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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 591-596

An epidemiological study of tramadol HCl dependence in an outpatient addiction clinic at Heliopolis Psychiatric Hospital


1 Department of Neuropsychiatry, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Neuropsychiatry, Nasser Institute, Cairo, Egypt

Date of Submission17-Nov-2014
Date of Acceptance16-Dec-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Mohammad M Abd Allah
Department of Neuropsychiatry, Nasser Institute, 11 Abo Elhoda Street, El Hadka, Fayoum Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163924

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  Abstract 

Objectives
The aim of this study was to detect the prevalence of tramadol HCl dependency among substance abusers, assess the severity of addiction, recognize comorbid psychiatric disorders, and identify risk factors to start tramadol abuse.
Background
An increasingly alarming phenomenon of tramadol drug abuse has been demonstrated in the Egyptian community.
Participants and methods
The studied group had 330 Egyptian substance abusers. They were subjected to the following: a semistructured interview sheet, a structured clinical interview for DSM-IV (SCID-I) to diagnose psychiatric disorders, the addiction severity index scale, and urine screening for substance abuse.
Results
The prevalence of tramadol HCl dependency according to all substance abusers was 49%. The prevalence of comorbid psychiatric disorders was 43%. On studying risk factors for tramadol abuse we found sexual purpose and pleasurable effect were the strongest predictors.
Conclusion
The increase in the prevalence of tramadol HCl dependency over other substances in the Egyptian community calls for more attention from family and educational and health institutes.

Keywords: Egypt, substance abuse, tramadol


How to cite this article:
Mohamed NR, El Hamrawy LG, Shalaby AS, El Bahy MS, Abd Allah MM. An epidemiological study of tramadol HCl dependence in an outpatient addiction clinic at Heliopolis Psychiatric Hospital. Menoufia Med J 2015;28:591-6

How to cite this URL:
Mohamed NR, El Hamrawy LG, Shalaby AS, El Bahy MS, Abd Allah MM. An epidemiological study of tramadol HCl dependence in an outpatient addiction clinic at Heliopolis Psychiatric Hospital. Menoufia Med J [serial online] 2015 [cited 2019 Dec 11];28:591-6. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/591/163924


  Introduction Top


Tramadol HCl is a centrally acting synthetic opioid analgesic used in the treatment of moderate to severe pain. It has a low affinity to opioid receptors and inhibits the reuptake of norepinephrine and serotonin. Its analgesic effect is partially blocked by naloxone [1] .

Tramadol was approved for marketing as a safe analgesic in 1995.The manufacturer initially claimed that it produced only very weak narcotic effects. Recent data have demonstrated that its opioid activity is the overriding contributor to its pharmacological activity. The inadequate product labeling and lack of an established abuse potential have led to the safety feeling of many physicians to prescribe it to recovering narcotic addicts and to be known as narcotic abusers. As a consequence, numerous reports of abuse and dependence have been received [2] .

An increasingly alarming phenomenon of tramadol abuse has been heavily demonstrated in the Egyptian community in the last 4 years [3] . Although the issue of drug abuse is not new to the Egyptian society, tramadol is associated with a wide range of abuse and illegal transactions as it is easily accessible and readily provided at cheap costs despite it being scheduled. The alleged usages of tramadol have contributed considerably to its popularity and massive use, especially among the youth and middle-aged individuals as a remedy for premature ejaculation and for extended orgasm and to increase sexual pleasure [3] .

It also seems that it is not only an Egyptian problem but also had been reported in Iran and Israel. Their low price and availability without prescription make them very popular. It relieve psychosomatic symptoms related stress [4] .

In the United Arab Emirates, the phenomenon of selling tramadol in an unlawful manner has been on the rise. Twenty-one cases of trafficking tramadol have been probed since January 2010 [5] .

Tramadol use is largely considered to be safe by physicians. The most commonly reported side effects are dizziness, nausea, constipation, and headache. However, tramadol toxicity may be underestimated; several deaths have been reported when tramadol was ingested alone in overdose [6] .

The most common symptoms of acute tramadol overdose are central nervous system depression, nausea, vomiting, tachycardia, and seizures. Higher doses can be associated with classic opioid toxicity features of coma, respiratory depression, and cardiovascular collapse [7] .

Tramadol has inhibitory actions on the 5-HT2C receptor. Antagonism of 5-HT2C could be partially responsible for tramadol's reducing effect on depressive and obsessive-compulsive symptoms in patients with pain and comorbid neurological illnesses. 5-HT2C blockade may also account for its lowering of the seizure threshold, as 5-HT2C knockout mice display a significantly increased vulnerability to epileptic seizures, sometimes resulting in spontaneous death. However, the reduction of the seizure threshold could be attributed to tramadol's putative inhibition of GABA-A receptors at high doses [8] . Higher doses of tramadol can be associated with cardiovascular collapse, coma, and respiratory depression. Each of these features should be treated accordingly, with no other specific treatment for seretonin and norepineohrine reuptake inhinibitors (SSRI) toxicity [9] .This study aims to detect the prevalence of tramadol HCl dependency among substance abusers, assess the severity of addiction, recognize comorbid psychiatric disorders, and identify risk factors to start tramadol abuse.


  Participants and methods Top


Participants

This was a cross-sectional study carried out over a period of 12 months (from 1 November 2012 to the end of October 2013). The study group comprised of 330 Egyptians participants. Their age ranged between 12 and 70 years, and both men and women are included. They fulfilled the criteria for substance abuse according to DSM-IV-TR criteria. They were selected from the outpatient addiction clinic of Heliopolis Psychiatric Hospital. The protocol was previously approved by the Ethics Committee of this institution and followed the tenets of the Declaration of Helsinki. All of the patients included in the study read the informed consent by themselves.

Measurements and questionnaire

After obtaining oral consent from each participant, the study was developed according to the standard in quality improvement system in the ministry of health and population in Egypt. Participants were evaluated using a semistructured interview sheet that gathered general data and drug habits of the patients (the type of drug, the route of administration, the dose, etc.), a structured clinical interview for DSM-IV Axis I disorders (SCID-I), which was used to diagnose psychiatric disorders, the addiction severity index (ASI) scale, which provides multidimensional assessment for the problems presented by patients with substance abuse disorders, and urine screening for substance abuse.

Statistical analysis

Data were summarized as mean and SDs and qualitative data were summarized as numbers and percentages. Comparison between two means were made using Student's t-test. The χ2 table and test were used for exhibition of data. Meanwhile, the binary logistic regression model with the enter method was used for the calculation of odds ratio and 95% confidence interval for tramadol misuse-related risk factors.The SPSS software, version 11.0.1 (SPSS Inc., Chicago, Illinois, USA), was used for the statistical analysis.


  Results Top


The study was conducted on 330 patients who came to the outpatient addiction clinic of Heliopolis Psychiatric Hospital. The study was conducted as shown previously in the Participants and methods section.

[Figure 1] shows the prevalence of substance abused in the studied group. About 43.94% (n = 145) of the patients used polysubstances, whereas patients who used one substance were as follows: tramadol 30.30% (n = 100), heroin 11.52% (n = 38), sedatives and hypnotics 4.24% (n = 14), alcohol 3.64% (n = 12), cannabinoids 3.03% (n = 10), nalbuphine 1.82% (n = 6), and cocaine 1.52 (n = 5).

[Table 1] shows the prevalence of each drug within polysubstance users.
Figure 1: The prevalence of substances abuse in the studied group according urine screening for drugs

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Table 1 The prevalence of each drug among polysubstance users

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When analyzing the frequency of each drug among polysubstance addicts, we found that the prevalence of cannabis within the group was 83.4% (n = 121), the prevalence of tramadol within this group was 43.45% (n = 63), the prevalence of heroin was 46.9% (n = 68), the prevalence of sedatives and hypnotics was 48.97% (n = 71), and the prevalence of alcohol was 19.31 (n = 28).

[Figure 2] shows the prevalence of all substance abused, with analysis of polysubstances.
Figure 2: Analysis of all substance abused by urine screening for all drugs

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When analyzing the frequency of each drug within the whole sample (polysubstance and one substance), we found that the prevalence of tramadol was 49%.

This was followed by cannabinoids 40%, heroin 32%, sedatives and hypnotics 25%, alcohol 12%, nalbuphine 0.18%, and cocaine 0.15.

[Table 2] shows the sociodemographic characteristics of tramadol-dependent patients. It was found that the main age of onset of starting tramadol abuse was 26.02 ± 12.01 years: 80% of our sample was male and 20% was female; 23% had a positive family history of psychiatric disorders and 25% had a positive family history of substance abuse.
Table 2 Sociodemographic characteristic data of tramadoldependent patients

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[Figure 3] shows that 41% had comorbid psychiatric disorders as follows: 9% suffered from schizophrenic and other psychotic disorders, 6% had anxiety disorders, 4% had obsessive compulsive disorders (OCD) and related disorders,12% had depressive disorders, 1% had bipolar and related disorders, 4% had somatic symptoms and related disorders, and 7% suffered from other diseases (3% feeding and eating disorders, 2% sleep-wake disorders, and 2% sexual dysfunctions).
Figure 3: Comorbid psychiatric disorders among tramadol-dependent patients

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[Figure 4] shows that the severity of tramadol dependence according to the ASI scale was as follows:
Figure 4: The severity of tramadol dependence according to the addiction severity index ( ASI)

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The psychiatric dimension was the most considerable problem in the studied individuals, followed by the family history dimension, the social dimension, the occupational dimension, and the legal dimension. The drug and alcohol dimension and the medical status were the least considerable problems among the various dimensions of the ASI scale.

[Table 3] shows the risk factors to start tramadol abuse as follows: 20% of the patients started tramadol abuse for its pleasurable effect (to improve mood), 19% of the patients for sexual purpose (prolongation of the time of intercourse), 13% to get more power for hard work (to delay the sensation of fatigability), 13% for pain relief, 11% as self-medication to relieve depression, 10% as self-medication to relive anxiety, 9% due to peer pressure, and 5% for other purposes.
Table 3 Risk factors to start tramadol abuse

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[Table 4] shows the relationship between the tramadol dose and the occurrence of seizures; it was found that patients who suffer from seizures as a complication were on a significantly higher dose than those who did not develop seizures.
Table 4 The relationship between the tramadol dose and the occurrence of seizures

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  Discussion Top


In the present study, opioids were the substance of major problem in 43.73% of the substance abusers (tramadol tablets were the substance of major problem in 30.30% of the participants, heroin in 11.72%, and nalbuphine in 1.82%). The present study are consistent with those of Hatata [10] , who found that 61.9% of their participants used opiates, 18.5% used cannabis, 15.8% used sedatives, and 3.9% used alcohol; results of the study of Mohamed et al. [11] showed that opioids were the substance of major problem (in 30% of their participants), especially tramadol tablets. Concerning the sex, 80% were males and 20% were females. The finding raises the following questions: the low number of women in the sample because of the low percentage of drug intake in women or because of the difficulty and the lack of availability of treatment options for women? or because of shame and stigma a woman would encounter if she joins a substance dependence treatment program?

The prevalence of male patients over female patients in this study is consistent with the WHO global survey [12] , which supports the finding that the estimated attributable burden due to illicit use of drugs is 0.8% among men and 2% among women.

The study shows that 53% of the patients were single, 36% were married, 5% divorced, and 6% widowed. Our results were consistent with Abdel-Mohsen et al. [13] , who found that 21.1% of the patients were married, 64.9% were single, and 14% were separated. Forty-three percent of the participants in our study were from the middle socioeconomic level, 28% were from the high socioeconomic level, and 24% were from the low socioeconomic level.

This result is consistent with Abulmagd et al. [14] , who found that 60% of the opioid users were from the middle socioeconomic level, 27% were from the high socioeconomic level, and12.5% were from the high socioeconomic level. Twenty-five percent of our sample had a positive family history of substance abuse; this results are consistent with those of Okasha [15] , who reported that more than one-third of the users' fathers and almost half of their relatives were substance abusers, and this indicates the effect of exposure to drug-related stimuli and the distorted models of fathers and relatives; we also detected the significant role of identification and learning in entering the dilemma of substance abuse.

The age of onset of drug abuse was 26 years. This was consistent with the studies of Hafeiz [16] , who found that in 83% of the patients, the age of onset was in the range of 21-32 years, which can be explained by the fact that most substance users are also within this age range. Forty-one percent of our sample suffered from comorbid psychiatric disorders (SCID-I).We can explain this by the fact that in some cases, substance is used as a self-medication that helps in the resolution of the symptoms together with the rewarding effect of the substance. This is consisted with Mohsen et al., that found higher percentage of the co-morbid group use tramadol more than the co-morbid group, which use sedative hypnotic and cannabis. It is also consistent with many studies that found that chronic drug intake, especially opiates, is associated with a broad range of psychiatric manifestations ranging from intensely dysphoric withdrawal symptoms, depression, impulse control symptoms, intense anxiety, psychotic symptoms, especially paranoid delusions and hallucinations, and suicidal and self-injurious behavior. These psychiatric disorders occur in addition to tolerance, withdrawal, and intoxication symptoms of the different types of drugs [18] .

Kieffer and Evans [19] reported that psychiatric manifestations co-occurring with substance dependence were interpreted as the long-term consequences of neurobiological adaptations and the opioid system dysregulation to prolonged drug use. These phenomena are a consequence of sustained m receptor stimulation by opiate drugs inducing neurochemical adaptations in opioid receptor-bearing neurons. The results extend well beyond the reward circuits to other brain areas, notably those involved in learning and stress responses. Important regions are the amygdala, the hippocampus, and the cerebral cortex, which are all connected to the nucleus accumbens. The severity of tramadol dependence according to the ASI scale was as follows: the psychiatric dimension was the most considerable problem in the studied individuals, followed by the family history dimension, the social dimension, the occupational dimension, and the legal dimension. The drug and alcohol dimension and the medical status were the least considerable problems among the various dimensions of the ASI scale. This is agreement with the study by Strakowski et al. [20] , who found that psychiatric patients who use substances had more severe symptoms due to higher rates of hospitalization, lower rates of remission during hospitalization, more experience of mixed episodes, rapid mood cycling, and persistent mood symptoms with treatment and residual symptoms during recovery. The family and social dimensions of addiction severity index (ASI) were consistent with Mohsen et al. [17] , who found that 1% of their participants had mild family problems, 38% had moderate problems, 23% had severe problems, whereas 36% had extreme problems. It can be explained by the attribution of the genetic factor [21] , which is also consistent with a review on substance dependence consequences, which states that substance use and dependence is more than a health problem; it is a formidable moral, social, and economic challenge with pandemic dimensions [21] . It was found that some patients who were dependent on tramadol suffered from seizures as a complication. We found a significant relation between the tramadol dose and the occurrence of seizures. Patients who developed seizures were on a significantly higher dose than those who did not develop seizures. The dose was found to be of no significance with regard to developing seizures as a withdrawal symptom. Ogata et al. [8] explained the reduction of the seizure threshold by high doses of tramadol due to the inhibition of GABA-A receptors. Shadina et al. [22] also reported that excessive dosage of tramadol leads to the development of seizures.


  Conclusion Top


Tramadol HCl dependency is at the top of all substances abused in Egypt, at 49%, followed by polysubstances at 43%.The prevalence of tramadol HCl dependency in men is more frequent than in women. Tramadol HCl dependency is more prevalent among young people than in the older age group. The most common reason for tramadol HCL abuse is to have a good time (pleasure effect), to have a good sexual relation (prolong the time of the intercourse), to increase the ability to work hard (delay the sensation of fatigability), peer pressure, and to relieve emotional distress in the form of anxiety and depression. The Egyptian community needs more attention from family and educational and health institutes for the prevention and the treatment of tramadol abuse.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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