Tramadol is a centrally acting synthetic analgesic of the aminocyclohexanol group with opioid-like
effects. Its mode of action is not completely understood but it appears to act by modifying
transmission of pain impulses via inhibition of noradrenaline and serotonin re-uptake and also by
weakly binding to mu-opioid receptors.
In Australia it is marketed under the trade name Tramal and is available as capsules (50mg),
sustained release tablets (100mg, 150mg, 200mg) and ampoules (100mg/2ml) for relief of moderate
to severe pain.
On the basis of published evidence, tramadol appears to have reasonable dose related efficacy in
comparison with other opioid analgesics, with a relative lack of respiratory depression, major organ
toxicity or abuse potential.
Because of its side-effect profile in comparison with other analgesics, tramadol may have a role in
patients who are intolerant of conventional opioid and other non-opioid analgesics, those who have
pre-existing cardiopulmonary disease, such as the elderly or obese, and those in whom codeine use
is inappropriate. In the acute and post-operative settings, it may have a place in multi-modal
analgesia, where opioid and non-opioid drugs are given in combination to achieve analgesia, with a
reduction in the incidence and severity of side effects.
Similarly, in chronic pain conditions, tramadol may be considered (as a single agent or in
combination) where non-opioid analgesics have proven ineffective or where multimodal therapy
might be advantageous in order to limit side-effects (eg where a reduction in NSAID dosage is
desirable). The reduced constipating effect of tramadol compared with other opioids may be useful
in patients with chronic cancer pain, although nausea may be a dose-limiting side-effect and
sustained-release morphine is more effective in severe cancer pain. Because of its extended duration
of effect, the sustained release formulation may provide convenience in ambulatory patients with
chronic pain. However, studies of long-term use have not yet been reported and the potential for
serious drug-drug interactions with tramadol should not be under-estimated.
As a single agent, tramadol’s place in therapy is likely to be limited by both cost and tolerability
(particularly nausea). In the majority of patients it offers few advantages at considerable additional
cost. However, it may be a useful alternative to other analgesics in selected patients with moderate
to severe pain.

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