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Abstract

This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked. Buy Tramadol 200mg online in Australia

Tramadol (Ultram^®) is a commonly prescribed analgesic because of its relatively lower risk of addiction and better safety profile in comparison with other opiates. However, two significant adverse reactions are known to potentially occur with tramadol—seizures and serotonin syndrome. These two adverse reactions may develop during tramadol monotherapy, but appear much more likely to emerge during misuse/overdose as well as with the coadministration of other drugs, particularly antidepressants. In this article, we review the data relating to tramadol, seizures, and serotonin syndrome. This pharmacologic intersection is of clear relevance to both psychiatrists and primary care clinicians. Buy Tramadol 200mg online in Australia

Keywords: tramadol, analgesic, opiate, seizure, serotonin syndrome, antidepressant, polypharmacy, psychiatrist-physician interface

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Introduction

According to Miller et al,¹ chronic pain affects a vast number of US patients and results in billions of dollars in annual healthcare expenditures. In Australia, the cost of managing chronic pain is estimated to be $34 billion per year.² Given the narcotic alternatives for treatment, tramadol (Ultram^®) is a unique pharmacological bullet in the fight against chronic pain. To attest to its popularity, prescriptions for tramadol in Canada reached almost 26 million in 2006, representing total sales of $800 million.³ In this edition of The Interface, we discuss two potential adverse events related to this commonly prescribed analgesic—seizures and serotonin syndrome. Buy Tramadol 200mg online in Australia

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Description of Tramadol

Tramadol is an analgesic medication that is a synthetic analogue of codeine. In comparison with other opiates, tramadol is renowned for having less abuse potential and less respiratory depression.⁴ In terms of specific neurotransmitter effects, at the central level, tramadol is a mu-opioid receptor agonist. The affinity of tramadol for mu-opioid receptors (analgesic effect) is 10-fold less than codeine. However, the active metabolite of tramadol, o-desmethyltramadol, has a far greater affinity (up to 200-fold) than the parent compound. In addition to its central effects on mu receptors, at the peripheral level, tramadol inhibits serotonin and norepinephrine reuptake. These latter effects are likely to be an important element in analgesia, but may also account for some of the adverse properties of the drug. Buy Tramadol 200mg online in Australia

According to Reeves and Cox,⁵ tramadol has many characteristics that are similar to venlafaxine, including structural similarities and serotonergic/noradrenergic reuptake inhibition. In keeping with this perspective, Yalcin et al⁶ describe tramadol as having antidepressant-like effects. Not surprisingly, using liquid chromatography to detect levels of tramadol in urine, venlafaxine may cause false positive results.⁷

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Drug Interactions

Tramadol accounts for a significant number of drug interactions. For example, in an Australian veterans study, Roughead et al⁸ examined adverse drug interactions in 46,859 participants taking antidepressants. Of the 8.1 percent who experienced these interactions, tramadol was the most often implicated drug (3.6%). Buy Tramadol 200mg online in Australia

Of these various interactions, tramadol has the potential to trigger two dramatic events—seizures and serotonin syndrome. These may develop during tramadol monotherapy either at routine or excessive doses, but are particularly likely during tramadol coadministration with antidepressants (Tables (Tables11 and and22).^4,9 (In addition to antidepressants, tramadol may interact with a number of other psychotropic drugs including antipsychotics and anticonvulsants.) Buy Tramadol 200mg online in Australia