Tramadol Contraindications: When is it Contraindicated?

Tramadol Contraindications: When is it Contraindicated?

When the pain is moderate or severe, well-established pain relievers might not help. For those patients, tramadol can be effective treatment choice. This opioid analgesic that binds to opiate receptors in the central nervous system has been used for pain management for years but with limited usage due to contraindications and side effects. (1-2)

Habit forming, seizures, and serotonin syndrome are possible side effects that you should be careful of if you use tramadol. Moreover, hypersensitivity, breathing problems, and other conditions can be life-threatening, so tramadol usage is not recommended. (1-2)

In this article, you can find all about tramadol contraindications. Read it to find helpful information on when tramadol cannot be used and what you should tell your doctor before prescribing medication for your pain.

Tramadol: How Does it Work, and How is it Used?

Before explaining when and why tramadol is contraindicated, let’s briefly go through its mechanism of action and recommendations.

Tramadol is an analgesic used for severe pain when alternative analgesics are not enough to relieve moderate or severe pain. In the body, tramadol is converted into two metabolites. One of them is M1 metabolite, an active form with a stronger affinity to bind to opiate receptors in the brain. As a result, by binding to the receptors, signals for pain are interrupted, and pain is decreased. (4-6)

Adults and children over 12 can use tramadol, while for those younger than 12, tramadol is contraindicated. Tramadol is available as an immediate and extended-release formulation in tablets, capsules, and syrup. (1-3)

Tramadol is taken every day at the same time, despite the formulation, with or without food. (3)

When Shouldn’t You Use Tramadol?

As with other medications, in some patients, tramadol or other drug components may cause allergic reactions. The allergic reaction usually occurs after the first dose with symptoms such as swelling of the face, tongue, or throat, rash, and difficulty swallowing or breathing. Rarely the hypersensitivity reaction can be fatal. (1-3)

If you notice any of the allergic signs, stop using tramadol immediately and call your doctor for medical help.

Aside from hypersensitivity, tramadol can’t be used:

  • If the Patient is a Child, Younger than 12 Years of Age or Younger than 18 Years, and has undergone Tonsillectomy and/or Adenoidectomy

Tramadol is contraindicated in this group of patients due to ultra-rapid metabolism and the risk of respiratory depression.

Tramadol absorption is rapid, and 75% becomes available in the body. It is metabolized in the liver with the activity of two enzymes, whereas CYP2D6 is one. In 7% of children, CYP2D6 is genetically changed and has reduced activity. In these individuals, tramadol becomes more available in plasma for 20% more than regular. (3, 7)

In some children, about 5% tramadol is metabolized faster into M1 metabolite. So these patients are called ultra-rapid metabolizers, in which higher doses of the active ingredient are available in the body. (3, 7)

Higher levels of tramadol and its M1 active metabolite increase the risk of overdose with possible signs of confusion, shallow breathing, or extreme sleepiness. (2)

Respiratory depression is life-threatening when breathing becomes slow or shallow. In such a condition, the oxygen supply to the body will be insufficient, the level of carbon dioxide will rise, and the acids in the body will increase. (8)

Lack of oxygen and increased carbon dioxide levels make the patients sleepy. The risk is higher at the treatment initiation and when increasing dosing. (2)

  • In Case of Significant Respiratory Depression

Respiratory depression, as explained earlier, may rarely occur in other patients as well, even in recommended doses. It is a well-known opioid effect that depends on the intaken dose, how fast it is absorbed in the body, and how the individual tolerates the opioid. (1, 2, 9, 10)

In opioid-naive patients (those who haven’t used opioids before) with acute pain, respiratory depression is more likely to occur. Depression can happen in any severity; if the respiratory depression is serious, it can cause hypoxic brain injury, even death. (9-10)

As a most serious side effect of acute opioid therapy, always follow your doctor’s dosage recommendation to avoid respiratory depression. (2)

  • If you Have Acute or Severe Bronchial Asthma, COPD, or other Breathing Problems

Patients who have significant breathing problems such as:

  • Asthma,
  • Chronic obstructive pulmonary disease (COPD),
  • Cor pulmonale (right side of the heart fails to work),
  • Substantially decreased respiratory reserve,
  • Hypercapnia,
  • Hypoxia,

And take tramadol, are at increased risk of decreased respiratory drive, including apnea. (1, 2, 4)

Asthma is an inflammatory lung disease in children and adults when the patient has difficulty breathing and causes breathlessness, wheezing, chest tightness, and coughing at night or early in the morning. In COPD, patients also have breathing-related problems with airflow blockage. It includes emphysema and chronic bronchitis; unlike asthma, COPD is irreversible. (11-12)

Patients with breathing difficulties are at risk when taking opioid medication, including tramadol, because tramadol can depress breathing.

So if you have asthma, COPD, or other lung diseases, tell your doctor before you start using tramadol. (1-2)

  • If you have Gastrointestinal Obstruction, Including Paralytic Ileus

One of the effects that tramadol can cause is a spasm of the sphincter of Oddi. The Sphincter of Oddi is a muscle that regulates the communication between the pancreas and biliary duct with the small bowel. When the muscle opens and closes, it controls the flow of the bile from the liver and the pancreatic juice, which are necessary for food digestion. (1, 2, 13)

If tramadol causes muscle spasms, the bile and pancreatic juice will not flow through and cause stomach pain. Nausea, vomiting, fever, diarrhea, or chills are other symptoms when the sphincter of Oddi does not work. Backed-up pancreatic juice can cause pancreatitis, an inflammation of the pancreas that can reduce its functionality (digestion enzymes and insulin production). (13)

People with some blocking in the intestine or muscles that move food through the intestine are paralyzed (paralytic ileus), and are contraindicated from using tramadol. (1-2)

  • If you use Monoamine Oxidase Inhibitors (MAOIs)

People who treat depression, panic disorder, or other disorders with MAOI (e.g., phenelzine, isocarboxazid, or selegiline) should not use tramadol due to drug-drug interaction, according to the Food and Drug Administration. (1-2) MAOIs are medications that help the body increase serotonin levels. These medications block the enzyme monoamine oxidase so the neurotransmitters, including serotonin, cannot be broken down. Increased serotonin levels can lead to serotonin syndrome, a life-threatening condition. (14-15)

In addition to serotonin syndrome, the interaction of tramadol and MAOIs can result in opioid toxicity, including respiratory depression and coma. Therefore, concomitant use of tramadol and MAOIs is not recommended. In addition, tramadol is contraindicated even for 14 days after MAOI discontinuation. Therefore, before getting your prescription for pain medication, tell your doctor if you use MAOI. (1, 2, 16)

Tramadol Side Effects and Warnings

Tramadol has other possible side effects that are acceptable and manageable, so, not a reason for contraindications. However, if your doctor prescribed tramadol for your pain, take care if some of the following side effects occur.

The most common side effects of tramadol reported in clinical trials with an incidence ≥15.0% are dizziness/vertigo, headache, somnolence, nausea, constipation, vomiting, and pruritus. In addition, if you use extended-release, you may experience flushing, vomiting, insomnia, and dry mouth. (1-2)

Like other opioids, tramadol has a high potential for addiction, abuse, and misuse. In some patients, tramadol can initiate seizures, especially in patients with epilepsy, head trauma, alcohol withdrawal, metabolic disorder, or CNS infection. In addition, in patients with a history of misuse or on antidepressant or tranquilizer therapy, tramadol should be used with caution due to suicidal thoughts or behavior that may cause. (1-2)

The side effects listed above are not a complete list of side effects. Read the Medication Guide carefully, and discuss with your doctor all your concerns.


Tramadol can relieve severe pain when other non-opioids are not effective. It should be used as short as possible in the lowest effective dose to prevent side effects. Therapy introduction and discontinuation should be step by step to avoid respiratory depression.

Be careful about respiratory depression if you use tramadol for the first time. Never give tramadol to a child younger than 12. Tell your doctor if you have asthma or other breathing problems and the medications you use.

Read in detail the Medication Guide about tramadol contraindications, possible side effects, and warnings. Knowing the medicine you take will keep your treatment safe and effective.

See Also

Tramadol Side Effects

Tramadol Interactions

Gabapentin Interactions

Shingles Vaccine Side Effects

Lisinopril Contraindications

Is Ibuprofen a Blood Thinner?

Do Blood Thinners Affect Oxygen Levels?

What is Creatinine Level in Blood Tests?

Acetaminophen Contraindications

Aspirin Contraindications

  1. Food and Drug Administration, Ultram (tramadol hydrochloride) tablets, for oral use, 2019 Oct,
  2. Food and Drug Administration, ULTRAM® ER (tramadol hydrochloride) extended-release tablets for oral use, C IV, Prescribing information, 2017 Aug,
  3. MedlinePlus, Tramadol, 2022 Jan,
  4. National Library of Medicine, Tramadol, 2022 Jun,,equipment%2C%20should%20avoid%20taking%20tramadol.
  5. M. Subedi, S. Bajaj, M. S. Kumar, Mayur YC, An overview of tramadol and its usage in pain management and future perspective, Biomedicine & Pharmacotherapy, 111 (2019) 443–451
  6. F. Rodieux, L. Vutskits, K. M. Posfay-Barbe et al., When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children, Front Pharmacol. 2018; 9: 148., 2018 Mar,
  7. Marcia L. Buck, PharmD, Tramadol: Weighing the Risks in Children, Pediatric Pharmacotherapy, 2015 Oct,
  8. J.Ramirez, N.J.Burgraff, et al., Neuronal mechanisms underlying opioid-induced respiratory depression: our current understanding, JPN Journal of Neurophysiology, 2021 May,
  9. Jane C. Ballantyne M.D., Complications Associated with Systemic Opioids and Patient-controlled Analgesia, Complications in Regional Anesthesia & Pain Medicine, 2007
  10. A.H. Ghodse, S. Galea, Side Effects of Drugs Annual 32, Side Effects of Drugs Annual, 2010
  11. Centers for Diseases and Control Prevention, Learn How To Control Asthma, 2021 Jul,,What%20Is%20Asthma%3F,or%20early%20in%20the%20morning.
  12. Centers for Diseases and Control Prevention, Chronic obstructive pulmonary disease (COPD), 2022 Apr,,Americans%20who%20have%20this%20disease.
  13. Cleveland Clinic, Sphincter of Oddi dysfunction, 2018 May,
  14. Mayo Clinic, Serotonin Syndrome, 2022 Jan,,cause%20death%20if%20not%20treated.
  15. Mayo Clinic, Monoamine oxidase inhibitors (MAOIs), 2019 Sept,,Tranylcypromine%20(Parnate)
  16. Drugbank online, Tramadol, 2023 Jan,

Follow us