Tramadol withdrawal psychosis.

Sir,

Tramadol is a synthetic 4-phenyl-piperidine analog of codeine, and it is effective in mild-to-moderate analgesia. Tramadol acts on μ-opioid receptor mainly and to a lesser extent on δ-opioid receptor and κ-opioid receptor. It also has action as a serotonin and norepinephrine reuptake inhibitor.[1]

In addition to typical withdrawals of opiate, tramadol can also have atypical withdrawals in the form of anxiety, paranoia, depersonalization, derealization, and auditory hallucinations.[1] Tramadol has relatively less potential for abuse and dependency than morphine.[2] In literature, there is handful of case reports of psychosis emerging from tramadol withdrawal which were managed with antipsychotic and without antipsychotic.[34] Here, the authors have reported a case of tramadol withdrawal having predominant auditory hallucinations and responded to the management of opioid withdrawals without use of antipsychotic.

CASE REPORT

A 42-year-old male presented with acute onset of symptoms of aggressive behavior, difficulty in sleeping, self-muttering, severe and diffuse leg pain for the past 3 days. The patient accepted that he could hear the voices of his demised father and grandfather. He would hear these voices 8–10 times throughout the day, from outer objective space. The patient had a history of opioid dependence and was treated with tablet tramadol. However, he continued to use tablet tramadol 50 mg, 5–10 tablets per day in a dependent fashion continuously for the last 3 years, and the last dose was 36–48 h before onset of current complaints. There is no history of delirium or seizure and no history of psychiatric illness. General physical examination and neurological examination were within normal limits. Mental status examination revealed second-person auditory hallucinations, and higher mental functions were within normal limits and absent insight. All routine blood investigations and contrast-enhanced computed tomography of the head were within normal limit.

Urine screening with poly-kit for substance was positive for tramadol (>100 ng/ml). However, it was negative for benzodiazepines and cannabis. Baseline clinical opiate withdrawal scale (COWS)[5] score was 19 and subjective opiate withdrawal scale[6] was 30. The patient was managed for opioid withdrawal with tablet clonidine, benzodiazepines, and painkillers and the COWS score came down to 6 within a week. Auditory hallucination disappeared completely in 2 weeks of abstinence. Naranjo scale for causality assessment score came out to be 9 which suggests a definite correlation.[7] The patient is coming for follow-up and maintaining abstinent from tramadol and free from auditory hallucination.

Since tramadol binds to opioid μ-receptors, it is expected that its cessation after chronic use causes withdrawal symptoms and signs like the other opioid drugs. However, there are instances in which tramadol withdrawal symptoms are similar to serotonin reuptake inhibitor withdrawal symptoms.[18] This has a direct correlation to tramadol's mechanism of action as a serotonin and norepinephrine reuptake blocker, which explains the auditory hallucinations in the index case.

Index case was managed without use of antipsychotic which is similar to another case report[3] but contrary to the case report by Lakhal et al.[4] Hence, atypical withdrawal of tramadol can appear in the form of psychosis, and one should manage such patients solely by treating the opioid withdrawal and do not require the addition of an antipsychotic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.