Tramadol, a synthetic opioid long used to treat moderate to severe pain — and commonly prescribed in South Africa — is under fresh scrutiny.
A study published last week in BMJ Evidence-Based Medicine argues its benefits for chronic pain are minimal and its risks may outweigh them. The researchers, led by Dr Janus Jakobsen of the University of Southern Denmark, found only a “slight effect” on chronic pain.
“The findings indicate that the benefits of tramadol are questionable or, at the least, uncertain,” Jakobsen said, adding that “evidence suggests the presence of potentially harmful effects”.
Their analysis points to serious side effects associated with tramadol use, such as cardiac strain, heart disease and congestive heart failure, among other risks.
“Alternative treatment options should be considered before prescribing tramadol,” Jakobsen recommended.
We should reserve tramadol only for cases where alternative pain-relief options are ineffective and ensure close monitoring
— Dr Vinesh Padayachy
A vascular surgeon at Lenmed eThekwini Hospital and Heart Centre, Dr Vinesh Padayachy, said South Africa has long relied on tramadol in pain management.
“Clinically we see quite a few patients on tramadol for chronic pain, especially in rural and public settings, who gain only marginal relief but suffer side effects that can compromise quality of life,” he said.
Padayachy pointed out several side effects doctors encounter:
- Sedation and drowsiness, which interfere with patients’ ability to function daily.
- Gastrointestinal issues such as nausea, constipation and dry mouth.
- Cardiac strain: “In patients with other health problems, especially heart disease or hypertension, tramadol can worsen cardiac risks.”
- Severe hypotension, particularly in patients who are already volume-depleted or are taking other medications such as phenothiazines, tricyclic antidepressants or general anaesthetics. These patients should be monitored for signs of low blood pressure after starting or adjusting the dose.
- It also interacts dangerously with certain medications, “especially some antidepressants, increasing the risk of serotonin syndrome or seizures”.
Padayachy said South Africa’s treatment guidelines caution about many of these risks. “For example, the National Essential Medicines List advises restarting tramadol at low doses after breaks and avoiding it in individuals at high risk of opioid dependence.”
His advice is: “We should reserve tramadol only for cases where alternative pain-relief options are ineffective and ensure close monitoring.”
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