Tramadol: When the 'safe option' painkiller turns out to be lethal | Mail Online
By Jo Waters
PUBLISHED: 19:17 EST, 8 April 2013 | UPDATED: 19:17 EST, 8 April 2013
Accidental overdose: Lizz Bowker died after taking just two extra pills
John Bowker gasped in horror as he realised his wife Lizz had stopped breathing.
‘I’d been out of our bedroom for only six minutes.
'When I came back Lizz was lying there lifeless,’ recalls John, 67, a retired engineer from Eastbourne, Sussex.
He tried in vain to resuscitate his wife, as did the paramedics, who arrived within minutes, but it was too late.
‘I was devastated — I’d been laughing and joking with her 20 minutes before and she’d showed no sign of being unwell,’ says John.
Lizz, 57, a mother of three, died from an accidental overdose of the opioid painkiller tramadol, which she’d been taking for the previous year for back pain and leg ulcers.
She had taken just two more tablets than her usual daily dose of eight 50mg tablets.
‘She’d been sorting out her weekly pill box and I think she just got confused and took two doses,’ says John, who was married to Lizz for 38 years.
Tragically, her death is by no means an isolated case and highlights the dangers associated with a drug too often regarded as the ‘safer’ option.
Tramadol is an increasingly commonly prescribed painkiller — prescriptions have almost doubled in the past seven years, from 5.9 million in 2006 to 11.1 million in September 2012.
Its popularity has soared partly because it’s cheap — now available as a non-branded generic drug, it costs the NHS £1.99 for 100 tablets.
Fears about other painkillers have also made tramadol an attractive option.
Lizz's death is by no means an isolated case and highlights the dangers associated with a drug (Tramadol) too often regarded as the 'safer' option
The non-steroidal anti-inflammatories (NSAIDs) are linked to side-effects such as indigestion, stomach ulcers, a perforated gut.
One of these drugs, Vioxx, was withdrawn in 2005 because of a link to heart attack and stroke.
Meanwhile, another painkiller, co-proxamol, was withdrawn after concerns about it being used in suicides.
Tramadol — which also comes under brand names including Zydol and Zamadol — is a synthetic opioid drug, similar to natural opioids derived from poppy seeds, such as morphine.
It’s prescribed to prevent or treat moderate to severe pain after surgery, toothache or long-term pain conditions including back pain, fibromyalgia and osteoarthritis.
Tramadol is regarded by many doctors as a weaker opioid. But in fact it has the same risks of overdose as with morphine.
As with all opioids, tramadol acts directly on the central nervous system, blocking pain signals from the nerves to the brain; but it also enhances the effects of two brain messengers, serotonin and noradrenaline.
This dual action makes interactions with other drugs more likely — the risk is if the patient is taking medications or other substances with a sedative effect on the central nervous system, because this can affect breathing and, in some cases, lead to death.
So tramadol should not strictly be used if you’re taking sleeping tablets, tranquilisers, and antidepressants, other painkillers that act on the brain, or are under the influence of alcohol.
But despite these well-known interactions, some patients end up being prescribed tramadol as well as sleeping pills and antidepressants, as often pain, mood and sleep problems go together.
Deaths from tramadol overdose have soared from just one in 1996 to 154 in 2011.
More than 500 people died from tramadol overdoses between 2006 and 2011.
While it’s not clear how many of these were accidental, the figures are beginning to ring alarm bells with clinicians and policy makers, says Dr Cathy Stannard, consultant in pain medicine at North Bristol NHS Trust, author of Opioids in Chronic Pain.
Tramadol is an increasingly commonly prescribed painkiller - prescriptions have almost doubled in the past seven years
‘Apart from the whole issue of tramadol’s dual mechanism for acting on pain and the increased risk of drug interactions, prescribers still regard tramadol as a safer opioid than morphine — a sort of “opioid-lite”,’ she says.
‘But it’s a strong opioid drug.’
Three years ago, it was moved to the strong opioids section of the British National Formulary — a doctors’ reference guide produced by the British Medical Association and the Royal Pharmaceutical Society.
But tramadol is seen as ‘somehow safer and softer than stronger opioids, in a similar way that codeine is’, even though it’s actually twice as strong as codeine, says Roger Knaggs, associate professor of pharmacy at Nottingham University.
‘This may well be why this problem of accidental overdose is beginning to emerge. ‘Patients prescribed opioids such as tramadol need close monitoring — and should be seen at least once a month to see if they are getting any benefit from them.’
And Dr Stannard says: ‘Probably less than a third of patients will get pain relief from tramadol in the long term.
'Although there’s evidence to show tramadol works well in the short term for conditions such as post-operative pain, the evidence for long- term benefit is disappointing.’
And patients on antidepressants, sleeping pills and benzodia-zepines should not be prescribed tramadol because of the risks of respiratory depression.
Dr Knaggs suggests seeing your GP for a review of your prescription — but do not stop taking tramadol suddenly as there is a risk of withdrawal symptoms.
The difficulty is that GPs have fewer and fewer options when it comes to prescribing painkillers, says Dr Martin Johnson, a pain expert for the Royal College of General Practitioners.
‘Taken as prescribed, tramadol is a highly effective drug — the problems seem to arise where the dosage is exceeded or it is taken with alcohol and/or other drugs that have a sedative effect.
‘The other problem is patients sometimes top up their prescribed painkillers with other painkillers they can buy over the counter.’
Although tramadol can be taken with paracetamol or NSAIDs, with any other opioids such as codeine, it increases the opioid load and also the sedating effect.
‘But I do think GPs need to come out with consistent messages to patients about all opioids from codeine upwards,’ says Dr Johnson.
‘Those should be: never take them with alcohol, and stick to the prescribed dose. They should also be specific in the prescription dosages they write.’
The Advisory Council on the Misuse of Drugs, an independent body that advises the government on drug-related issues, has recommended tighter controls; this would involve putting tramadol under the Misuse of Drugs Act 1971, which would make possession of unprescribed tramadol illegal.
Although the report focused on the non-medical misuse of tramadol, it also recommended prescribers should be given training and support concerning its misuse and adverse effects — especially the drug’s dual action.
Dr Johnson said the main advantage of rescheduling tramadol would be that it made practitioners think more before prescribing it.
In the meantime, there may be more families such as John Bowker’s having to come to terms with the needless heartbreak of an accidental overdose.
John suffered a breakdown shortly after Lizz’s death.
‘I kept going over and over what happened that night,’ he says.
While it is not clear what of her other medications might have interacted with her tramadol (Lizz was on a number of medications for diabetes, high blood pressure and leg ulcers), when she died Lizz had two-and-a-half times the normal dose in her bloodstream.
Says John: ‘The evening before she died, Lizz had been sitting at the computer doing her internet supermarket shop.
‘The next day was Father’s Day and she had all her clothes laid out ready for a day with our son and grandchildren.
'One of her favourite phrases was one from the TV sitcom Only Fools And Horses — the one where Del Boy says: “The world is our lobster.” ’
John wants other people to know of the dangers of tramadol.
‘I’ve never blamed the GP for prescribing the drug — like lots of people Lizz was in pain and she needed it,’ he says.
‘The post-mortem did reveal Lizz also had undiagnosed heart disease — which the coroner said was a contributory factor — but I feel very strongly that more needs to be done to warn patients about how strong a drug tramadol is and how it appears to be quite easy to accidentally overdose.
‘I don’t think Lizz realised what she was dealing with — and that just a few extra pills could kill her.’