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Drug info - Tramadol withdrawal, tapers, and half-life

Discussion in 'Tramadol' started by DaftNotStupid, Nov 11, 2012.

  1. DaftNotStupid

    DaftNotStupid Newbie

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    M, my wife, had been taking Tramadol daily for over two years, originally to relieve pain from shingles, and occasionally for fibromyalgia and back pain for a few years more. She was on 100mg per day until March when she bumped up to 200mg/day – for other reasons that I might go into later. M also takes Diazepam, 4mg/day, for anxiety, and Mirtazapine, for depression. On medical advice, M started to reduce her intake of Tramadol late September, with the plan to do that first, and then come off Diazepam. Seven weeks in, I decided to write this post to share our experiences, which echo those of many other people writing here.

    One piece of medical advice said that her Tramadol withdrawal would take about six to eight weeks but it would be harder to come off than to come down. Another just said she should start by reducing from 200 to 100 mg/day. M thought this was a little aggressive, but agreed to start at 150 – 1 capsule, three times a day. That appeared to work well, she had moderate withdrawal symptoms – sea-legs and some dizziness, so after about 10 days, she dropped to 100 – going back to two doses per day.

    Withdrawal symptoms started to get worse, but after a couple of weeks levelled off a bit, so after another few days M dropped to 80 mg/day. After a couple of days on 80, the withdrawal symptoms got worse – buzzing feelings, pain, fatigue, raised blood pressure, lots of others, but worst of all for someone already taking Diazepam, greatly increased anxiety. M persevered for a couple of weeks, then went back up to 100, where she still is now.

    One of M’s major anxieties was driven by lack of knowledge of a positive outcome, that she would always feel the way she does now. A number of informed people had told her that it was even worse at the end of the program, making her doubt her ability to carry on.

    To get a better understanding, I started to search the internet, finding this and other forums – full of people with similar stories. There’s quite a bit of technical literature available on the pain-management properties of Tramadol, most of which have some reference to its dependency and addiction properties, but the approach to its withdrawal is not consistent at all and certainly doesn’t reflect the feedback on the forums as regards ease or duration. What saddens me, is the number of web sites selling Tramadol on-line appear when I gooogle “Tramadol withdrawal” so people who may be looking for help are tempted instead.

    The best recommendation I found actually has the greatest variance, “Can vary from 10% of the total daily dose every day to 5% every 1 to 4 weeks” (Canadian guideline for safe and effective use of opioids for chronic non cancer pain) and “Once a third of the original dose is reached, slow the taper to half of the previous rate” (same place). Box 5 in the same document has a useful withdrawal protocol, suitable for other opioids too. Other sources usually just mention the lower end of the range, e.g. “A withdrawal syndrome may be avoided by tapering doses by 10% to 20% per day” (Opioid Pharmacology and Considerations in Pain Management).

    It’s not surprising that with so little, sometimes conflicting or incorrect information available, there are so many people asking questions about effective Tramadol withdrawal. Often the answer is “Consult your doctor, who will recommend a taper schedule”, but if your experience is like ours, what you hear may not be best practice.

    I wanted some idea of how long the withdrawal would last, so I built an Excel spreadsheet that plots a number of options, including my wife’s actual dose, and a couple of reasonably conservative tapers – 10% reduction every week (green line) and 10% reduction every two weeks (blue line).

    [​IMG]

    The chart shows quite graphically that withdrawal can take many months – possibly as long as a year. My chart doesn’t yet factor in the advice to halve the rate when the dose is one third the original, which will further extend the end date. Compared with the slower tapers, M’s (pink line) was far too sharp – more of a cliff than a slope.

    For now, M is staying a 100, waiting until her blood pressure comes down and her anxiety has reduced. Then she’ll take it slowly, probably dropping by 10 mg or 10% each time. It’s hard to say how long each period of stability will last, but I’ve read somewhere that the goal of the taper is to avoid withdrawal symptoms, and if taking it longer can avoid them, it’s worth taking the extra time. We bought a little blood pressure monitor that goes around her wrist, and she measures it sitting and standing before and an hour after her Tramadol dose, keeping a record, which she’ll use to help judge when to reduce again.

    I’ve also been looking into the half-life effect of Tramadol consumption, since M mentioned that she had noticed that round about 2pm she started to feel edgy. She says that she feels even worse in the morning.

    My search on the internet didn’t reveal much more than that Tramadol’s half-life varied between 5 and 7 hours, but nothing about what that might mean. I created another chart using the standard half-life calculation which shows how the effective dose varies through the day. The peaks on the second day and thirds days are larger since they incorporate the residual dose.

    [​IMG]

    The chart clearly shows the two big troughs in the effective dose. M takes her doses at 9am and 6pm, so by 2pm, the remaining effective dose is close to 50%. Our thinking is that while these have only just become apparent now, they have probably been contributing to her mood for the past couple of years.

    I added a plot for 33.33 mg doses taken three times per day, which reduces the afternoon trough. The daily dose will remain the same at 100 mg, so this should be relatively easy to move to. I also show an option for four doses per day, but we think that would be too difficult to manage.

    M’s next step will probably be changing to 3x33.33 mg doses per day, and she’ll stabilize on that before reducing further. I’ll try to keep you posted on her progress over the coming period.
     
  2. DaftNotStupid

    DaftNotStupid Newbie

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  3. DaftNotStupid

    DaftNotStupid Newbie

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    Has anyone else experienced the lows during the day that are suggested by the half-life chart? M moved to 3 x 40mg doses per day, rather than the 3x33 that I mentioned earlier, and after a few very bad days - lots of anxiety etc - her withdrawal symptoms appear to be dying down a little. This may be a result of the increased daily dose, from 100 to 120 - but if it improves her mood significantly and gives her a level field to start the next slower, taper from, that's worth it.

    When M started taking three doses a day, she took them at 9am, 3pm, and 9pm, which seemed a good balance through the day, nice even six hour intervals, but it meant that she got hardly any benefit from the last one before going to bed, and there was a big drop in the residual level before she got to take it. She'd also previously taken her evening dose at 6pm, so having to wait until 9pm appeared to put an extra strain on her. So, after a couple of days, she moved to 9am, 2pm, and 7pm - 5 hour intervals, resulting in less steep drops, and a smoother average through the day. No way around the steep overnight drop, though, without getting up in the middle of the night :).

    I guess that the sustained release variant aims to achieve this same sort of smoothing and I'd be very interested to hear anyone's experiences of using it during Tramadol withdrawal.

    Today was a good day. Let them keep on coming.

    J
     
  4. longwaytogo

    longwaytogo Newbie

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    I know how frustraiting it is SWIm had an expience just like that, she had three surgeries on a nerve and ended up with a dependecy on painkiller specifically with tramadol.
    I'm not going to lie it is going to be hard, it took SWIM six months to be completely of the Tramadol id de anxiety is being to much to handle go with a therapist and psyquiatrist that specialise on this kind of situations.
    Best luck to M and you
     
  5. DaftNotStupid

    DaftNotStupid Newbie

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    Thank you, Longwaytogo. It's good to hear that your friend is clear now.

    It was getting to hard for M, so she has gone back up to 150 (3x50) mg. Her psychiatrist now suggests that she transfer to Buprenorphine (Subutex) which has a much longer half-life (32-72 hours) with less intra-day variance, and much less effect on her seratonin and noradrenaline receptors. Then, after a period of stability, a long, slow taper down, using the skip method, described elsewhere, towards the end. Anyway, that's the plan du jour. Now we need to find someone to prescribe it to her in the community.

    I'd love to hear from others who have used Subutex to withdraw from Tramadol. I know it's more widely used to switch from heroin, methadone, etc, but the principle should be the same, right? Just a matter of getting the dose correct?
     
  6. scartissue_68

    scartissue_68 Palladium Member

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    I do not have personal experience with using Subs for withdrawal, but having read many posts on both substances under discussion, my conclusion is that the switch from Tramadol to Buprenorphine may not be as good as it sounds. Tramadol has SSRI properties that would not be addressed by the Bupe. The psychiatrist's conclusion about Bupe having less interference with SSRI and NorE receptors would be true, but it would seem that going Cold Turkey on the anti-depressant component of the Trams may have a withdrawal effect all it's own. I do know that jumping off long-term anti-depressant use in general is ill advised and can be dangerous. Perhaps your doc has considered this and feels that the current AD med may cover the loss of Tram's SSRI effect.

    A little more research might be a good idea. There are also many on this forum who know far more than I about this subject. Perhaps they will jump in and add their expertise or correct my theory.
     
    Last edited: Nov 23, 2012
  7. DaftNotStupid

    DaftNotStupid Newbie

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    Probably good advice, in the general case, scartissue_68, but she's also taking Mirtazipine, for long term depression, and it's the possible interference with that and Tramadol that we're trying to get away from.
     
  8. scartissue_68

    scartissue_68 Palladium Member

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    Understood. Glad your considering the easily overlooked interaction possibilities that come with Tramadol and Buprenorphine. They both are unique, complex opioids.

    It would be helpful if someone who has experience or knowledge about what your considering can jump in and contribute info to help with your strategy.

    I hope things progress in her favor.
     
  9. DaftNotStupid

    DaftNotStupid Newbie

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    Thanks, scartissue_68.

    I built another model and chart for Buprenorphine's long, 72 hour half life, showing both single (red line) and double (green line) doses daily, along with a line showing residual decay. This clearly shows that it takes about a week for the maximum dose to build up in the body, after which time the 2 mg daily dose builds up to an effective 8mg. The green line shows how long it take any residual dose to decay - with around 0.5 mg still active after two weeks.
    [​IMG]
     
  10. Tallulah

    Tallulah

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    Hi Everyone!

    I am on a break from Kratom for my severe pain, and my Dr. prescribed Tramadol sustained release 100 mg.

    After reading some posts here I'm afraid. Should I just not take them and ask for something else?

    I felt sweating and uneasy this morning while walking my dog. I had not taken the med for 10 hours. I have been taking them for 4 days total now. I'm really worried this is not a good medication. I am afraid of withdrawal.

    I certainly don't feel anything special on Tramadol. It does take the edge off the pain somewhat. There must be something better. What is a good medication to replace it that would not cause withdrawals?
    My pain is neuro-muscular.
    Any ideas?

    Thanks.
     
  11. DaftNotStupid

    DaftNotStupid Newbie

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    Hi Tallulah, I'm pretty new to this, so I won't comment much, but since you posted on my thread, I didn't want to leave you hanging :) Tramadol can be very effective, I used it myself to manage terrible pain for 6 or 8 weeks while a dead nerve was regrowing and stopped without any trouble. My wife, M, on the other hand is having a lot of trouble coming off after a couple of years sustained use for chronic pain and fybromyalgia. Sweating and increased anxiety are common withdrawal symptoms, but I'm surprised that you became dependent so quickly - but others can comment here. Maybe your increased anxiety and resulting sweating is driven by your new concern about Tramadol itself and maybe fear that without it your pain will return. One thing I must say, is that you shouldn't stop taking prescribed medication with first talking to you doctor. If, as you say, Tramadol is only taking the edge of your pain, then you need to see him anyway.

    Hope this helps,
    J
     
  12. Tallulah

    Tallulah

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    Thanks Daft for replying!

    I am very small and low weight and maybe that's why I had the sweating/addiction/withdrawl so soon. After taking my next dose I was fine.

    I called my dr's office and a nurse called me back. She told me that Tramadol is not addictive and it must have been my activity, drinking something hot like coffee, or that my clothing was too warm.

    I do not believe her. My dr. of course is only talking through her. I have an appointment in a month.
    I think I am more like your wife and likely to have difficulty getting off of it in the long run. What are you substituting for Tramadol? What will she be substituting? My pain is chronic with no cure.

    Fentanyl patches gave me a bowel obstruction and I weened myself off those. Never again. At least with Tramadol I pooh no problem. I feel good as long as I take it. I hate to be dependent on anything.

    I have taken Soma in the past and it helped until the crackdown on Pain docs in my area perscribing it. My doc will not perscribe it to me anymore.
    I also had no withdrawl from Soma. Too bad about some of the best meds being monitored and less scripted.

    I used kratom for a bit, but my doc said it raised my liver enzymes so much that I should not use it. It also caused inflamation of my bile duct according to labs and ultrasound. Inflamtion and problems stopped after discontinuing the kratom so he thinks I should'nt use it again. I like kratom so thats not good news for me. It actually worked better than other meds I used.

    Thanks again for you reply. Please let me know what you and your wife are using because we are in the same boat.
     
  13. DaftNotStupid

    DaftNotStupid Newbie

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    M is planning to transfer to Buprenorphine (Subutex) - she's seeing her doctor on Thursday, so I'll know more after that.

    The best guide to pain medication that I've found so far is a document called Chronic pain medical treatment guidelines. Forum rules mean I can't post the link here, but if you goooogle mtus chronic pain medical treatment guidelines it should be at the top of the list. This is one of a number of MTUSs (Medical treatment utilization schedules) available from the State of California's department of Industrial Relations - not where you'd expect to find this sort of thing.

    J
     
  14. Tallulah

    Tallulah

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    Thanks and please keep me posted with a pm to let me know how it works for her.
     
  15. scartissue_68

    scartissue_68 Palladium Member

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    @Tallulah - Have you considered Medical Marijuana? It's available in California. The only problem, compared to an extended relief pill is that you will have to deal with the psychoactive properties of whatever MMJ product best fits your needs. You can get quite "mellow" on modern MMJ.

    I have chronic pain and see a pain a management specialist, but I'm in Indiana. I have heard that some "chewables" provide relief greater than most opiates (equivalent to Tramadol and even stronger pills), with no effect on your Gi system and it provides good, unbroken REM sleep. The "next day" effect is actually quite pleasant.

    I'm currently on BuTrans which is a 7 day patch of Buprenorphine. I would recommend it, but it has a high potential for constipation. So, based on your Fentanyl experience, BuTrans may not be the best option. I survive with daily dosing of senna, but it's still no fun.

    4 days seems too soon to start getting withdrawal symptoms, but you can be sure that if you continue with the Tramadol, your tolerance will only continue to build and your potential for withdrawal symptoms enhanced.

    See the comments above for Tramadol's double-effect withdrawal issues.

    Best of luck.
     
  16. luvrespectnrg

    luvrespectnrg Newbie

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    I have withdrawan from Tramadol numerous times, some times from about 600-1200 mgs a day, it wasn't that difficult.I couldn't even take a car riode without losing my food,couldn't move bowels for almost two days at some time.
    One thing I used was cannabis however that may not be an option as it is illegal in the UK as it is in my state. Another way your wife could fight the depression parts of withdrawal is a nootropic like phenibut or piracetam I know a few years ago I had a series of bad cocaine binges and discovered phenibut sometime afterward and never considered cocaine again.

    Pehnibut is possibly controlled in UK as in a lot of EU but here it is sold as a nutritional suplement. It is a derivitive of the nuerotransmitter GABA and really helps one sleep and not worry about things in low doses it can be beneifical but has it's own w/d problems you can use a low dose even in children so I imagine it would be safe in an adult going thru opiod w/d.

    I have not much experience with piracetam but it acts as a cholinergenic and helps the brain commmunicate better it is used to repair the brain off alchohol w/d and as well. Just be warned about phenibut it has worse w/d's than alot of opiods it is serious stuff but if used in small amounts once every few days because it last for 24 hours or more with its half life.
    I had way worse w/d's of phenibut after nearly a year of 6grams a day use(nearly needed to be hospitalized I pretty much went cold turkey) but I can really see it being beneficial if used properly and under controlled settings like 500mgs every other day or a gram every two to three days depending on the source.
     
    Last edited by a moderator: Aug 28, 2013
  17. Tallulah

    Tallulah

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    Excellent idea about the medical MJ. I did not think of it. Perhaps I will make an appointment.
    About the Buprenorphine, it sounds great, I tend towards constipation so always have colon clenz on hand. I'm glad that works for you. I am feeling great today so maybe the tramadol is starting to work. I was able to do activities without pain or even thinking of it today. I also like that one pill will last for several hours for me. That's a bonus. When my doc had me on Hydrocodone I had to take 4 a day.

    Thank you!
     
  18. DaftNotStupid

    DaftNotStupid Newbie

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    M started to titrate from Tramadol to Subutex yesterday under medical supervision. She has a 10 mcg/hr, 7-day patch, so it'll take a 2-3 days to build up to reasonable level, given its long half-life. She still feeling pretty rotten, but things should improve soon. I'll keep you posted.

    Good luck with the MJ, @Tallulah.

    J
     
  19. Tallulah

    Tallulah

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    Daft,
    Thanks for the update. I hope M feels better soon! That Subutex is prob. much better than Tramadol.

    I stopped cold turkey on the tramadol, 200 dose per day for about 1 and a half months. Still have a few. I am thinking of refilling as it does help with pain. For those that may wonder, no high at all. Pain relief only. Worked pretty well but not the best ever.

    I only stopped to see if any withdrawls were setting in. The answer is no with me for whatever reason. I was so sure I would be feeling bad now, but no. I guess for me it would take more than 200 dose per day. No-Scratch that it must be having to take it for a longer period of time. Right now I'm not taking anything for pain control. I'm hurting, but surprisingly not as bad as I thought I would. I got a new special "temperpedic pillow" which may help some, but not a lot.

    Update: Still having pain. Still hate to depend on doctors for pain relief. A forumite above suggested phenubut. Must research this.

    Tallulah added 6 Minutes and 38 Seconds later...

    To Luverspectnrg:
    I am interested in this Phenubut. Pain free nights? Can I keep to very small dose without w/d troubles? I saw this as an ingredient in a "relax" supplement in many of my local health food stores here in California, so it is legal here.
    It must not have had much in it because it didn't help with pain. Or relaxation, for that matter.
    Should I buy it online instead? How is it taken?
     
    Last edited: Dec 11, 2012
  20. DaftNotStupid

    DaftNotStupid Newbie

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    I thought I'd bring you all up to date with M's progress. She's been on Sub for about 10 weeks now and is gradually reducing. She started on a 10mg patch and has reduced in different-sized jumps to about 4mg. She'll now be following the blue line in the chart, reducing the patch size by 0.5mg (1/10 of the patch) each week. We're hoping this rate is slow enough to avoid any withdrawal symptoms - I'll keep you posted.
    John
    [​IMG]