Can tramadol and Norco (hydrocodone) cause akathisia?

Can Tramadol and Norco Cause Akathisia?

No, tramadol and Norco (hydrocodone) do not typically cause akathisia—in fact, opioids may actually improve akathisia symptoms when they occur from other medications like antipsychotics.

Understanding Akathisia and Its Typical Causes

Akathisia is a movement disorder characterized by subjective inner restlessness and an urge to move, commonly presenting with objective signs like rocking, pacing, or inability to sit still 1. The primary culprits for drug-induced akathisia are antipsychotic medications (both typical and atypical agents) and serotonin reuptake inhibitors (SSRIs), not opioid analgesics 2, 3.

• Akathisia results from dopaminergic blockade, particularly affecting D2 receptors in the basal ganglia and projections to the ventral striatum 3
• Antipsychotics cause akathisia in 5-36.8% of patients, typically within the first few days of therapy 2, 4
• The condition is associated with poor medication adherence and can lead to severe outcomes including aggression and suicidality 1

Opioids and Akathisia: The Evidence

Opioids like tramadol and hydrocodone do not cause akathisia through their mechanism of action. In fact, the evidence suggests the opposite relationship:

• A study of five patients with neuroleptic-induced akathisia showed substantial to complete improvement when treated with opioids (propoxyphene or codeine), and symptoms returned when naloxone (an opioid antagonist) was administered 5
• This suggests the endogenous opioid system may actually be protective against akathisia, and exogenous opioids can be therapeutic 5

Tramadol's Unique Considerations

While tramadol is not associated with causing akathisia, it does have important neuropsychiatric side effects that should not be confused with akathisia:

• Tramadol carries a high risk of delirium, particularly in elderly patients and perioperative settings 2, 6
• Tramadol can cause cognitive impairment and memory problems through its effects on serotonin metabolism 6
• The American Society of Anesthesiologists specifically notes tramadol's association with delirium risk, which is distinct from akathisia 2, 6
• Tramadol lowers seizure thresholds and can cause serotonin syndrome when combined with other serotonergic medications 6, 7

Clinical Pitfalls to Avoid

Do not confuse opioid-induced restlessness or agitation with akathisia:

• Opioid withdrawal can cause restlessness and agitation, but this is pharmacologically distinct from akathisia
• Delirium from tramadol may present with motor restlessness but lacks the specific subjective inner restlessness and dopaminergic mechanism of true akathisia 6
• If a patient on tramadol or hydrocodone develops akathisia-like symptoms, look for concurrent antipsychotic use, SSRIs, or antiemetics (like metoclopramide or prochlorperazine) as the actual cause 2, 3

When Akathisia Occurs in Patients Taking Opioids

If akathisia develops in a patient taking tramadol or Norco, the opioid is not the cause—investigate other medications:

• Review for antipsychotic medications (haloperidol, risperidone, quetiapine, etc.) 2
• Check for SSRIs or other serotonergic agents 3
• Consider dopamine-blocking antiemetics 2
• The opioid itself may actually provide some symptomatic relief and should not be discontinued for this reason 5