Review of: Dunn K et al, JAMA Psychiatry 2017. doi:10.1001/jamapsychiatry.2017.1838. [Epub ahead of print]

Opioid withdrawal protocols often rely on a buprenorphine taper, but other medications are regularly used either in addition to or in the place of buprenorphine. In particular, tramadol ER, a mild opiate, may be effective and was recently studied at Johns Hopkins University School of Medicine.

A total of 103 participants with opioid dependence were enrolled in this study comparing tramadol ER (n = 36), buprenorphine (n = 31), and clonidine (n = 36) for opioid withdrawal. Overall, 88 of the subjects (85.4%) were male, 43 (41.7%) were white, and average age was 29 years. Past 30-day use of heroin was reported by 96 (93.2%) of the ­participants vs. 49 (47.5%) who reported using prescription opioids in that time period (some used both).

People in the study were randomized to three arms: tapering with tramadol (up to 600 mg/day), clonidine (up to 0.8 mg/day), or buprenorphine (up to 8 mg/day). Following the week-long taper, all participants were crossed over to placebo for a week, then were given a naloxone challenge to verify successful withdrawal.

The trial used several measures, including the Subjective Opiate Withdrawal Scale (SOWS) completed by participants, the Clinical Opiate Withdrawal Scale (COWS) completed by clinicians, pupil diameter, and concomitant medication use (mostly over-the-counter meds for GI symptoms, pain, and sleep).

Researchers found that tramadol ER was more effective than clonidine and comparable to buprenorphine in terms of patient retention and withdrawal symptom suppression during the 7-day detox period. Patients treated with clonidine and tramadol used more concomitant supportive medications during the taper than those on buprenorphine, though the number of meds used was low (0–2) across all three groups.

CATR’s Take
Based on this study, tramadol seems like an attractive option—you don’t need a buprenorphine waiver, and it may be more effective than clonidine. Considering it is an opioid agonist, it’s no surprise that tramadol helps alleviate withdrawal symptoms. But the doses of tramadol used were particularly high (usual dose in pain is 50–200 mg/day), whereas the doses of buprenorphine were relatively low (usual dose in detox is 8–16 mg/day). Still, if buprenorphine is not an option, then tramadol could be worth considering. Just be cautious of drug interactions, especially with serotonergic agents (increased seizure risk).