10.26.2017 | Abigail Mathews

This process does not find industrial application, since tramadol is used as a racemate, despite known different physiological effects of the (1 R, 2 R )- and (1 S, 2 S )-isomers, because the racemate showed higher analgesic activity than either enantiomer in animals and in humans. Minor amounts of the racemic mixture of the (1 R, 2 S )-isomer and the (1 S, 2 R )-isomer are formed as well. The synthetic pathway leads to the racemate (1:1 mixture) of (1 R, 2 R )-isomer and the (1 S, 2 S )-isomer as the main products. The isolation of the (1 R, 2 R )-isomer and the (1 S, 2 S )-isomer from the diastereomeric minor racemate [(1 R, 2 S )-isomer and (1 S, 2 R )-isomer] is realized by the recrystallization of the hydrochlorides. The drug tramadol is a racemate of the hydrochlorides of the (1 R, 2 R )-(+)- and the (1 S, 2 S )-(–)-enantiomers. The resolution of the racemate [(1 R, 2 R )-(+)-isomer / (1 S, 2 S )-(–)-isomer] was described employing ( R )-(–)- or ( S )-(+)-mandelic acid.

Antagonism of 5-HT 2C could be partially responsible for tramadol's reducing effect on depressive and obsessive-compulsive symptoms in patients with pain and co-morbid neurological illnesses. In addition, tramadol's major active metabolite, O-desmethyltramadol, is a high-affinity ligand of the δ- and κ-opioid receptors, and activity at the former receptor could be involved in tramadol's ability to provoke seizures in some individuals, as δ-opioid receptor agonists are well known to induce seizures. However, the reduction of seizure threshold could be attributed to tramadol's putative inhibition of GABA A receptors at high doses. Tramadol has inhibitory actions on the 5-HT 2C receptor. 5-HT 2C blockade may also account for its lowering of the seizure threshold, as 5-HT 2C knockout mice display significantly increased vulnerability to epileptic seizures, sometimes resulting in spontaneous death.

Compared to hydrocodone, fewer persons choose to use tramadol recreationally. Tramadol can cause a higher incidence of nausea, dizziness, loss of appetite compared with opioids, which could deter recreational use. Because of the possibility of convulsions at high doses for some users, recreational use can be very dangerous.

Some of the additional affinity of tramadol have been reported as follows: μ-opioid receptor (K i = 2.1 µM), κ-opioid receptor (K i = 42.7 µM), δ-opioid receptor (K i = 57.6 µM), serotonin transporter (K i = 0.99 µM), norepinephrine transporter (K i = 0.79 µM). Relative to tramadol, its active metabolite O-desmethyltramadol has far higher affinity for the μ-opioid receptor (K i = 3.4 nM (0.0034 µM) for the (+)-isomer). Tramadol mainly acts as a μ-opioid receptor agonist, serotonin reuptake inhibitor and releasing agent, norepinephrine reuptake inhibitor, NMDA receptor antagonist ( IC 50 = 16.5 μM), 5-HT 2C receptor antagonist ( EC 50 = 26 nM), (α7) 5 nicotinic acetylcholine receptor antagonist, TRPV1 receptor agonist, and M 1 and M 3 muscarinic acetylcholine receptor antagonist.

Tramadol may be used to treat post-operative, injury-related, and chronic (e.g., cancer-related) pain in dogs and cats as well as rabbits, coatis, many small mammals including rats and flying squirrels, guinea pigs, ferrets, and raccoons.

Its analgesic effects take about one hour to come into effect and 2 h to 4 h to peak after oral administration with an immediate-release formulation. On a dose-by-dose basis tramadol has about one-tenth the potency of morphine and is approximay equally potent when compared to pethidine and codeine.

There are suggestions that chronic opioid administration may induce a state of immune tolerance, although tramadol, in contrast to typical opioids, may enhance immune function. Some have also stressed the negative effects of opioids on cognitive functioning and personality.

Tramadol is used primarily to treat mild–severe pain, both acute and chronic.

Effective May 2008, Sweden classified tramadol as a controlled substance in the same category as codeine and dextropropoxyphene, but allows a normal prescription be used currently.

Thus, reduced doses may be used in renal and hepatic impairment. Phase II hepatic metabolism renders the metabolites water-soluble, which are excreted by the kidneys.

Its use during lactation is also generally advised against, but a small trial found that infants breastfed by mothers taking tramadol were exposed to about 2.88% of the dose the mothers were taking. A small prospective study in France found that, while there was an increased risk of miscarriages, there were no major malformations reported in the newborn. There was no evidence of this dose having a harmful effect on the newborn. Tramadol's use in pregnancy is generally avoided as it may cause some reversible withdrawal effects in the newborn.

However, in August 2009, US District Court for the District of Delaware ruled the patents invalid, which, if it survives appeal, would permit manufacture and distribution of generic equivalents of Ultram ER in the United States. The FDA listed the patents' expiration as 10 May 2014. Tramadol is protected by US patents nos. 6,254,887 and 7,074,430. Food and Drug Administration (FDA) approved tramadol in March 1995 and an extended-release (ER) formulation in September 2005. The U.S.

In 2013, researchers reported that tramadol was found in relatively high concentrations (1%+) in the roots of the African pin cushion tree ( Nauclea latifolia ). Therefore, tramadol and its mammalian metabolites were found in tree roots in the far North of Cameroon, but not in the South where it is not administered to farm animals. In 2014, however, it was reported that the presence of tramadol in the tree roots was the result of tramadol having been administered to cattle by farmers in the region: tramadol and its metabolites were present in the animals' excreta, which contaminated the soil around the trees.

The enzymes are crucial to the therapeutic effects of tramadol, by means of enabling tramadol's metabolism to O-desmethyltramadol. Use of tramadol is not advised for people deficient in CYP2D6 enzymes.

Based on three small trials with weak study design, there is fair evidence for tramadol as a second line treatment. As of 2015 tramadol was not approved in the United States for fibromyalgia.

It is marketed under many brand names worldwide. Tramadol was launched and marketed as "Tramal" by the German pharmaceutical company Grünenthal GmbH in 1977 in West Germany, and 20 years later it was launched in countries such as the UK, US, and Australia.

A 2014 editorial in Lab Times online contested the notion that tramadol in tree roots was the result of anthropogenic contamination, stating that samples were taken from trees which grew in national parks, where livestock were forbidden; it also quoted researcher Michel de Waard, who stated that "thousands and thousands of tramadol-treated cattle sitting around a single tree and urinating there" would be required to produce the concentrations discovered.

It is often combined with paracetamol (acetaminophen) as this is known to improve the efficacy of tramadol in relieving pain. When taken as an immediate-release oral formulation, the onset of pain relief usually occurs within about an hour. Second, it inhibits the reuptake of serotonin and norepinephrine. Tramadol, sold under the brandname Ultram among others, is an opioid pain medication used to treat moderate to moderay severe pain. First, it works by binding to the μ-opioid receptor. It has two different mechanisms.

There is an increased risk of opioid-related adverse effects such as respiratory depression, falls, cognitive impairment and sedation.

In 2015, radiocarbon analysis confirmed that the Tramadol found in N.latifolia roots could not be plant-derived and was of synthetic origin.

The UK classified tramadol as a Schedule 3 controlled drug (CD) on 10 June 2014, but exempted it from the safe custody requirement.

The chemical synthesis of tramadol is described in the literature. Thus, 2-(dimethylaminomethyl)-1-(3-methoxyphenyl)cyclohexanol may exist in four different configurational forms:. Tramadol has two stereogenic centers at the cyclohexane ring.

Its use as an analgesic during labour is generally advised against due to its long-onset of action (one hour). The ratio of the mean concentration of the drug in the fetus compared to that of the mother when it is given intramuscularly for labour pains has been estimated to be 94.

Its analgesic effects are only partially reversed by naloxone, hence indicating that its opioid action is unlikely the sole factor; tramadol's analgesic effects are also partially reversed by α 2 adrenergic receptor antagonists like yohimbine and the 5-HT 3 receptor antagonist, ondansetron. Pharmacologically, tramadol is similar to levorphanol and tapentadol in that it not only binds to the mu opioid receptor, but also inhibits the reuptake of serotonin and norepinephrine due to its action on the noradrenergic and serotonergic systems, such as its "atypical" opioid activity.

Cyclobenzaprine, a commonly-used muscle relaxant, atypical analgesic adjunct, as well as a potentiator often used with analgesics like codeine, dihydrocodeine, hydrocodone and the like, is structurally related to the tricyclic antidepressants and therefore should not be used with tramadol; this is also the case for trazodone. Tramadol may interact with serotonergics, monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, serotonin antagonists and reuptake inhibitors, other opioid analgesics ( pethidine (meperidine), tapentadol, oxycodone, and fentanyl ), dextromethorphan, certain migraine medications ( triptans, ergots ), certain anxiolytics (such as the SSRIs and buspirone ), certain antibiotics (namely, linezolid and isoniazid ), certain herbs (e.g. John's wort, passiflora, etc.), amphetamines, substituted amphetamines, phenethylamine and substituted phenethylamines, phentermine, lithium, methylene blue as well as numerous other therapeutic agents. St. A pressor response similar to the so-called " cheese effect " was noted in combinations of amphetamine and tramadol, which appears to cause dysfunction of or toxicity to epinephrine/norepinephrine receptors. As it is a substrate of CYP3A4 and CYP2D6, any agents with the ability to inhibit or induce these enzymes will likely interact with tramadol.

It is advised that the drug be used with caution in those with liver or kidney failure, due to the high dependence of the drug on the liver and kidneys for metabolism to O-desmethyltramadol and elimination, respectively.

These painkilling effects peak at about 3 h, post-oral administration and last for approximay 6 h. For pain moderate in severity its effectiveness is equivalent to that of morphine; for severe pain it is less effective than morphine.

military have already classified tramadol as a Schedule IV controlled substance under state law. Effective August 18, 2014, tramadol has been placed into Schedule IV of the federal Controlled Substances Act. In addition, many states, including Arkansas, Georgia, Kentucky, Illinois, Mississippi, New York, North Dakota, Ohio, Oklahoma, South Carolina, Tennessee, West Virginia, Wyoming and the U.S.

Seven days or more of acute withdrawal symptoms can occur as opposed to typically three or four days for other codeine analogues. Psychiatric symptoms may include hallucinations, paranoia, extreme anxiety, panic attacks, and confusion. Tramadol withdrawal typically lasts longer than that of other opioids. These include both symptoms typical of opioid withdrawal and those associated with SSRI withdrawal; symptoms include numbness, tingling, paresthesia, and tinnitus. Long-term use of high doses of tramadol will cause physical dependence and withdrawal syndrome. In most cases, tramadol withdrawal will set in 12–20 hours after the last dose, but this can vary.

Tramadol is classified in Schedule 4, in Australia, rather than as a Schedule 8 Controlled Drug like most other opioids.

This is because the two isomers complement each other's analgesic activity. The (+)-isomer is predominantly active as an opiate with a higher affinity for the µ-opiate receptor (20 times higher affinity than the (-)-isomer). Tramadol is marketed as a racemic mixture of both R - and S - stereoisomers.

The concentration of O -desmethyltramadol in the blood or plasma of a person who has taken tramadol is generally 10–20% those of the parent drug. Tramadol and O -desmethyltramadol may be quantified in blood, plasma or serum to monitor for abuse, confirm a diagnosis of poisoning or assist in the forensic investigation of a sudden death. Most commercial opiate immunoassay screening tests do not cross-react significantly with tramadol or its major metabolites, so chromatographic techniques must be used to detect and quantitate these substances.

Available dosage forms include liquids, syrups, drops, elixirs, effervescent tablets and powders for mixing with water, capsules, tablets including extended release formulations, suppositories, compounding powder, and injections.

Its use in children is generally advised against, although it may be done under the supervision of a specialist. The FDA lists age under 12 years old as a contraindication. The investigation was initiated because some of these people have experienced slowed or difficult breathing. On September 21, 2015 the FDA started investigating the safety of tramadol in use in persons under the age of 17.

Tramadol undergoes hepatic metabolism via the cytochrome P450 isozyme CYP2B6, CYP2D6 and CYP3A4, being O - and N -demethylated to five different metabolites. Those with decreased CYP2D6 activity require a dose increase of 30% in order to achieve the same degree of pain relief as those with a normal level of CYP2D6 activity. As with codeine, in the 6% of the population that have reduced CYP2D6 activity (hence reducing metabolism), there is therefore a reduced analgesic effect. Of these, O -desmethyltramadol is the most significant since it has 200 times the μ-affinity of (+)-tramadol, and furthermore has an elimination half-life of nine hours, compared with six hours for tramadol itself.

A change in dosage may be recommended in those with kidney or liver problems. It is not recommended in those who are at risk of suicide. Common side effects include: constipation, itchiness and nausea, among others. While not recommended in women who are breastfeeding, those who take it should not stop breastfeeding. Serious side effects may include seizures, increased risk of serotonin syndrome, decreased alertness, and drug addiction, although the risk of serotonin syndrome appears to be low.

Compared to other opioids, respiratory depression and constipation are considered less of a problem with tramadol. The most common adverse effects of tramadol include nausea, dizziness, dry mouth, indigestion, abdominal pain, vertigo, vomiting, constipation, drowsiness and headache.

Tramadol is a synthetic opioid of the benzenoid class (it contains a benzene ring). In the body it is metabolized to O -desmethyltramadol, which is a more potent opioid.

Fatalities with tramadol overdose have been reported and are increasing in frequency in Northern Ireland ; the majority of these overdoses involve other drugs including alcohol. Recognised risk factors for tramadol overdose include depression, addiction and seizures. Naloxone only partially reverses the toxic effects of tramadol overdose and may increase the risk of seizures.

The German expert group found a low prevalence of abuse or dependence in clinical practice in Germany, and concluded that Tramadol has a low potential for misuse, abuse, and dependence in Germany”. the evidence for physical dependence was considered minimal. Consequently, Tramadol is generally considered as a drug with low potential for dependence. but. However, according to a 2014 report by the World Health Organizations Expert Committee on Drug Dependence '".in many cases of tramadol dependence, a history of substance abuse is present. In a recent German study (including a literature study, an analysis of two drug safety databases, and questionnaires analyses), the low abuse and low dependence potential of Tramadol were re-confirmed.

Its volume of distribution is approximay 306 L after oral administration and 203 L after parenteral administration.