Tramadol Revisited: Some Patients Say It Helps Relieve Pain

By Pat Anson

A recent study that found tramadol was only slightly effective in relieving chronic pain – but not worth the side effects – is stirring some debate.

The Danish study analyzed findings from 19 clinical trials of tramadol involving over 6,500 patients, and found that the synthetic opioid was not only ineffective for many patients, it may raise the risk of heart disease and perhaps even cancer.

“The potential harms associated with tramadol use for pain management likely outweigh its limited benefits,” researchers reported in the journal BMJ Evidence Based Medicine.

That conclusion is being disputed by John Bumpus, PhD, a Professor of Chemistry and Biochemistry at the University of Northern Iowa.

“In my view, the authors’ analysis and evidence base are far too sparse and fragile to justify the conclusion that harms likely outweigh benefits. Their claims appear overstated and are not supported by the biomedical literature and the underlying data,” Bumpus told PNN.

Bumpus reviewed several studies on his own, including one that found a high dose of tramadol provided “good” pain relief to 74% of cancer patients. The same study found tramadol “satisfactory” for 10% of cancer patients and “inadequate” for about 16% of them.

That wide variability in response, according to Bumpus, is likely due to the individual metabolism of each patient. The effectiveness of tramadol depends on whether they have variations in a gene (CYP2D6) that helps convert tramadol to a metabolite that binds to mu opioid receptors in the brain, resulting in pain relief. 

Another study estimated that 0.5–6.5% of patients are “poor metabolizers” of tramadol, 10–44% are “intermediate metabolizers” and only 43–67% are “normal metabolizers.” Poor and intermediate metabolizers are likely to experience little pain relief from tramadol.

‘It’s the Only Thing That’s Working’

Over the years, many PNN readers have told us tramadol didn’t give them any pain relief. But some say it works for a wide variety of pain conditions.

“I am one who receives adequate pain relief from tramadol. It's all I took, besides ibuprofen, when my pain was being treated, and it was especially effective if I took half a dose on top of regular dose of ibuprofen. After surgery, I took a whole dose of tramadol as prescribed, with adequate pain relief,” one reader said.

“I have autoimmune arthritis and take tramadol so that I can numb the pain to be able to sleep,” another reader wrote.

“It’s the only thing that’s working for my pain. Hydrocodone didn’t even touch it. Oxycodone works only if I add tramadol,” another pain patient told us.

“It does help cut the pain down for me quite a bit. Does it take it all away? No it does not. And some types of pain it doesn’t even touch,” said a woman with arthritis, fibromyalgia and degenerative disc disease. “My sleep has improved quite a bit also since being back on it. But you have to keep it in your system for it to help. You can’t really take it just whenever.”

“It most definitely takes the edge off of my peripheral neuropathy. I have a neurostimulator implant too, but by the end of the day my pain is worse and that’s when I take tramadol,” another patient wrote.

If tramadol is only effective in about half of patients, should it be used at all? Bumpus says it should. Just because tramadol is a “weaker” opioid doesn’t make worthless.

“Tramadol’s analgesic potency is approximately one-tenth that of morphine. Interestingly, this is one reason it is often prescribed first, consistent with the principle of using the lowest effective opioid dose,” Bumpus said.

“For patients whose pain is not adequately controlled, stronger opioids (e.g., oxycodone, hydrocodone) or combination agents (e.g., acetaminophen/oxycodone 325/5 mg) may be appropriate. Thus, for patients who do not respond to tramadol, the remedy is straightforward. They should consult their healthcare provider and consider another medication or alternative therapy.”

That may not be an option for some patients, who have doctors that are only willing to prescribed tramadol and other less risky opioids. The DEA classifies tramadol as a Schedule IV controlled substance in the United States, meaning it has “a low potential for abuse.” Oxycodone and hydrocodone, on the other hand, are Schedule II drugs, meaning they have a “high potential for abuse.”

Bumpus also disputes the notion that tramadol raises the risk of heart problems, pointing out that coronary heart disease (0.45%) and chest pain (0.32%) occurred in less than one percent of patients on tramadol, which is not considered a statistically significant risk.

“The claim… that tramadol’s potential harms outweigh its benefits is not supported by the numerical data presented. Across thirteen clinical trials, tramadol was consistently found to be an effective and generally safe analgesic for chronic pain,” Bumpus said. “Taken together, the available evidence supports tramadol as a reasonable option for appropriately selected patients, provided it is used with good clinical judgment and proper monitoring.”

Although tramadol is the only opioid that some doctors will prescribe for pain, its use is actually declining in the United States. In 2023, over 16 million prescriptions were written for tramadol, down from 25 million a decade earlier.