into the light.
Don Drake, a retired licensed addictions counselor in Massachusetts and presenter from Connelly Law's community education series reported that problems with Tramadol in older adults were usually not the result of a long standing addiction disorder.
“Those we saw in out-patient were referred to us because they were taken off oxycodone or hydrocodone and put on Tramadol due to the scrutiny providers were receiving around the prescribing of stronger pain medications. Many of them suffered from severe arthritis, spinal stenosis or other painful conditions and Tramadol just did not work. So, they took more than the prescribed amount seeking pain relief, unfortunately they developed a tolerance to the medication and had some pretty severe withdrawal issues. This is one of the unintended consequences of the opioid epidemic,” said Drake.
As we have discussed in the past, older adults are more susceptible to adverse effects of medications in general and it is essential for medical providers to recognize that there is a Tramadol associated risk with this group. In fact, a recent study done of Emergency Room visits regarding Tramadol found that just over one-third involved patients 65 and older.
Some of the side effects of Tramadol can include include nausea, vomiting, constipation, drowsiness, dry mouth, perspiration, dizziness, tremor, confusion, hallucination, and blood pressure instability.
Tramadol has also caused central nervous system (CNS) depression leading to breathing problems and death. The causes of this CNS depression appears to be the result of using more Tramadol than prescribed to address out of control pain or because of interactions with other medications. Seniors who have been prescribed other medications that depress the CNS like sedatives, tranquilizers, muscle relaxants, antidepressants should be evaluated thoroughly before adding Tramadol to their medication list.
Tramadol has also been associated with seizures in seniors over the age of 65 with nearly 25% of new seizure activity in this group being attributed to the use of this medication. Research seems to indicate that this increase is the result of changes in the brain caused by stroke, heart disease, Alzheimer's disease, and brain tumors.
In seniors with existing renal disease or diabetes, according to one study, Tramadol has been associated with hypoglycemia, although in a small number of cases those without the risk factors also developed hypoglycemia. Compared with codeine, Tramadol use was associated with a 52% increased risk of hospitalization and appeared to be at the greatest risk of hospitalization due to hypoglycemia during the first 30 days of initiating Tramadol.
But there is another problem that has been noted with those taking Tramadol –serotonin syndrome. And it can be deadly.
Serotonin is a chemical produced by the body that allows brain cells and other nervous system cells to communicate with one another. When there is too little serotonin in the brain, depression is the result. But too much serotonin can lead to excessive nerve cell activity, causing a potentially deadly collection of symptoms known as serotonin syndrome. This can be a potentially lethal condition.
According to the Mayo Clinic, symptoms often begin within hours of taking a new medication that affects serotonin levels or excessively increasing the dose of one that was being used. These symptoms include:
Agitation or restlessness
Changes in blood pressure and/or temperature
Nausea and/or vomiting
Rapid heart rate
Loss of muscle coordination or twitching muscles
Shivering and goose bumps
As stated earlier, serotonin syndrome can be life threatening. Those who experience these symptoms need to seek medical care immediately:
The drugs most commonly associated with serotonin syndrome and Tramadol use are the selective serotonin reuptake inhibitors (SSRIs), a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders.
Some of the most commonly prescribed SSRIs are:
Other drugs such as opioid analgesics, antibiotics, antimigraine agents, illicit drugs and over-the-counter drugs alone or in combination with tramadol can also lead to serotonin syndrome.
Complicating matters even further is the fact that according to some medical researchers, more than 85% of physicians are unfamiliar with the diagnosis or treatment of serotonin syndrome or the drugs or drug combinations that are potentially involved. So if these symptoms are present, the medical provider must be made aware of Tramadol use in conjunction with other medications.
So what needs to be done?
Seniors prescribed Tramadol, and their families or caretakers, need to be
counseled to watch for symptoms of serotonin syndrome, which can be reversed if detected early. With the ongoing concerns about prescribing some of the stronger opiates and seniors experiencing the painful conditions associated with aging, it is probably a good bet that Tramadol will continue to be prescribed at high rates. Given that, education is the key.
“With the trend towards keeping seniors in their homes and out of institutional care, it is imperative that family members and home health care providers have knowledge of the medications their loved ones or clients are using, understand why they are using them and what side-effects are possible,” said Attorney Connelly.
"Further, all medications should be counted on a regular basis to insure that they are being taken as directed," Connelly continued. "Staying in the home without the constant oversight of medical professionals means that those with day to day contact with the senior are the first line of defense in keeping them safe."
If you have concerns about Tramadol or any medication being used by a senior, consult with their medical provider and let them know what you are seeing.
Attorney Connelly practices in the area of elder law. This area of law involves Medicaid planning and asset protection advice for those individuals entering nursing homes, planning for the possibility of disability through the use of powers of attorney for the both health care and finances, guardianship, estate planning, probate and estate administration, preparation of wills, living trusts and special or supplemental needs trusts. He represents clients primarily in the states of Rhode Island, Connecticut and the Commonwealth of Massachusetts. He was certified as an Elder Law Attorney (CELA) by the National Elder Law Foundation (NELF) in 2008. Attorney Connelly is licensed to practice before the Rhode Island, Massachusetts, Connecticut, and Federal Bars.