Tramadol Withdrawal Timeline, Symptoms and Tips
Tramadol is labeled as a Schedule IV controlled substance by the Drug Enforcement Administration (DEA), as it is an opioid narcotic medication prescribed to relieve pain. There were almost 44 million prescriptions dispensed for tramadol products in the United States in 2013.
Tramadol acts on opioid receptors, monoamine reuptake systems, and the central nervous system to suppress pain sensations and enhance feelings of calm and relaxation. Regular interference of tramadol with the brain’s chemical messengers can cause physical changes in some of the pathways and structures of the brain. A person taking tramadol regularly may become tolerant to its effects, meaning that the drug will no longer work at the same dosage, and more will need to be taken in order for it to be effective. This is called drug tolerance. The U.S. Food and Drug Administration (FDA) places warnings on the labels and in the prescribing information for one of the common brand name products with tramadol as an active ingredient, Ultram ER, stating that the drug has a potential to create tolerance and dependency in users. A dependency is caused when the changes in the brain have become more fixed, and it no longer functions the same way without tramadol’s interaction.
Drug dependence can occur even when a person takes a drug exactly as prescribed, although dependency often sets in more rapidly when the drug is abused. The DEAreports that 3.2 million Americans had used tramadol for nonmedical purposes at some time in their lives, as of the 2012 National Survey on Drug Use and Health (NSDUH). The potential for becoming dependent on tramadol may be higher for individuals abusing it, or with a history of substance abuse or addiction, although studies have shown that tramadol can induce drug dependence when taken for long periods of time with a legitimate prescription, the World Health Organization (WHO) publishes.
Traditional opioids like oxycodone and hydrocodone increase sensations of pleasure and can produce a “high” when taken in larger doses than prescribed. Tramadol works a little differently by not only activating opioid receptors in the brain but also by blocking neurotransmitters like serotonin and norepinephrine from being reabsorbed back into the system. Thus, tramadol withdrawal may actually take two different forms: traditional opioid withdrawal syndrome or atypical opioid withdrawal syndrome.
Opioid withdrawal generally has two main phases: early and late withdrawal. Early withdrawal starts when the drug leaves the bloodstream, and late withdrawal occurs a little later. Signs of opioid withdrawal vary according to the stage.
- Runny nose
- Tearing up
- Muscle and body aches
- Trouble sleeping and/or insomnia
- Racing heart rate
- Fast breathing
- Chills and goosebumps
- Stomach pain and cramping
- Loss of appetite
- Pupil dilation
- Difficulties concentrating or thinking clearly
- Drug cravings
Tramadol has a relatively short half-life. WHO reports that immediate-release forms of tramadol products are quickly absorbed into the bloodstream, with their effectiveness peaking in 1-4 hours. The effects of extended-release tramadol products may last a little longer, peaking in 4-6 hours.
In general, opioid withdrawal symptoms are thought to start within about 12 hours of the last dose. The DEA publishes that 90 percent of people experiencing tramadol withdrawal suffer traditional opioid withdrawal symptoms while the other 10 percent may experience severe confusion, extreme paranoia, anxiety, panic attacks, hallucinations, and tingling or numbness in their extremities.
The physical side effects of tramadol withdrawal may be similar to symptoms of the flu. They are likely to peak within a few days and taper off while the psychological withdrawal side effects may linger a little longer. Everyone will experience withdrawal differently, and certain factors may influence how long it will last and the potential severity of the symptoms.
The level of dependency to tramadol is a major contributor to the duration and severity of the withdrawal symptoms, as a brain that is significantly dependent on tramadol may need extra time to bounce back and repair circuitry that may have been damaged by long-term and chronic drug use. Therefore, individuals taking tramadol for a long time, and especially those taking large doses, may be more heavily dependent on the drug.
The manner in which a person takes tramadol is a factor in withdrawal and drug dependence as well. Someone taking the drug as directed, for example, is less likely to be as dependent as an individual who is injecting, snorting, or smoking it.
Taking other drugs, or alcohol, in combination with tramadol can also increase all of the potential risk factors and impact drug dependence and withdrawal as well.
A person’s personal physiology, genetics, and biology play a role in drug dependence, and one person may become dependent more easily than another. Underlying medical or mental health conditions may impact drug dependence as well. In addition, genetics are believed to be a factor in drug dependence about half of the time, the National Council on Alcoholism and Drug Dependence (NCADD) reports. Someone with a family history of substance abuse and addiction may be more prone to becoming dependent on tramadol than someone without this possible risk factor.
Trauma, neglect, chronic stress, and abuse can contribute to the onset of a substance use disorder, as can the age at which a person first uses or abuses drugs. Adolescent brains are not fully formed, and regions responsible for sound decision-making, controlling impulses, learning, and memory may be damaged by drug use during the teenage years, the journal of Clinical EEG Neuroscience publishes. The NSDUH of 2013 reported that individuals abusing drugs before the age of 14 were more likely to suffer from a substance use disorder as an adult than those who waited until after age 18 to initiate drug use.
Managing Withdrawal Pharmaceutically
Tramadol dependence and withdrawal may be best managed through medical detox, which is the most comprehensive form of drug detox. Like with other opioids, once a person is dependent on tramadol, it is not recommended to stop taking it suddenly and without professional input.
Medical detox offers a high level of care with around-the-clock monitoring by medical professionals. Since chronic tramadol use or abuse affects the regions of the brain involved in feeling pleasure and controlling impulses, individuals dependent on the drug may desire to keep using it, or return to tramadol use in an effort to self-medicate withdrawal symptoms. Some of the more intense psychological symptoms of withdrawal, like depression and drug cravings, may be managed with the help of medications during medical detox.
The FDA approves three types of medications for opioid withdrawal, the Office of National Drug Control Policy (ONDCP) reports: methadone, buprenorphine, and naltrexone. These medications can ease withdrawal symptoms, manage drug cravings, and help a person refrain from returning to drug use.
- Methadone: A long-acting opioid agonist, methadone has one of the longest durations of action, with an average half-life of around 30 hours, the National Highway Traffic Safety Administration (NHTSA) publishes. This makes it a candidate for substitution with a short-acting opioid like tramadol as it stays in a person’s system longer, thus keeping withdrawal symptoms at bay. Methadone is still an opioid, however, with its own potential for abuse, dependency, and addiction; it should therefore be used with caution.
- Buprenorphine: Another long-acting partial opioid agonist, buprenorphine also fills opioid receptors for a longer amount of time than tramadol; however, buprenorphine is only a partial opioid agonist, meaning it shouldn’t activate these receptors in the same way. While it can help minimize opioid withdrawal symptoms, it shouldn’t cause a person to feel “high” or produce the same mind-altering effects. Buprenorphine may also have a plateau effect, meaning that if someone attempts to take more than the recommended dose, the drug will no longer produce any effect, thus reducing the desire to abuse it. The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes that there are four types of buprenorphine products approved by the FDA for the treatment of opioid dependency: Subutex and other buprenorphine transmucosal products, Zubsolv, Suboxone, and Bunavail. Suboxone, Zubsolv, and Bunavail all contain buprenorphine and the opioid antagonist naloxone. If the product is abused, naloxone can precipitate withdrawal symptoms and therefore acts as an abuse-deterrent. Buprenorphine products containing naloxone may be helpful to prevent relapse, and they are optimal when used after the initial stages of detox.
- Naltrexone: As an opioid antagonist, naltrexone may be best suited for use after early withdrawal, when tramadol is fully removed from the body to maintain opioid abstinence. Naltrexone products include Vivitrol, ReVia, and Depade, the National Institute on Drug Abuse (NIDA) reports. They work by blocking opioid receptors from being activated by opioid drugs.
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Medical personnel may use a variety of medications or supplements to target specific symptoms of tramadol withdrawal. Antidepressant and mood-enhancing medications may be commonly used during detox to help with withdrawal symptoms, although monoamine oxidase (MAO) inhibitors or selective serotonin reuptake inhibitors (SSRIs) should not be mixed with tramadol at the risk of causing serotonin syndrome that may result in muscle pain or rigidity, convulsions, and hyperthermia, the DEA warns.
Drug Withdrawal Symptoms, Timelines, & Treatment
What Are Some Drug Withdrawal Symptoms?
The symptoms of drug withdrawal, and the length of that withdrawal, vary depending on the drug of abuse and the length of the addiction. These are a few withdrawal symptoms and timelines for major targets of abuse:
- Heroin and prescription painkillers: flu-like symptoms lasting 24-48 hours
- Benzodiazepines: anxiety and/or seizures lasting weeks or (in some cases) months
- Cocaine: depression and restlessness lasting 7-10 days
- Alcohol: tremors and/or seizures lasting three days to several weeks
In 2011, the National Survey on Drug Use and Health(NSDUH) published that almost 25 million Americans over the age of 12, approaching 10 percent of this section of the population, had used an illicit drug in the month prior to the survey, classifying them as current drug users.
Addictive drugs and alcohol make changes to the way the brain processes emotions and regulates mood. Many of these changes create a flood of neurotransmitters like dopamine and serotonin, which create an artificial feeling of pleasure, or a “high.”
Continued abuse of drugs or alcohol interferes with the motivation and reward chemistry and circuitry, resulting in drug cravings and dependence.
Once a dependence on a substance has formed, withdrawal symptoms will start when the substance is then removed. Different drugs and substances will have different withdrawal symptoms and timelines, depending on how they interact with the brain and bodily functions. Drugs are absorbed and remain active in the body for differing amounts of time. This is often referred to as the drug’s “half-life,”which relates to the different withdrawal timelines for each substance.
The severity and duration of withdrawal is influenced by the level of dependency on the substance and a few other factors, including:
- Length of time abusing the substance
- Type of substance abused
- Method of abuse (e.g., snorting, smoking, injecting, or swallowing)
- Amount taken each time
- Family history and genetic makeup
- Medical and mental health factors
For example, someone who has regularly injected large doses of heroin for several years, with a family history of addiction and underlying mental health problems, is likely to experience a longer withdrawal period with potentially more powerful symptoms than someone who has used smaller dosages for a shorter period of time.
A general overview of certain drugs and their withdrawal timeline is as follows:
- Heroin: Withdrawal begins within 12 hours of the last dose, peaks within 24-48 hours, and lasts a week to up to a few months, per the National Institute on Drug Abuse.
- Prescription opiates (such as Vicodin, OxyContin, methadone, and morphine):Withdrawal starts in 8-12 hours for most prescription opiates, peaks in 12-48 hours, and lasts 5-10 days usually. Methadone withdrawal begins within 24-48 hours, peaks in the first few days, and lasts 2-4 weeks, per Cambridge Health Alliance.
- Benzodiazepines (such as Xanax, Valium, Klonopin, and Ativan): Withdrawal may begin within 1-4 days, peaking in the first two weeks. In some cases, protracted withdrawal can last months or even years without treatment, per the Comprehensive Handbook of Drug and Alcohol Addiction.
- Cocaine: Withdrawal starts within hours of the last dose, peaking in a few days and lasting from a week to 10 weeks, per the Australian Government Department of Health.
- Alcohol: Withdrawal usually begins between eight hours of last drink up to a few days after drinking, peaks within 24-72 hours, and can last a few weeks, according to the S. National Library of Medicine.
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Heroin and Opiates
Opioid drugs increase feelings of pleasure while numbing symptoms of pain. These drugs include the illegal drug heroin and prescription opiates, such as OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), morphine, codeine, Percocet(oxycodone and acetaminophen), and methadone.Opiates are considered highly addictive, and in 2013, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that 517,000 people were classified with a heroin abuse disorder. An additional 1.8 million Americans suffered from an opioid use disorder involving prescription painkillers.
Opioid withdrawal produces both physical side effects that may mimic the flu and psychological symptoms, during two distinct phases, known as early and late withdrawal. Early on during opioid withdrawal, muscle aches, tearing, runny nose, yawning, insomnia, agitation, anxiety, and sweating are common, according to The New York Times. Later on, nausea and vomiting, chills or goose bumps, diarrhea, abdominal cramps, and dilated pupils occur during late withdrawal.
Heroin has the shortest half-life only a few minutes per Mayo Clinic of all opiates. Therefore, it takes effect the quickest, but also leaves the body quickly, according to the Drug Enforcement Administration, or DEA. To put it into perspective, OxyContin has a half-life of 3-4 hours for its immediate-release format and 12 hours for the extended-release form, while morphine has a half-life of 6-10 hours, the journal Clinical and Translational Oncology reports. Withdrawal starts when the drug’s half-life expires, and the drug is no longer active in the bloodstream. While not technically considered to be life-threatening, opioid withdrawal can be dangerous and should be performed under medical supervision and guidance.
Benzodiazepines, often called “benzos”for short, make up a class of prescription drug used primarily to treat anxiety, panic disorders, and seizures. They may also be used as sleep aids or muscle relaxants. These drugs are considered central nervous system depressants that work to dampen the “fight or flight” reflex that may be hyperactive in someone suffering from heightened levels of anxiety or stress by activating the inhibitory neuron gamma amino-butyric acid, or GABA, which acts as a natural sedative.
When the brain is dependent on a benzo, if the drug is suddenly removed, a rebound effect can occur.
This is when the brain is trying to regain its state of balance as GABA levels potentially drop, opening the door to heightened levels of anxiety and insomnia in the early stage of withdrawal.
The bulk of withdrawal symptoms will be present during the acute withdrawal phase and may include:
- Panic attacks
- Difficulty concentrating
- Short-term memory loss
- Disturbed sleep
- Heart palpitations
- Muscle pain and stiffness
- Irregular heart rate
More serious side effects may also occur during benzo withdrawal, such as delirium, hallucinations, extreme confusion, fever, and seizures. Benzodiazepine withdrawal can be life-threatening due to grand mal seizures that may result in coma or death in someone heavily dependent on benzodiazepines who stops taking them suddenly, the Journal of the Oklahoma State Medical Association states.
Anxiety and psychological withdrawal symptoms may continue for several month or even years in about 10 percent of those addicted to a benzodiazepine, ABC News reports. This is called “protracted withdrawal”and can be managed with therapy and mental health services.
Benzodiazepines are generally considered to be short-acting, intermediate-acting, or long-acting and the differing half-lives will dictate when withdrawal may start.
A short-acting benzo, for example, will have the shortest half-life and faster onset of withdrawal than a long-acting benzodiazepine. Short-acting benzodiazepines include Halcion (triazolam) and Serax (oxazepam). Ativan (lorazepam) and Xanax (alprazolam) are intermediate-acting, and Valium (diazepam), Klonopin (clonazepam), and Librium (chlordiazepoxide) are long-acting, per Primary Psychiatry. All three types of benzos produce similar withdrawal symptoms, and detox should be medically managed.
The stimulant drug cocaine has a very short half-life of less than an hour, meaning that it quickly takes effect and also rapidly leaves the bloodstream. Stimulant drugs elevate heart rate, temperature, and blood pressure. The “high” can produce extreme euphoria, heightened energy levels, and elevated self-confidence, although the feelings do not last very long. This often results in cocaine being abused repeatedly in a binge pattern.Cocaine is produced in two main forms: powdered cocaine that is smoked, snorted, or injected, and rock form or “crack” cocaine that is typically smoked. Smoking and injecting cocaine send it straight into the brain and may result in higher “highs” and quicker “crashes,” according to the DEA.
Cocaine withdrawal is usually manifested in three main phases: the initial crash, acute withdrawal, and extinction period.
- Crash period: The crash may last between nine hours and four days, the National Highway Traffic Safety Administration (NHTSA) reports. The crash symptoms are generally the opposite of the stimulant effects. A person in the crash phase of cocaine withdrawal may sleep for days, notice an increase in appetite, and feel depressed and agitated.
- Acute withdrawal: During acute withdrawal — which may continue for 1-3 weeks NHTSA publishes — irritability, fatigue, depression, insomnia, anxiety, and drug cravings are common.
- Extinction period: Cravings for cocaine along with depressed moods and even potentially suicidal thoughts may continue for several months after stopping use of cocaine, NLM
Stimulant withdrawal is unlike withdrawal from most other substances, as there is a lack of many physical symptoms. As a result, withdrawal from cocaine is not considered to be life-threatening. Drug cravings and emotional turmoil associated with withdrawal may be best treated by a mental health professional trained in substance abuse and dependency who can provide necessary psychological support and care during detox and throughout recovery.
Alcohol is the most commonly abused substance in the US, with one in every 12 adults battling an alcohol dependency or abuse issue, according to the National Council on Alcoholism and Drug Dependence (NCADD). Alcohol withdrawal has a wide range of side effects, from mild hangover-type symptoms to coma and death. The more and longer an individual engages in patterns of heavy drinking, the more likely the brain is to become seriously dependent on alcohol and the more grave withdrawal symptoms may be during the detox process.According to data published in the New England Journal of Medicine (NEJM), about half of those with an alcohol use disorder will experience some form of alcohol withdrawal symptoms when alcohol use is cut down or eliminated. Between 3 and 5 percent will suffer from the most serious form of alcohol withdrawal: delirium tremens, or DTs. Seizures, fever, severe confusion, agitation, hallucinations, and delirium may signify DTs, which can be fatal without swift medical intervention.
Other side effects of alcohol withdrawal include:
- Nausea and vomiting
- Trouble concentrating or thinking clearly
- Muscle aches
- Loss of appetite
- Clammy skin
- Mood swings
- Elevated heart rate
- Loss of color in the face
- Shallow breathing
Alcohol withdrawal is usually most intense in the first few days, with physical side effects typically tapering off in a few days to a week. The emotional effects and cravings for alcohol may continue for longer.
While alcohol withdrawal can start within the first few hours after the last drink, delirium tremens may not start for an additional few days, and appear suddenly, making alcohol withdrawal safest when monitored around the clock by a medical professional.
When Detox Is Necessary
Addiction is a disease with many symptoms that may affect each individual person in a unique way.
Withdrawal from any substance of abuse after a dependency has formed is best performed in a substance abuse treatment center that offers medical detox.
Medical detox means that medical professionals are on hand to ensure the individual’s personal safety by monitoring vital signs and emotional states. The initial goal of detox is to achieve a safe and comfortable level of physical stability so the psychological manifestations of withdrawal can be addressed. Someone addicted to alcohol, opioids, or benzodiazepines should always undergo medical detox to safely remove these substances from the body with the fewest number of adverse consequences. Many times, these substances will need to be weaned out of the body slowly under the direction of a medical professional.
Use of Medications in Detox
For someone addicted to benzodiazepines, a longer-acting benzodiazepine may be used during detox to control withdrawal and taper the drugs down slowly. Medications such as antidepressants or mood stabilizers may be used during medical detox from many addictive substances in order to target specific psychological symptoms, such as depression, anxiety, and panic. NIDA reports that the mild stimulant drug modafinil may help with cocaine withdrawal symptoms. Benzodiazepines are sometimes used to smooth out alcohol withdrawal and to help prevent seizures by calming the overactive nerves and neurons.Depending on the level of dependency and care needed, detox from illicit drugs may be done in either an outpatient or inpatient capacity. An assessment of physical and emotional symptoms should be first conducted by a trained professional in order to determine what level of care will produce the best results.
Different drugs have different withdrawal timelines and symptoms, and treatment should be tailored to the specific drug and its side effects. Mental health and medical issues can complicate withdrawal as can poly-drug abuse, and these issues should be considered during substance abuse treatment.