Tramadol as Opiate Discontinuation Aid in Patients With Comorbid Anxiety/Depression

[SPC123]

I was clinically diagnosed with social anxiety disorder by a psychiatrist and prescribed venlafaxine which has worked very well for me at a fairly low dose of 150mg daily.

Last year I was in a bad motorcycle accident that required extensive pain management. Since my last surgery I am virtually pain free and no longer in need of strong pain medications. I am currently in the process of tapering off a high dose of oxycodone. I went from 400mg daily to 40mg daily without issue, however at these lower doses I am finding increased issues with depression and anxiety. My family doctor wants to increase my venlafaxine dose by 75mg per day in order to combat the increased depression and anxiety associated with my opiate withdrawal symptoms. I am wary of this as my current dosage works fine for my anxiety, and I feel the depression and anxiety I am experiencing now are entirely related to the opiate withdrawal. I don't want to be in a situation where once I am off the opiates I am stuck with a higher venlafaxine dose which I would then have to either continue or taper risking SNRI discontinuation syndrome.

I plan to present the following theory to my doctor:

Tramadol is similar to venlafaxine in structure, and in fact has the same effect in that it releases serotonin and inhibits norepinephrine re-uptake. In addition it is a μ-opioid agonist. It is because of the serotonergic and noradrenergic effects that tramadol is not recommended as an opioid discontinuation aid. However in the case of patients already taking venlafaxine this worry becomes moot. By taking 1 x 37.5/325 tramadol capsule per day in addition to an opiate taper and regular venlafaxine dosage tramadol could be an effective aid in both combating the depression and anxiety associated with opiate withdrawal (without increasing the venlafaxine dose), while also helping ease the taper via its μ-opiate action. Taken over a short period, four weeks maximum, there would be little worry of additional discontinuation symptoms upon cessation of tramadol as the comparatively high venlafaxine dose would counteract any possible SNRI discontinuation syndrome.

This seems sound to me, and could potentially be valuable to anyone in my situation. I would very much appreciate any feedback you guys could provide.

 

[bpayne]

I dont think you can take it if your taking the other snri.. most likely would interact.. it would have to be one or the other. of course there may be something I'm missing or thinking of incorrectly here so anyone else with more knowledge on the subject jump in and correct me

 

[SPC123]

As I understand it it's an additive effect. If the venlafaxine dose were very high there'd be a risk of serotonin syndrome, but at lower therapeutic venlafaxine dosages, I would think the risk would be close to nil. I don't believe the drugs themselves interact with each other in any way that would lead to additional dangers.

 

[sekio]

Me personally, I would be taking the tramadol in lieu of both the SNRI and the opioids, just cause it make it easier to handle drug interactions (as there are none )

Remember that not all drugs are as additive as you think... What I do know is that too much norepinephrine caused by overusage of norepinephrine reuptake inhibitors is really really unpleasant and feels like a combination of ahving an anxiety attack and the flu. You don't want to be there.

There will definitely be a little bit of a disconnect when you switch onto tramadol; but you should be able to titrate the whole mess down slowly from there. Don't give up hope.

 

[SPC123]

Wouldn't replacing an anti-depressant with tramadol eventually lead to tolerance and extremely high dosage? I know tolerance to tramadol occurs more slowly than true opiates but tolerance does occur, none the less.

 

[sekio]

The idea is to titrate off them (ADs and opioids) using a slowly decreasing tramadol dosage, preferably with the aid of environment enrichment and some form of talk therapy.

Keep in mind opioid withdrawal will naturally elevate norepinephrine levels.

 

[SPC123]

The question still remains: would the tramadol be an effective aid in an oxycodone taper particularly with respect to mood elevation?

Edit: The assumption being a clinical anxiety disorder requiring the continuation of the venlafaxine long term.

 

[adder]

I don't know to what extent this is true as I don't believe the psychiatrist who put this statement but nonetheless in Fall 2009 he prescribed me tramadol which I was supposed to taper down and stop RIGHT AWAY ~160-200mg morphine / 40mg levorphanol addiction. I know this is ridiculous prescribing such a weak partial opioid agonist for such high doses of morphine and levorphanol. I debated with him that tramadol has no usage as a detox medication or maintenance drug and then he replied it is used in Germany for this purpose.

I have never found any proof for that. And I don't think it's a good idea to exchange oxycodone and venlafaxine for tramadol. If I understood correctly because if you want to take a combo of tramadol and one of the two drugs you take now - this is impossible that a doctor would agree. Tramadol with its SNRI properties lowers the seizure threshold and even if you wanted to use it as a substitute for both drugs you take now, I don't think the maximum daily dosage would do fine for you (it's 400mg and doctors don't prescribe more on the scripts).

I think it's still better for you to upper your daily dose of venlafaxine to 225mg. This is still a fairly low dose and I'm guessing this is an ER medication as I don't think there are still psychiatrists making people take the drug a few times a day if they don't have to. Different people react differently when the time comes to taper down an SSRI/SNRI medication but I was at 300mg of venlafaxine and I felt nothing. I could drop it just like that right away. The real pain in the ass was paroxetine. I'm very thin and it started working for me at a very low dose of 40mg. The result was it eventually stopped working and I went back into a massive depression episode again. My psychiatrist opinion was serotonin receptors probably don't response so well anymore so she thought that adding a 5HT{1A} agonist - buspirone - would boost the effects of paroxetine and besides it's an anxiolytic. The effect was disastrous. I went into a manic episode and it finally became clear it's neither plain depression nor social anxiety but BPD. I did a terrible thing at school after which a girl I was attracted to never really forgave me and after the end of the school I never saw her again (the shitty situation haunts me now as I'm taking a very low dose of methadone tapering down and it's always painful).

Well, to cut the long story short, I don't think 400mg of tramadol will replace successfully both 150mg of venlafaxine and 40mg of oxycodone (400mg tramadol and 40mg oxycodone? no way for me...).

 

[negrogesic]

At the moment I have not the time to answer this question in length (plus the responses thus far have been very good), but I will tell you this:

Do not present your 'findings' to your physician in respect to structural similarity of the two drugs, a pharmacological overlap, etc.....

You have already made the mistake of assuming that your physician is even familiar with the molecular structure of either drugs (physicians are not pharmacologists or medicinal chemists), and for many, it has been years if not decades since their last MCB or med-school psychopharmacology classes.

Psychiatrists should be somewhat more familiar/current, and should have a 'working' understanding of the basic mechanisms for the drugs which they prescribe.

However, I must reiterate, that unless you truly know the physician well and can speak very frankly and directly with him (or, 'her'), your proposition will be turned down, and may appear to be a form of 'drug-seeking behavior'.

As the polish man above stated (very well, I might add), tramadol is unlikely to substitute for oxycodone, and as seiko mentioned; you are currently in opioid withdrawal, which mimics or exacerbates any underlying psychiatric disorder. Do not treat said disorder until that variable is gone.

 

[SPC123]

I speak of tramadol in ADDITION to venlafaxine and oxycodone. I am not in any way suggesting tramadol as a viable alternative to either of these medications. The theory is that adding (not replacing with) tramadol to the taper process of an oxy dependant person who concurrently takes venlafaxine might be beneficial in treating the short term depression and anxiety that come with opiate discontinuation without the SNRI dependency issues that normally contraindicate tramadol as a cessation aid.

As for me personally and my relationship with my doctor, he has always given me what I ask for as long as I present him with a valid medical reason.

 

[bpayne]

I still worry that taking tramadol and effexor together can cause serotonin syndrome.. as as well.. if both are effecting norepinephrine your seizure possibility raises quite high much higher in my opinion than either drug on it's own

 

[pofacedhoe]

Me personally, I would be taking the tramadol in lieu of both the SNRI and the opioids, just cause it make it easier to handle drug interactions (as there are none )

.

my thoughts exactly. tramadol for me was a great antidepressant and although uncomfortable to come off it was still way less unpleasant than citalopram withdrawl