When to Discontinue Tramadol
Tramadol should be discontinued gradually rather than abruptly, with a typical taper reducing the dose by 10% of the original dose per week, particularly after prolonged use, to minimize withdrawal symptoms. 1
Duration of Use Before Discontinuation
For acute postoperative pain, tramadol should be prescribed for no more than 5-7 days. 1 The hospital discharge letter must explicitly state the recommended tramadol dose and duration, with usual duration being 5 days and no more than 7 days. 1
For osteoarthritis, tramadol taken for up to 3 months may decrease pain and improve function. 1 Beyond this timeframe, reassessment is warranted.
If a patient not usually on long-term opioids (including tramadol) is still taking the medication 90 days after surgery and remains in pain, this should trigger further assessment in primary or secondary care, which may include referral to a pain service. 1
Indications for Discontinuation
Discontinue tramadol when:
Clinically meaningful improvements in pain and function are not sustained 1
The patient is taking tramadol without evidence of benefit 1
Benefits no longer outweigh risks, or the patient requests dosage reduction or discontinuation 1
The patient experiences overdose or other serious adverse events (e.g., events leading to hospitalization or disability) or warning signs of serious adverse events 1
At least every 3 months, reassess whether tramadol continues to meet treatment goals, including sustained improvement in pain and function 1
Tapering Protocol
The recommended tapering approach is:
Start with a reduction of 10% of the original dose per week as a reasonable starting point 1, though tapers slower than 10% per week (e.g., 10% per month) may be better tolerated, particularly when patients have been taking tramadol for longer durations 1
The taper should be slow enough to minimize withdrawal symptoms (drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, sweating, dilated pupils, tremor, rapid heart rate) 1
Tapers may need to be paused and restarted when the patient is ready, and may need to be slowed once patients reach low dosages 1
Once the smallest available dose is reached, extend the interval between doses, and tramadol may be stopped when taken less frequently than once daily 1
Critical Warnings About Abrupt Discontinuation
Abrupt withdrawal of tramadol, even at recommended doses, can induce withdrawal symptoms and should be avoided. 2 Tramadol carries a risk of dependence and abuse, even in patients with no history of drug abuse. 2
Physical dependence can develop after at least 10 years of use, and potentially much sooner, leading to both classic and atypical withdrawal symptoms after abrupt cessation. 3 Atypical symptoms may include significant mucus production, chest fullness, and neck soreness. 3
Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), tramadol should not be discontinued abruptly. 1
Common Pitfalls to Avoid
Do not trivialize the use of tramadol or consider it a "safer" opioid without potential for withdrawal symptoms, abuse, misuse, or addiction. 3 The misconception that tramadol is safer than other opioids can lead to overlooking withdrawal symptoms after discontinuation. 3
Prescription renewals are an opportunity to reassess the need for tramadol. 2 Patients must be advised to stop treatment gradually, especially after lengthy treatment periods. 2
Avoid adding tramadol to a "repeat" prescribing template; it should only be added to the patient's record as an acute medicine and must be reviewed at each issue by the prescriber. 1
Patient agreement and interest in tapering is likely to be a key component of successful tapers. 1 When patients and clinicians are unable to agree on whether tapering is necessary, acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment. 1