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mise à jour du 28 février 2003
 European J of Pain
2000;4:307-311
lexique
Acute abstinence syndrome following abrupt cessation of long-term use of tramadol : a case study
E. Freye and J. Levy
Pain Center, Extension of the Heinrich-Heine-University of Düsseldorf
Department of Physiology Pharmacology, University of the Pacific
San Francisco

Chat-logomini

Introduction : Tramadol is considered an analgesic with a potency about 1/10 that of morphine. Because of its reduced magnitude in inducing side-effects such as respiratory depression and obstipation when given in equieffective doses of standard opioids like morphine or pethidine (Houmes et al., 1992, Sunshine, 1994; Barsoum, 1995), it became a popular analgesic for various painful conditions (Moore and McQuay, 1997). The compound is advocated since it lacks addiction liability (Preston et al., 1991) and docs not result in the development of an acute abstinence syndrome when the specific opiate antagonist naloxone is given (Barth et cil., 1987). Therefore, tramadol is considered a nonscheduled analgesic which is widely used as an analgesic in treating painful conditions where strong opioids are not required (Moore and McQuay, 1997).
 
Although this compourid is also recommended for the long-term alleviation of chronic musculoskeletal or myofascial pain, little is known about its potential side-effects when taken for a longer period of time when the drug is stopped abruptly. This is of special interest since some papers have reported on an abuse potential (Liu et al., 1999; Jensen. 1997) respiratory depression (Barnung et cil., 1997« Sachdeva and Jolly, 1997), cerebral depression (Riedel and Stockhausen, 1984; Sticht et al., 1997) and even fatal outcome when tramadol was given in conjunction with a benzodiazepine (Michaud et al., 1999). We would like to report on a case where opioïd-like withdrawal symptoms developed following abrupt cessation of intake of tramadol.
 
PATIENT HISTORY:
The patient is a 45-year-old caucasian female who had no previous history of musculoskeletal pain when being admitted to the pain clinic. She demonstrated classical symptoms of fibrornyalgia such as insomnia, and evoked pain sensations when administering pressure to at least 12 tender points. Intermittently she also complained of cephalalgia at the occipital-temporal area and had a mean VAS of 7.7. The patient did not respond to classical antidepressive therapy with amyltriptiline given for 1 week, and showed only little relief following injection of a local anaesthetic (lidocaine) into tender points. However, she expressed significant relief following the intake of tramadol liquid, instant release at a dose of 50-100 mg. Usually taken every day in the morning for the past 12 months. Pain relief lasted over the whole day and no other medication was taken apart from this analgesic, except that the patient was taking milk thistle as a remedy 'to support her liver function'. Side-effects were intermittently experienced by the patient consistmg of some sedation and drowsiness, which were noted shortly after medication intake. These sideeffects however, did not affect her activities and concentration at work. Within the last 3 months, however, she frequently noted nausea shortly after intake, following a dally dose of tramadol of at least 100 mg.
 
Whilst on vacation in a foreign country, she ran out of tramadol. After a week, she developed marked and long standing pain at her back with a VAS of 7.5, making it impossible for her to walk. Seeking medical advice by a general practioner involved in pain therapy in a major US city, and since she had not experienced a similar type of back pain in the past, a specific COX-2 class inhibitor (celecoxib) was prescribed in a dose of 200 mg/day. Although this inedication did result in a moderate relief from a VAS 6.5 to 4.0 within the following 2 days, the patient now additionally developed restless leg syndrome. This resulted in a significant disruption of sleep pattern throughout the whole night. In order to help her gain some night rest and to ease the accompanying.cramp-like pain sensations in her legs, a moderate dose of the benzodiazepine lormetazepam (NoctamideO 0.5 mg/day) was given. This medication resulted in sleep and some relief of the cramps and the restless legs.
 
However, within the following hours additional symptoms were noted: (1) slight mydriasis, (2) a depressive mood, together with (3) moderate tremor and (4) repetitive yawning and sneezing. Additionally, (5) a moderate tachycardia of 95/min accompanied by (6) a slightly elevated BP of 145/90 mmHg was noted. Also, there was (7) an increased feeling of thirst, (8) a feeling of tension within the whole body and (9) heat waves taken off by cold sensations were experienced. Psychologically, (10) aggressiveness together with an increased level of nervousness was noted and the patient complained of (l1) migrating pain over the whole body with intermittent bouts of cephalalgia and nausea which was later followed by (12) intra-abdominal cramps with diarrhoea.
 
The clinical picture was not that of an excerbation of fibromyalgia for which tramadol was introduced, as the patient had never before experienced a similar symptomatology. Also, the patient's history and examination had ruled out another type of musculoskeletal disorder, mild lupus erythematosus, a beginning polyarticular osteoarthritis, rheumatoid arthritis, polyrnyalgia rheumatica, an acute or chronic infection or a hypermobility syndrome. These possibilities were ruled out since body temperature and blood tests revealed no pathology. Also, renal and liver function were normal as there was no elevated creatinine and/or transaminase level. Therefore, an acute abstinence syndrome was diagnosed (Jasinski, 1977) and the patient treated with a selective peripherally acting antidiarrhoeal (loperamide 4 mg/day) in order to stop intraabdominal cramps and diarrhoea. This was accompanied by an increased intake of fluids of up to 3 l/day while the patient remained on the benzodiazepine lormetazepam (Noctamide(W 0.5 mg/day) in order to treat insomnia. The restless leg syndrome and her muscle pain was successfully treated with dextromethorphan (2x5Omg/ day). For the alleviation of the excruciating headaches and nausea, sumatriptan was given nasally (20 mg/day). Ail these medications resulted in an alleviation of the symptoms within 3 days and within 1 week the patient recovered uneventfully with no further sequelac.
 
DISCUSSION
This report is, to our knowledge, the first observation of a patient who took the instant release formulation of the analgesic tramadol on a dally base for over 1 year, developing an abstinencelike syndrome after cessation of the drug Tramadol, which is a non-scheduled class drug, is cited to be a mixed analgesic agent as it mediates its action partly via the opiate receptor system and partly via an activation of the descending serotinergic/noradrenergic inhibitory system (Desmeules et al., 1996). As to the mode of action of these abstinence-like symptoms, the oploidlike action of the compound had to be taken into consideration.
 
This is corroborated by the following:
(1) The observed symptoms were characteristic following long-term use of a classical opioldtype analgesic being stopped abruptly (Jasinski, 1977).
 
(2)The parent compound tramadol shows very little affinity to the opiold receptor site. However, aside from its activity to inhibit noradrenaline and serotonine re-uptake, the pharmacologically active metabolite M1 (0desmethyltramadol) has a 300-fold higher affinity to the opioid receptor (Raffa et al., 1992). Although affinity does not equate with intrinsic activity, and the opiold moiety of the M1 metabolite of tramadol is in dispute, numerous studies have suggested that it is this metabolite which plays an important part in mediating analgesla via interaction with the opiold receptor (Raffa el al., 1992; Miranda and Pinardi, 1998).
 
(3) The use of tramadol over more than 1 year, as in our patient, eventually may have resulted in a build up of the active metabolite M1 in peripheral tissue sites such as skin, muscles, fat and connecting tissue, which do not participate in the mediation of effects but in fact may act as a reservoir. This assumption is corroborated by forensic data where tramadol was involved in an overdose fatality (Moore et al., 1999), suggesting that a build-up of tramadol and/or its metabolite within peripheral tissues following long-term use does occur. Data with other analgesics and their build-up in peripheral tissues further supports this possibility (Taeger, 1981). It therefore is conceivable that with the discontinuation of the drug, levels of the parent compound tramadol and/or its metabolite M1 slowly declined, followed by reduced binding to the opiold receptor. This resulted in the developinent of a classical abstinence-like syndrome only after 1 week. Although our data are not in rapport with other data from patients who developed no abstinence after having recelved tramadol for 3 weeks followed by naloxone (Richter et aL, 1985), there is no follow-up data in patients who were treated for more than 3 weeks and where drug intake was stopped abruptly.
 
(4)The phenomenon of physical dependence of this analgesic has been noted in animal models (Yanagita, 1978; Miranda and Pinardi, 1998) and also in humans (Meyer et al., 1997, Liu et al- 1999). While being minor when compared to other oploids, reinforcing properties may became evident when tramadol was given at doses of 1 mg/kg (Villareal and Seevers, 1968).
 
(5)Abstinence symtoms did pot develop within the first day after cessation of intake in our patient. In spite of the fact that elimination of tramadol and its metabolites is primarily by renal excretion (Lintz, 1990), elimination half-life. for tramadol is 4.9 h while its metabolite M1 is 6.7h after a single dose (Liao and Nayak, 1992). This at least suggests some difference in the elimination half-lives between the parent compound and its metabolite. This is is further substantiated by the fact that after a single intravenous dose of 100 mg of tramadol, the parent compound is excreted renally by 17.8% while that of MI by only 6.3% (Lintz, 1990). Since our patient had taken multiple doses over a period of at least 12 months, such small differences between parent compound and its metabolite following a single dose may become pronounced after multiple dosing over a long period of time. Thus, high concentrations of M1 in body tissues, as demonstrated in a case of fatal overdose (Moore et ai., 1999), and at the receptor site, are followed by a slow decline resulting in the appearance of abstinence-like symptoms only after 1 week.
 
Of unique interest was the appearance of the restless le- syndrome (RLS), which is characterized by ill-defined, deep-seated and unpleasant sensations in the legs inducing an irresistible urge to move, vath symptoms occurring during periods of immobility. The RLS has been related to alterations in tryptophan and serotonin metabolism (Sandyk and Fisher, 1988, Sandyk, 1992). Since tramadol, unlike morphine, codeine and other oploids, inhibits the neuronal re-uptake of noradrenaline and serotonin (Raffa et al., 1992, Reimanil and Hennies, 1994) it is likely that longterm use may result in a monoaminergic withdrawal of 5-HT at the spinal cord level, with ensuing peripheral sensory symptoms such as back pain and RLS. In the absence of clear understanding of the disorder's pathophysiology, treatment of RLS has been largely empirical and reports have quoted that the precursor of serotonin, ie. tryptophan, attenuated symptoms of RLS and insomnia (Sandyk, 1986).
 
One might argue that the medication with dextromethorphan was not the appropriate agent to treat RLS but since dextromethorphan is an opioid-like agent of the morphinane series, which is used as a cough suppressant and does not lead to addiction (Jaffe and Martin, 1990), it also has been shown to act as an NMDA-receptor antagonist (Dickenson, 1994). It therefore seemed appropriate to use this ligand as musculoskeletal pain together with an increased NMDA-activity are involved in opioid dependency (Manning et cil., 1996).
 
In summary, we have presented a case of an acute abstinence-like syndrome in a patient having taken the centrally active, mixed analgesic tramadol for over 1 year followed by a sudden abstinence of intake. Although abstinence symptomatology was opiold-like in appearance, it lacked the psychological urge for continuation of intake whichis typical for an opiate such as morphine (Richter et al., 1985, Preston et aL, 199 1). The low abuse potential makes the compound less prone to act as a reinforcer and less likely to be a drug which will gain attention by the drug community. Nevertheless, patients having taken the drug for a longer period of time should be informed not to abruptly stop intake as typical opioid-like abstinence symptoms are likely to develop.
 
Philibert C, Sauveplane K, Pinzani-Harter V et al. Le bâillement: de la physiologie à la iatrogénie. La lettre du pneumologue. 2011;14(5):168-172