Tramadol Withdrawal and Tapering Guidelines

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This is the 1st article in a series on tramadol withdrawal and addiction. Also read part 2, on coping with tramadol withdrawal symptoms and part 3, on tramadol addiction and the health risks of chronic use.

Some people have little difficulty with tramadol withdrawal symptoms, some people find them excruciating - but no matter who you are, you can ease the discomfort greatly with a sensible tapering schedule.

Tramadol affects the brain’s opioid and serotonin/norepinephrine systems. Sudden stoppage can induce opioid withdrawal symptoms and antidepressant-like withdrawal symptoms – at the same time.
You are more likely to experience severe withdrawal symptoms when discontinuing from lengthy use at a high daily dose.
By tapering sensibly you can minimize your withdrawal symptoms.

Read on for a how-to guide to tramadol tapering that should answer your questions on:

What to expect from withdrawal (symptoms, duration, etc.)
How to taper (with example schedules)
How to handle small-dose reductions

Tramadol Withdrawal: Basic Info

Why are the withdrawals so tough?

Since tramadol isn’t as strong an opioid agonist as true opioids you’d think that tramadol withdrawal would be milder than withdrawal from these stronger drugs (heroin, OxyContin, Vicodin, etc.).

However, tramadol works as an opioid and as an antidepressant-like drug, so when you stop too suddenly after chronic use, you experience opioid and antidepressant withdrawal symptoms together - which can make for a synergistically very difficult few weeks.

There are two classes of withdrawal symptoms associated with tramadol withdrawal:

Opioid-like withdrawal symptoms associated with under-activation of opioid receptors
Atypical withdrawal symptoms associated with under-activation of serotonin and norepinephrine receptors

Typical opioid based withdrawal symptoms include:

Insomnia
Anxiety
Pain (muscle aches)
Nausea
Tremors
Diarrhea
Cold or flu-like upper respiratory symptoms
Sweating
Piloerection (hair on skin standing on end)
Restless leg syndrome (Tips on Coping with Withdrawal RLS)
Agitation
Abdominal cramping
Yawning¹

Atypical withdrawal symptoms include:

Symptoms associated with the discontinuation of serotonin and norepinephrine reuptake inhibitor drugs.

Paranoia
Hallucinations
Anxiety
Panic
Confusion
Numbness and tingling in extremities
Psychosis²
Dysphoric mood
Irritability and agitation
Dizziness
Sensory disturbances (such as brain zaps...get more info at Coping with Brain Zaps)
Headache
Lethargy
Emotional instability
Insomnia
Hypomania
Tinnitus³

People coming off a high daily dose are more likely to experience atypical withdrawal symptoms. Widely quoted research from 10 years ago suggests that 1 person in 8 experiences atypical withdrawal symptoms during tramadol withdrawal, though logically, since there’s some overlap between the symptoms, you have to wonder how people tapering at home - except in extreme situations - could differentiate between the atypical and opioid based symptoms.⁴

Cold-Turkey Tramadol Withdrawal Duration

Tramadol withdrawal symptoms last longer than withdrawal symptoms from true-opioid medications.

Acute withdrawal symptoms will persist for about a week after stoppage but secondary and atypical withdrawal symptoms can persist for much longer.⁵

Your expectations and state of mind can also play a significant role. Studies show that people feeling very anxious about opiate withdrawal symptoms tend to experience more difficult withdrawals than people who feel less worried about the period.⁶

Can Cold-Turkey Withdrawal Cause Seizures?

This is a tough question to answer with certainty.

No authoritative source (that I could find) lists seizures as one of the possible withdrawal symptoms (authoritative sources such as Medline, medication package inserts, etc.)

However...

The Wikipedia page currently lists seizures as a possible tramadol withdrawal syndrome (but provides no citation for this fact!)
And if you spend much time browsing through internet forums discussing tramadol withdrawal, you will read that cold-turkey withdrawal can provoke seizures - and you’ll see this often enough to give you pause for concern.
If you stop tramadol suddenly while also withdrawing from another drug or alcohol, this assuredly does raise the seizure risk.⁷

Take-Home Message:

So this remains a disconcerting gray area. In any case, hopefully you’ll have the time and inclination for a tapered withdrawal - which is probably safer and certainly more humane.

(If any reader can answer this question with certainty, please contact me so I can amend this section.)

Tramadol Tapering Guidelines

Pharmaceutical companies that sell Tramadol caution against an abrupt stoppage after chronic use and recommend tapering as the best way to avoid or minimize withdrawal symptoms.

Unhelpfully, they offer no guidance whatsoever on the optimum taper rate.

To start with then, let’s break tramadol down into its 2 basic parts and look at tapering recommendations for these individual components.

Tramadol is composed of 2 primary component halves – both of which can induce a syndrome of withdrawal, even in isolation:

An opioid-like half (which stimulates mu opiate receptors)
An antidepressant-like half (which increases serotonin and norepinephrine levels through reuptake inhibition – similar to SSRIs and SNRIs)

So with tramadol you have to taper off an opioid and an antidepressant, at the same time.

In the following sections we will...

Examine opioid tapering and then antidepressant tapering guidelines.
Combine these 2 sets of guidelines into a series of example tramadol tapering schedules.

Opiate Tapering Guidelines

Let’s look at how to taper off opioids.

According to the Canadian Guidelines for the Safe and Effective Use of Opiates, when tapering off an opioid:⁸

You can drop by as much as 10% daily or reduce by as slowly as 5% every 2 weeks.
People anxious about withdrawals or dealing with addiction issues should choose a slower rate of taper.
Slow the taper rate by half once you reach a third of your starting dose.
If experiencing severe withdrawal symptoms, hold on a dose until they subside.

For straight opioids and non-addicted patients seeking to discontinue use, common practice is a 2 to 4 week taper of 25% to 50% of the total starting dose per week.⁹

This may be too fast for anyone who is addicted and doing an outpatient self-directed taper (since faster tapers are associated with a higher risk of non-completion).¹⁰
Faster tramadol tapers are further complicated by the medication’s antidepressant-like components (see below).

Antidepressant Tapering Guidelines

According to the Royal College of Psychiatrists (UK) for SSRI/SNRI antidepressant tapering:¹¹

Go slow
If you’ve been using for less than 8 weeks, taper down over 1 to 2 weeks.
If you’ve been using for up to 6 months or so, taper down over a 6 to 8 week period.
If you’ve been using chronically, don’t reduce your total dose by more than 25% every 4 to 6 weeks

Note – these guidelines are targeted at people treating depression and taking straight SSRI/SNRI medications – not for tramadol.

5 Example Tapering Schedules

Your tapering needs will vary dramatically depending on your age, history, genetics, physical health, addiction status, mental health and other factors – and so you should develop your own tapering schedule in conjunction with your doctor.

Note - It’s easier to taper by percentages, rather than by set amounts. While it might seem logical to taper by 10 mg per week this is hard on your body. If you started at 400 mg a day, a 10 mg reduction would be 2.5% reduction in the first week and by the time you got down to 20 mg and went to 10 mg, you’d be doing a 50% reduction in the last…your brain can definitely tell the difference!

These tapering schedules assume a multi-year history of use and a daily starting dose of 800 mg per day (twice the maximum daily recommended intake). Adjust accordingly based on your own situation and starting dosage point.

Reducing by 10% Per Week (a 35 Week Plan)

Week 1 – 720 mg per day
Week 2 – 648 mg per day
Week 3 – 583 mg per day
Week 4 – 524 mg per day
Week 5 – 472 mg per day
Week 6 – 425 mg per day
Week 7 – 382 mg per day
Week 8 – 344 mg per day
Week 9 – 309 mg per day
Week 10 – 278 mg per day
Week 11 – 250 mg per day
Week 12 – 225 mg per day
Week 13 – 202 mg per day
Week 14 – 182 mg per day
Week 15 – 164 mg per day
Week 16 – 147 mg per day
Week 17 – 132 mg per day
Week 18 – 119 mg per day
Week 19 – 107 mg per day
Week 20 – 97 mg per day
Week 21 – 87 mg per day
Week 22 – 78 mg per day
Week 23 – 70 mg per day
Week 24 – 64 mg per day
Week 25 – 57 mg per day
Week 26 – 51 mg per day
Week 27 – 46 mg per day
Week 28 – 42 mg per day
Week 29 – 38 mg per day
Week 30 – 34 mg per day
Week 31 – 30 mg per day
Week 32 – 27 mg per day
Week 33 – 24 mg per day
Week 34 – 22 mg per day
Week 35 – Jump off

Example 2 - A 28 Week Program of Reducing by 20% per week

Reducing by 20% per week and cutting down to a 10% reduction per week once at a third of your original dose.

Week 1 – 640 mg per day
Week 2 – 512 mg per day
Week 3 – 410 mg per day
Week 4 – 328 mg per day
Week 5 – 262 mg per day
Week 6 – 236 mg per day
Week 7 – 212 mg per day
Week 8 – 191 mg per day
Week 9 – 171 mg per day
Week 10 – 155 mg per day
Week 11 – 139 mg per day
Week 12 – 125 mg per day
Week 13 – 113 mg per day
Week 14 – 102 mg per day
Week 15 – 91 mg per day
Week 16 – 82 mg per day
Week 17 – 74 mg per day
Week 18 – 67 mg per day
Week 19 – 60 mg per day
Week 20 – 54 mg per day
Week 21 – 49 mg per day
Week 22 – 44 mg per day
Week 23 – 39 mg per day
Week 24 – 35 mg per day
Week 25 – 32 mg per day
Week 26 – 29 mg per day
Week 27 – 26 mg per day
Week 28 – 23 mg per day

Example 3 - A 12 Week Program

Reducing your daily dose by 20% every 3 days and then slowing to a 10% reduction every 3 days once at a third of your starting dose.

Day 1 – 640 mg
Day 4 – 512 mg
Day 7 – 410 mg
Day 10 – 328 mg
Day 13 – 262 mg
Day 16 – 236 mg
Day 19 – 212 mg
Day 22 – 191 mg
Day 25 – 171 mg
Day 28 – 155 mg
Day 31 – 139 mg
Day 34 – 125 mg
Day 37 – 113 mg
Day 40 – 102 mg
Day 43 – 91 mg
Day 46 – 82 mg
Day 49 – 74 mg
Day 52 – 67 mg
Day 55 – 60 mg
Day 58 – 54 mg
Day 61 – 49 mg
Day 64 – 44 mg
Day 67 – 39 mg
Day 70 – 35 mg
Day 73 – 32 mg
Day 76 – 29 mg
Day 79 – 26 mg
Day 82 – 23 mg

Example 4 – A 7.5 Week Program

Reducing by 20% every 3 days.

Day 1 – 640 mg
Day 4 – 512 mg
Day 7 – 410 mg
Day 10 – 328 mg
Day 13 – 262 mg
Day 16 – 236 mg
Day 19 – 189 mg
Day 22 – 151 mg
Day 25 – 171 mg
Day 28 – 155 mg
Day 31 – 121 mg
Day 34 – 97 mg
Day 37 – 77 mg
Day 40 – 62 mg
Day 43 – 49 mg
Day 46 – 40 mg
Day 49 – 25 mg
Day 52 – 20 mg

Example 5 - A 5 week Program

Reducing your dose by 10% every day. A program like this might be something to consider if detoxing off a relatively short period of use, such as under 6 months of use.

Day 1 – 720 mg
Day 2 – 648 mg
Day 3 – 583 mg
Day 4 – 524 mg
Day 5 – 472 mg
Day 6 – 425 mg
Day 7 – 382 mg
Day 8 – 344 mg
Day 9 – 309 mg
Day 10 – 278 mg
Day 11 – 250 mg
Day 12 – 225 mg
Day 13 – 202 mg
Day 14 – 182 mg
Day 15 – 164 mg
Day 16 – 147 mg
Day 17 – 132 mg
Day 18 – 119 mg
Day 19 – 107 mg
Day 20 – 97 mg
Day 21 – 87 mg
Day 22 – 78 mg
Day 23 – 70 mg
Day 24 – 64 mg
Day 25 – 57 mg
Day 26 – 51 mg
Day 27 – 46 mg
Day 28 – 42 mg
Day 29 – 38 mg
Day 30 – 34 mg
Day 31 – 30 mg
Day 32 – 27 mg
Day 33 – 24 mg
Day 34 – 22 mg

Please note - these are example tapering schedules to illustrate how you might set up your own reduction schedule. These are not based on any medical advice, though they are based on common practices and they are fairly conservative.

Increasing Your Odds of Tapering Success

Modify your plan as needed. You won’t know how you’ll feel on any given tapering plan until you get into it, so just pick a plan that makes sense to you, get your doctor’s OK and try it out, and if it isn’t working for you, then slow or accelerate the reductions accordingly.
It’s OK to go slow. You are better off taking things slowly and getting to zero successfully than rushing through and giving up when you feel overwhelmed. If withdrawal symptoms are bothering you, give yourself an extra few days or a week on any given dose - time to acclimatize - before continuing with your reduction plan.
Try to space out your daily doses in a way that keeps your blood plasma levels relatively stable. This facilitates brain recovery and it also helps you curb your addiction to the high. So for example, instead of taking 2 in the morning, 2 at lunch and 4 in the evening (to get a little high) and a couple more before bed, you’d be better off taking doses of 2 pills, every 4 hours or so.
If you have trouble resisting the temptation to take just a little bit more or a little bit early, put a loved-one in charge of handing out your medications on a set schedule. You provide a written schedule in advance, they know not to deviate from your instructions and you don’t have any pills lying around to temp you.

Practical Matters – Tapering in Small Increments

If you’re tapering in increments of 25, 12.5 or 6.25 mg per reduction, you can probably get by with a pill splitter and a steady hand – splitting pills into 2, 4 or 8 segments. (Though pills segments exposed to open air may oxidize and lose potency, which may be a concern if splitting pills into very small segments for use over many days.)

But if you decide to do a long and slow tapering schedule, how are you supposed to reduce your doses by very minute amounts?

Well, when little kids need very small medication doses, what do they get(?)…syrups with meds in suspension – so when you need very small and easy to measure doses of diluted medications, this is a practical way to do it.

You can either buy tramadol already sold in suspension, or if you can’t get that, you may want to consider making your own suspension (though get medical advice before you do this).

Tramadol in Suspension - Synapryn

Ask your doctor about a possible prescription for tramadol in suspension (sold under the name Synapryn).¹²

This comes in either a 5 or 10 mg tramadol per ml oral suspension. If you get the less potent dose (the 5 mg per ml dose) and you use an accurate small-dose oral medication syringe for medication (easily found in well stocked pharmacies) you can measure a dose out fairly easily to the exact mg.

Note - If you can’t find an oral medication syringe that’s precise enough in your local pharmacy, these can be ordered online fairly easily; even Amazon carries a selection.

Make Your Own Suspension

If you can’t buy Synapryn or if you’d prefer to make a less potent suspension, you can always talk to your doctor or pharmacist about how to make your own suspension.

A Warning!

Please remember that this isn’t medical advice nor are we qualified to provide medical advice. Always talk to your doctor before making any changes to your medication regimen. There’s nothing very complicated about making a simple medication in suspension, but if you do this in your own kitchen you have to be confident in your ability to follow directions and do basic math. This is something you do at your own risk and if you make a serious mistake you put yourself at risk of overdose. If you’re not sure about your ability to do this, don’t try it, or better yet, ask a pharmacist to prepare a suspension for you.

Here are directions for making a 5mg/ml tramadol oral suspension from Nationwide Children’s Hospital in Columbus Ohio.¹³

Ingredients

Six 50 mg tramadol tablets (not extended release)
60 ml of Ora-Blend SF*

*This is a suspension vehicle that keeps the active ingredient (in this case tramadol) evenly distributed throughout the suspension. It also prevents the degradation of the active ingredient through oxidization, for a longer shelf life. You can buy Ora suspension products either as a neutral flavor or as a sweetened flavoring on Amazon or at well stocked pharmacies.¹⁴

Directions

Use a medicine mortar and triturate to grind the pills to a fine powder. (If you don’t have a mortar and triturate you could probably use a bowl and the back of a spoon to good effect – or you could pick up a medical set for only a few dollars at a well stocked medical supply store.)
Once you have a fine powder, add in a small amount of the suspension liquid and then stir that around until you get a completely smooth paste.
Continue adding the suspension liquid in small increments, stirring well after each addition, until you’ve added the whole 60 ml amount.
Transfer to a storage container with a tight fitting lid. Refrigerate for up to 90 days.

Precaution: you have enough medication in this mixture to seriously harm a small child. Label well and secure out of the reach of little-ones!

To use this suspension:

1 teaspoon or 5 ml = 25 mg tramadol
1/5 teaspoon or 1 ml = 5 mg tramadol
0.2 ml = 1 mg tramadol

With a good oral medicine syringe you should be able to use this suspension for dose reductions to as small 1 mg.

Water Taper (Liquid Taper)

There is no information (that I could find) endorsing the validity of a water taper for tramadol, but it should logically work. Please consult with your doctor before making any changes to your medication regimen and specifically before trying the water taper method. This is a hypothetical tapering method.

On internet forums and lay-person websites, water titration is commonly recommended for benzodiazepine tapering (given the difficulty inherent in making minute dose reductions you have to dilute the medication to make tapered reductions at all possible.)¹⁵

Tramadol is soluble in water, so you should be able to make a solution of water and tramadol for easier dose reductions (instant release forms of tramadol only).

An example 1mg/ml tramadol solution

Ingredients

Two 50 mg tramadol tablets (not extended release)
100 ml water

Methods

Crush the two 50 mg tramadol tablets in a mortar into a fine paste
Add a small amount of water to make a paste and then continue to add water slowly while stirring.
Transfer to a lidded container and shake vigorously for a few moments, or until the tramadol is completely dissolved into the water.
Measure out an appropriate dose. 1 ml of the solution equals 1 mg of tramadol.

Cautions

Since this would not look like medicine you have to be very careful to keep your finished mixture well labeled and out of reach of children.
The shelf life for such a mixture is unknown.
Please remember this is lay-information, not medical source information. Talk to your doctor about the safety and practicality of a liquid taper and get educated before you start. This method is commonly used for Suboxone, so if you Google ‘suboxone liquid taper’ you’ll find more info that might help.

References

Page last updated Dec 11, 2014

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Tramadol Detox – Withdrawal and Tapering Guidelines