Tramadol is a widely consumed opioid analgesic. When used for long periods, even at recommended therapeutic doses, sudden discontinuation carries a risk of withdrawal symptoms. A rebound effect characterised by a recrudescence of pain, as well as possible mental health disorders, such as anxiety and depression, should be anticipated after discontinuation.

In the absence of solid evaluation data, the approaches to withdrawal are based mainly on the experience of healthcare professionals and patients.

When tramadol's analgesic action is the main reason why it is still being taken, it is important to plan alternative strategies for pain relief, especially non-pharmacological approaches, in order to avoid potential recourse to other psychotropic drugs carrying a risk of addiction (including opioids), or alcohol.

Just as in the withdrawal of other drugs causing dependence, patient participation is crucial and a period of preparation for withdrawal is essential. One option is to progressively reduce the dose of tramadol, in steps of around 5% to 10%, every 1 to 4 weeks. Patients can adjust their withdrawal calendar, either by reducing the daily doses by a smaller amount, or by extending the duration of each step. When the decision has been taken to withdraw tramadol by progressive dose reduction, it is best not to treat any withdrawal symptoms with another opioid (including codeine or opium) or a benzodiazepine, which also carry a risk of dependence.

In case of repeated failure, or when patients have lost control of their consumption, an option to consider is supervised substitution therapy with buprenorphine or methadone (opioids already well-established for this purpose).

©Prescrire 1 March 2022

Source: "Stopping tramadol after prolonged use" Prescrire International 2022; 31 (235): 77. Subscribers only.

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