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Pristiq and Tramadol
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Pristiq and Tramadol

My wife suffers from bipolar disorder and fibromyalgia. She is currently taking Pristiq for the depression from the bipolar disorder.

When she went for her three-month followup today, the doctor wrote her a prescription for Tramadol for the chronic pain from the fibro.

However, shortly after taking the Tramadol (15 to 20 minutes after), she got some sudden sharp pains on the left side of her head, and they lasted for a few minutes then passed.

The pharmacist advised us that the Tramadol can interact with the Pristiq, causing seizures, hyperthermia and rigid muscles, but that these interactions are very rare.

Since she had the sudden sharp pains, is this something we should be concerned with? I really don't want to give her another Tramadol this weekend if the same thing is going to happen again.

(P.S. Why does this stuff always happen on the weekends??)
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1388999_tn?1370046414
I would not give her another Tramadol until you have seen your doctor.It is not worth the risk.I would be concerned yes but you have had a warning so do not temp fate and if it was caused by the interaction of these two drugs she should be ok.
Get into the doctor as soon as you can so he can sort this out.

Just try to relax and enjoy as best you both can.! please let me know the outcome.
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1042487_tn?1275283499
Tramadol is not only a painkiller by affecting the u-opioid receptor but it also have the proprieties of inhibiting the reuptake of serotonin and norepinephrine which would make it a painkiller with SNRI proprieties. Pristiq is a SNRI antidepressant so both are interacting together. So you have increased risk of serotonin toxicity and increased risk of seizures and other neurological symptoms.  Please call her doctor to let him know this is happening.

I would be cautious with the tramadol; so ask your doctor if he thinks the dosage needs to be changed. Also you didn't mention what was the dose. There is a good tramadol mixed with acetaminophen called tramadol acet. It's 37.5mg tramadol and 325mg acetaminophen. Since the tramadol dose is relatively low in tramadol acet I would use this one since she's already on Pristiq.
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1406964_tn?1283207466
Personally I would avoid Tramadol like the plague.

Read some of the other posts on the addictions forum to see how it's affected so many others.

It's addictive, it lowers the seizure threshold and can cause hallucinations and depersonalisation. The withdrawal syndrome is often worse than that for standard opiates.

It's certainly not a drug of choice for depression, and if it was prescribed for pain, ther's many better options available.

I'm not telling you NOT to use it, because I'm not your doctor, but research around the forum for yourself and think very carefully before deciding to continue with it.

With very best wishes
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1042487_tn?1275283499
''It's certainly not a drug of choice for depression''

Can you support this statement? Tramadol have SNRI proprieties first and second any drugs affecting the u-opioid receptor have euphoric effect.

Yes it is very addicting and indeed the withdrawal can be quite severe.

M4
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1406964_tn?1283207466
Can I support it? To be honest I think it's early days, but here in europe the drug is not licensed for depression due to 'the high incidence of acute psychiatric reactions including dysphoria, paranoia, exacerbation of depression and hallucinations at high dosage'  (BNF No 59, 2010), plus in the 2010 Scottish Office Health Departments' Evidence-based medicine guidelines- 'Use with caution in patients with a history of mental illness'.

I guess, as with everything else it's a case of weighing up the risks and benefits. If nothing else works, then maybe there's a case for off-label use of Tramadol.  There seem to be just as many reports of worsening depression and acute psych reactions with Tramadol as there are success stories, and I'm in no way denying that there have been success stories.

However we have such a broad armoury of effective antidepressants now (35 in Europe, not including the weirder ones like L-tryptophan,5HTP, Melatonin, Hypericin etc) that I cannot see the use of an atypical opiate as anything other than a last resort.

Bearing in mind that many people with depressive illness are more likely than the rest of society to develop problems with opiates, it remains, in my opinion a bad choice.

It's a good analgesic. no-one can deny that; as long as it isn't given to anyone who's had or is likely to develop dependency problems. In this particular case above, it appears to have been Rx for FM rather than depression. Again though, there's so many effective analgesics out there that I would have to question how appropriate a choice this is.

Am I biased? well yes! I see the human misery caused by Tramadol every single day!

I'm not sure there's a right or a wrong answer to this. Not yet anyway. To some extent we must use our informed opinion and day to day experience.   I think.........
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1042487_tn?1275283499
I like that you saw me coming because I was going to say this is an extremely biased opinion but since you are aware of it I think we can talk.

What you described as ''weirder ones'' are not antidepressants. They are amino acids and metabolites of serotonin. It's tryptophan --> 5-HTP --> serotonin --> melatonin. Meaning melatonin is synthesized from serotonin to regulate the circadian rhythm and various other functions. In EBM there are not a lot of evidences that supplementing with any of the mentioned above would help with depression. So far so good we don't have an argument here.

Depression is far more complicated than a single neurotransmitter called serotonin. It can various other monoamine transporters deficiencies, vitamins and minerals deficiencies and it can also be only a psychological issue meaning that treating with placebos for psychological depression would suggest the same efficiency as a typical antidepressant let's take a SSRI for example. This kind of depression, not from a neurobiological origin, are treated extremely well with the help of a psychologist.

The OP here is presenting with a depressed patient with a chronic pain disorder called FM. For a doctor the logical choice would be tramadol acet containing a 37.5mg dose of tramadol and 325mg acetaminophen, This is conservative and might help with depression due to it's SNRI activity which is also known to help with chronic pain disorder.

Tramadol acet is the first logical choice for a doctor for a patient expecting good relief before prescribing methadone or any other strong opiates. A bad idea would be to prescribe 100mg tramadol as a first choice for FM. The mistake here is that the patient is also taking a SNRI called Pristiq. So we have here an ''increase interaction''. This would require dose adjustment of both drugs and the tramadol should have been started at very low dosage by using tramadol acet with only 37.5mg tramadol. The patient don't want to be prescribed acetaminophen alone despite it can be very effective.

Antidepressants are widely used to treat FM supporting the use of tramadol due to it's dual action as both affecting the u-opioid receptor and SNRI activity. Tramadol acet is even more logical for this case since it's a lower dose of tramadol with a NSAID.

Lyrica could have been another logic choice but it's not that well tolerated in female patients. So when treating FM you must know your first line treatments and those are anticonvulsants, antidepressants and painkillers. Tramadol (brand names Ultram and Ultracet) is considered a first line treatment for FM. What the doctor tried here is a double combination of antidepressant/painkiller.

I think I'm not the only one thinking this way as I just came a bunch of websites supporting this theory.

-http://www.webmd.com/fibromyalgia/features/treating-fibromyalgia-pain-medication-options?page=2

M4
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1406964_tn?1283207466
I quite agree with you!

But in this case we're not just dealing with chronic pain, we're dealing with bipolar disorder, and I would argue that the AD effect of tramadol isn't required because the patient is already on an AD.

37.5mg tramadol isn't a high dose at all, but how much will be taken over the course of a day. Analgesic blood levels require to be kept as constant as possible to be effective, so it's not going to be just one or two doses a day.

It may well be a first line treatment for FM, but I've witnessed so many psych reactions from tramadol, that giving it to someone with bipolar disorder seems to me to taking a big risk. The next risk is that undeniably tramadol makes people feel good. For someone with depression that feeling can lead to self-medication by increasing the dose- witness the numerous posts on the addiction forum; and if that happens then attempting to come off them can be a real nightmare, more so for someone with mental health problems.

You know your stuff and you may well be right, but I would still maintain there is no right nor wrong answer. However the risk benefit analysis in this case is a bit worrying to me.
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1042487_tn?1275283499
You are right, we're dealing with manic depression here and not depression. I think a mood-stabilizer would have been appropriate in the first place.

Tramadol's half-life is 6 hour so 2 doses a day are required. You are right that self-medication may become an issue when not following the doctor's indication. Pharmacist are well aware of this and they won't give a refill if you come back like 2 weeks too early for a refill. They will give you some to avoid withdrawal untill you see your doctor but this may lead to self-medicating by ordering on the net which is a bad idea.

Just a reminder: any adjustments to her medications should be done under the supervision and approved by her doctor.

M4
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1406964_tn?1283207466
Just an afterthought, but given the circumstances, and given the risks of tramadol, would a better option not have been to try acupuncture or electro-acupunture, both of which I believe have had reasonable results in FM?
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1406964_tn?1283207466
Also I wasn't suggesting changing medications, I was just theorising for the sake of argument; a quite enjoying it too!

All the best
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1042487_tn?1275283499
Yeah good placebo indeed and might affect the release of endorphins but this is very very temporary. Not EBM tho. So I won't give any advice on this as I am into EBM.

M4

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1042487_tn?1275283499
Don't worry I was not addressing the reminder to you but to the OP as it is against the Term of Use to give medical advice without reminding that it should be addressed with the doctor first. Even if it's logic that it will be addressed with the doctor since some people might order online. Online pharmacies should be banned anyway...

M4
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1406964_tn?1283207466
I'm sorry we hijacked your thread, but the forum would be very dull if everyone agreed with each other!

How are things now? Did you decide to keep using the tramadol, and if so have there been any more side effects or benefits?

If you're still undecided you can get more information from both the addictions forum and the chronic pain forum.

As M4 stated, decisions are made between you and your doctor, but it never hurts to do a bit of research and general asking around.

Would you say that the main issue here is the FM pain or the depression?

I'd be really interested to know how things are going.

Take care
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Avatar_m_tn
She only had that one incident. Since she suffers from Fibromyalgia, which in itself can be quite debilitating at times, she decided to give it a try the second night, and there was no side effects. She's only taking it PRN and hasn't needed one in the past two days. I was sure to watch her carefully on the second night.

As far as what the main issue is? That's a rough one. The FM brings on anxiety which in turn heightens the pain (hypersensitivity) and which makes her depression worse. It's a vicious circle.

Before she got the Tramadol she had had a full panic attack at the Doctor's office. This is the first time he has seen her have one in the many years that we have been seeing him. She doesn't have them very often, but when she does, they can be doozies. She was anxious about the results of her blood tests that day, plus she had just gotten over her period and was feeling a bit depressed, and her FM was acting up on top of that. So, she broke down in front of the doctor, and of course her being embarrassed about it only made the circle more vicious, if you will.
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1042487_tn?1275283499
Tramadol due to its proprieties is linked with withdrawal symptoms. The administration of tramadol should be used as prescripbed by the doctor. Normally twice a day due to it's 6 hours half-life. Used ''as needed'' could result into withdrawal symptoms and those include anxiety due to the SNRI activities of tramadol and it's effect on the u-opioid receptor (always the case after chronic use). I don't know how the doctor indicated to take the medication but I would take them as indicated.

Like I said the first headache episode was probable a coincidence as it didn't happen again. The chance it was a reaction to the drug are low but it is still a possibility and even could be or psychosomatic origin to the the anxiety of taking a new drug.

Always consult you doctor before making any change into your medications and directions.

M4
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Avatar_m_tn
The directions indicate to take one every eight hours, no more than three a day, "as needed" for pain. She hasn't really needed more than one. And I don't want to push it considering she's taking the Pristiq as well.
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1406964_tn?1283207466
One a day should be fine.

I'd be concerned about 3, despite your doctors directions, because so many people on the list have ended up with dependency problems when the dose rises.

It's good that you're keeping an eye on the doses for her.

Take care
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