Tramadol is a synthetic, centrally acting analgesic and acts as a weak µopioid receptor agonist as well as a serotonin and norepinephrine reuptake inhibitor. The drug is easily available and widely prescribed for pain management. It has very high potential for being abused by opioids-dependent subject because of easy availability of tramadol. The case above highlighted the misuse of Tramadol by a 25 years old female patient who were suffering from a distressful situation. Her response to emotional turmoil with negative coping. The case also highlighted the misuse and diversion of Tramadol may become a bigger challenge in the future and there is a need to effectively regulate the distribution of this medication, and apply the appropriate safeguards, to prevent diversion.

The use of opioids has raised major concern in recent years impacting all groups of people, specifically within certain demographics such as age, race, and gender. Moreover, there are concerning trends among women. Women use prescription opioid pain medications for longer periods and are prescribed higher doses than men. Women are more likely to report chronic pain, compared to men and those patients suffering from pain are likely to receive an opioid prescription and opioids even in small doses can cause dependence.[1-5]

A 25 year old female, graduated, recently married, house-maker presented with chief complains of Weeping episodes, aggression, self inflicted harm, nausea, Pain in muscles, sweating, shivering, restlessness and suicidal threats since last two days. The initial presentation of the patient in the psychiatric unit, by the family members seemed quite unusual as her attendants were not very clear and open about the various complaints and symptoms of the client. As stated by the client, "Five years back, I could have never imagined that an easy and quick option chosen by me to relieve myself of the emotional pain and suffering can put me in such an embarrassing situation in the future where I may have to confess in front of everyone, that I have been using certain injections/ pain killers (tramadol) since last three years. According to the client, 7 years back, when she was pursuing graduation she had a relationship with a guy. Although desperate to get married to him, her parents completely opposed the relationship. while going through this emotional turmoil, she started finding out the ways and means to get out of this emotional pain. Being a daughter of health worker, the client was familiar with the effect of various medicines usually present at home .One day, while in distress because of lost relationship, she consumed couple of tramadol 50 mg tablets. That night, the she slept smoothly after a month's long disturbance. The relaxation and the pleasurable experience that the client felt by consuming those tablets lingered in her mind for a longer time. Thereafter, she started consuming these tablets on daily basis and the daily consumption increased from 2 to 3 ,4 and 5 tablets ( 2 morning and 3 evening) of tramadol 50 mg. As the time passed by, she started having frequent anger outburst, irritability, sadness of mood, interpersonal issues, cravings for tramadol tablets for which she was continuing taking these tablets. Three years back, situation aggravated, when her parents selected a guy for her to get married. Although initially she refused, but eventually she got married. To her surprise, after getting engaged, her usage of tramadol tablets, decreased, Few months after the marriage, were good but later on she started having various issues, with the family members. Her husband tried a lot to keep her happy but she always had numerous complaints, including inattention, along with gastritis and back pain, mood swings. Initially they visit to a local physician for the problem of gastritis, they she was complaining of generalized aches and pains after which she visited an orthopedician which resulted in getting tramadol injection on the prescription. After that, she often started complaining of pains and aches and would frequently visit hospital and clinics to get these injection prescribed. Although warned by the various medical professionals about the harm associated with these injections, the number of injection increased from once a week, to twice, thrice and daily within 2 months. This continued for 2 years, .Two days back, someone known to the family of the client, disclosed this information to the family. From last two days, she had been forcibly stopped to take injection. Then patient were complaining of depressed mood, decreased sleep, decreased appetite, anhedonia, and increased guilt. Weeping episodes, aggression, self inflicted harm, nausea, Pain in muscles, sweating, shivering, restlessness and suicidal threats. Then patient was admitted in the psychiatric unit where while undergoing detoxification on the inpatient psychiatric unit, where the patient experienced signs and symptoms of opioid withdrawal (tremulousness, hyperhidrosis, lacrimation, agitation, anxiety, diarrhea) in addition to the above mentioned symptoms.  Initially Injectable lorezepam was given as patient was very anxious and irritable. Buprenorphine 2mg/naloxone 0.5mg was administered every 2 hours as needed and a total of 3 doses were given to the patient over the first 24 hours along with oral benzodiazepines.  After which withdrawals symptoms reduced. Then next day when patient was feeling better the she was sent for a psychological assessment and motivational interviewing which revealed that then her premorbid personality was suggestive of cluster B traits. She had no history of other medical conditions, took no medications, and had no known allergies.  After discharge, the patient transitioned to the outpatient treatment center and continued to be maintained on the same buprenorphine/naloxone dose with negative urine drug screens and self-reports of abstinence.

Tramadol is a synthetic, centrally acting analgesic and acts as a weak µopioid receptor agonist as well as a serotonin and norepinephrine reuptake inhibitor. The drug is easily available and widely prescribed for pain management.[6] Tramadol is being used in patients with medical disorders especially pain disorders. It has very high potential for being abused by opioids-dependent subject because of easy availability of tramadol from pharmacies. [7,8]

The case above highlighted the misuse of Tramadol by a female patient who were suffering from a distressful situation. Studies found that most of the females often report using substances to cope with negative emotions which increases their risk of substance abuse.[9,10]

To conclude, tramadol has the potential for dependence and as medical practitioners we should be aware of the possibility of tramadol dependence and should resort to optimal and judicious use of such a substance.  Its misuse and diversion may become a bigger challenge in the future There is a need to effectively regulate the distribution of this medication, and apply the appropriate safeguards, to prevent diversion.

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