Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment

Abstract

Introduction: During the coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2, deaths from opiate drug overdoses reached their highest recorded annual levels in 2020. Medication-assisted treatment for opiate use disorder has demonstrated efficacy in reducing opiate overdoses and all-cause mortality and improving multiple other patient-centered outcomes. Treatment of tramadol dependence in particular poses unique challenges due to its combined action as opioid agonist and serotonin-norepinephrine reuptake inhibitor. Tramadol puts patients with dependence at risk for atypical withdrawal syndromes when attempting to reduce use. Little evidence is available to guide treatment of tramadol dependence. Case Report: We present a case of high-dose tramadol addiction that began with misuse of medically prescribed tramadol for treatment of musculoskeletal back pain. The patient’s use reached oral consumption of 5000-6000 milligrams of illicit tramadol daily. She complained of common complications of tramadol use disorder including memory impairment, excessive sedation, and tramadol-induced seizures. The patient was referred to the emergency department in a withdrawal crisis seeking treatment where she was successfully managed with buprenorphine and phenobarbital and then linked to ongoing outpatient treatment. Conclusion: Our report adds to the limited guidance currently available on the acute management of tramadol withdrawal and treatment of tramadol use disorder. Our case suggests the initiation of high-dose buprenorphine may be an effective and feasible option for emergency clinicians.

Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment

“…We appreciate the interest expressed by the commentators with regard to our tramadol dependence case report. 1 However, we respectfully disagree that not testing the tramadol product the patient obtained from Mexico nor testing the patient herself to confirm the presence of tramadol and exclude the presence of other opioids such as fentanyl is a major limitation of our case report.…”

A case of use of tramadol and alprazolam for mood altering effects: Intertwined hedonic and distress alleviating use

“…Buprenorphine was chosen given the high dosage of tramadol use and because previously, buprenorphine has been used for the treatment of tramadol dependence. [ 4 ] Hamilton Depression Rating Scale (HAMD) score at admission was 22. Escitalopram 15 mg was added to target depressive symptoms.…”

Caution Regarding Self-reported Tramadol Dependence

“…We are writing in regard to the following article in the current issue of CAL/ACEP’s Lifeline Volume 4, 2022–23, which was first published in Clinical Practice and Cases in Emergency Medicine in 2022. 1 In the report, the authors describe an opioid-dependent patient who was initially prescribed tramadol by her primary care physician but who ultimately began traveling to Mexico to purchase escalating doses of tramadol. The authors appropriately highlight the potential nuances of managing tramadol withdrawal versus that from pure opioid agonists.…”