Old doc, new drugs: Tapentadol versus tramadol

Casey Parker

29/08/2018 11:16:13 AM

Dr Casey Parker examines which is best to prescribe.

Tapentadol versus tramadol: Which is better to prescribe?
Tapentadol versus tramadol: Which is better to prescribe?

If you’re like me (as a rural GP), you probably started noticing a trickle – and then a flood – of patients being discharged from big city hospitals on this new drug tapentadol.
Now, I am a simple rural doctor. When I saw the name tapentadol, I immediately assumed that it was a new version of tramadol, but with more letters to confuse the chaps over at the patent office.
I was sort of correct. These drugs are very similar, so it’s worth comparing them.
Tramadol is possibly one of the most maligned medications in a GP’s toolbox.
It’s an opioid used for pain management. But it’s unpredictable, with a lot of side effects, and often just doesn’t provide much relief. It’s an older drug, dating back to 1977.
Tramadol is a prodrug. That means, on its own it doesn’t do much of anything. It gets metabolised in the liver by the cytochrome p450 enzymes into a few active chemicals.
But here is the problem – the actual amounts of each of the active metabolites is a bit of a genetic lottery. Depending on the makeup of your cytochromes, you may get:

  • a bunch of destramadol (aka M1), which has a strong mu-opioid receptor affinity and acts like morphine
  • some venlafaxine, which is a serotonin/noradrenaline reuptake inhibitor (SNRI)
  • a mixture of both of the above
  • a whole bunch of other receptors, such as N and M acetylcholine, direct serotonin agonists, and the list goes on.
To some extent, you can ask a patient what effects they felt if they had a dose of tramadol previously.
In my experience, you get pretty clear likes or aversion to tramadol. The most common reply is along the lines of, ‘Oh, the drug that made me spew’.
Then then there is the risk of serotonin syndrome and seizures. This may come about for a few reasons:
  • Older patients or people with renal/liver disease don’t clear metabolites and they build up
  • Combining it with other serotonin norad-active drugs like antidepressants leads to a double whammy
  • Patients with little metabolism to M1 take more and more doses to achieve analgesia and end up with a bunch of the SNRI metabolites in their systems
All in all, a tricky drug to use, since different patients may have a totally different experience with the drug.
Now let’s introduce tapentadol, first released in 2008. It’s the new and improved version of tramadol, which is arguably not hard to do.
So, how is the new kid on the block different?
Tapentadol is not a prodrug – it does not rely on metabolism to get it working. So it is what it says on the box – an opioid analgesic. In addition:
  • it has a strong mu-opioid receptor agonist effect, similar to oxycodone
  • it has noradrenaline reuptake inhibitory effects, but not much effect on serotonin reuptake, which makes it a little cleaner
  • there are no active metabolites yet known – so that sounds cleaner, too.
That all sounds nice and neat. A cleaner, direct-acting opioid with fewer side effects. But there must be a catch, right? There always is.
The biggest issue is that there is just not enough data available about the safety or efficacy of tapentadol. In the trials used to get it registered, the drug was only just better than a placebo for chronic pain. We need to see some real-world safety data and clinical outcome studies to say exactly how much benefit this drug has.
As with any potent opioid, tapentadol is to be used with caution in patients with respiratory failure, other sedatives or noradrenergic agents. It needs to be avoided for at least two weeks after ceasing monoamine oxidase inhibitors (MAOIs) such as moclobemide (though this is rarely used in Australia).
Tapentadol side effects are predictable: constipation, nausea and vomiting with some dizziness in up to a third of patients.
The risk of developing tolerance and potential for abuse or diversion is likely to be similar to other opiates once the word gets out. This is definitely one to watch carefully when prescribing.
In summary
Tapentadol is probably better than tramadol. Which is akin to stating it is funnier than the MIMS – it’s a low bar. It has a more predictable pharmacology, but the evidence is not yet in. We just don’t know the full risk/benefits in 2018.
And don’t be fooled by the ‘less abuse potential’ argument; it is a new drug and the same statement was made about oxycodone many moons ago.
Watch this space.
This article is adapted from Dr Casey Parker’s blog, Broome Docs.

drug mechanisms Tapentadol tramadol

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NEVILLE LUDBEY   31/08/2018 10:33:13 AM


Nadette   31/08/2018 1:13:40 PM

Thanks Casey, a great read, not often I get a laugh out of analgesic education!

Neel   31/08/2018 2:10:03 PM

Nice article Casey. Very easy to read.

Maria   31/08/2018 3:27:10 PM

Wow, you made that make sense .. answered a lot of questions! Thank you

Jana   2/09/2018 11:15:15 AM

Thanks Casey, good information !

Andrew Lane   4/09/2018 11:11:22 PM

Nicely done. Thanks.

Natalia   5/10/2018 12:48:22 PM

Great article! Look forward to seeing more from you in NewsGP.

Kamlesh meghwal   22/10/2018 11:16:04 PM


Cliff   24/10/2018 5:14:01 PM

Have been on Tapentadol 200mg slow release for chronic knee pain and arthritic pain for approx 6 months. I tend to have addictive traits. Smoker until 6 yrs ago. Drinker
Moderate most days yet i can not say the Tapentadol has any addictive draw to me. Even now i can stop taking it for a few days without withdrawls except return of increased pain. Anyway better than the highly addictive Oxy meds.

Charlotte   8/11/2018 2:45:34 AM

Wow, this was an interesting read! I'm currently on Tramadol, and I've been for nearly 2 years for chronic pain with 2 herniated discs in my neck (C4/C5, C5/C6), impingement syndrome in my left shoulder and so forth. I see now that I am in the latter category, the one that builds up tolerance. And that's a shame, because I'm terrified of drugs like these, but my pain was overwhelming. When I started taking it, I could do with 1-2 a day, and I had days where I didn't take any- mainly because I was too scared, not because the pain had lessened. Now my dose is anywhere from 3-5 in 24 hours, where 5 is a really bad day. I never take 2 at once, being a scaredy cat, and I monitor very intently when I took the pill. I was considering talking to my doctor about going cold turkey, but honestly I'm afraid of the pain becoming worse - and then have no form of lessening it. Should I try this other one, or just quit it all and see how it goes? Been with chronic pain for nearly 5 years now, and I'm 25 years. I'm tired of being in pain and tired of being tired.. Thank you for this post! Very informative, and a fun read.

Stevie   9/11/2018 8:28:10 PM

Is there any ssri or ssni in this drug like tremSR ?

Sandra   12/03/2019 1:46:41 PM

Charlotte, you poor girl, 25 and in so much pain! ☹
I've just had knee surgery, the hospital gave me tapentrool IR 50mg for the pain but I haven't taken any as I find all these things make me sick lol
But what I have started taking is ( now don't laugh, it's working!) Is ..... wait for it..... gelatine! I did the same after shoulder surgery a few years ago and that also worked unbelievably well, yep just plain old gelatine, get on the net and have a look at all the info on this , you will be surprised, I use about 1/2 a sachet a day , have used no painkillers for my knee at all.
Good luck I hope you get this as this post is fairly old.

Duncan   13/07/2019 2:46:19 PM

I have been experiencing pain and tingling in my left arm, which was later diagnosed as from a pinched nerve around C7 in my neck. Had Endone for 2 weeks for pain management, did not like it. Tried twice unsuccessfully to have Spinal MRI, even after taking 2 Endone before my second attempt. GP prescribed Targin - did not like, very wary of addictive properties of these oxycodones. While waiting to see neck specialist, GP suggested Palexia 50mg sustained release (Tapendatol). Started with 2 at night, got down to 1 per night within a fortnight. Used 2 hours before successful MRI. When I finally got results from neck specialist he deferred possible surgical procedure due to my controlled pain situation. Have now been off Palexia for over a week. Have 2 paracetamol tablets a day. Feel confident now that Palexia's Tapendatol worked well in my situation with less side effects than the oxycodones.

Nick   31/07/2019 9:45:49 AM

The mu-opioid receptor effect is much weaker than oxycodone. That’s what makes it safer, less addictive, and less euphoric. It is very effective, however, because unlike oxycodone it also utilizes noradrenaline.

Marie   18/10/2019 10:55:34 PM

My has had chronic pain for over five years tried everything from dry needling nerve blocks nothing worked her doctor gave her palexia to try . First time she took it she was pain free so excited. But this was the start of hell for me she got euphoric feeling from it then she started taking higher does she would be erratic at night scratching herself talking constantly totally different person then sleep till 2 in the afternoon because it kept her up all night . She wouldn’t remember what movie she watched or what she ate . Then it got to the point where she got depressed from it ,crying and saying she didn’t want to live . It is an opioid it’s now 18 months later and she takes opioids I have tried everything to try and get her to stop taking them but there is always a reason why she needs to take them . I wouldn’t wish this on anyone. Opioids maybe great for short term pain but they should never be given to someone with chronic long term pain .please be careful about what medications

Andy McCracken   23/11/2019 1:49:32 PM

Have been taking Tramadol for over 1 year ,was prescribed for pain from torn tendons in the shoulder , but I also found I would wake up feeling good , whereas before I would have to sit in a chair for 1/2 hr feeling crap , now the pain has gone but I was still taking them for the feeling in the morning , then a locum Dr said to get off them and try Palexia sustained release which I have been on for a few days but I wake up feeling crap and walk around like a zombie

Helen   10/01/2020 2:14:29 PM

I've had a really unusual experience with taking Palexia IR before I get out of bed in the mornings. I would do this to get on top of the pain and then take 50 mg with breakfast. The pain has been extreme for 6 approx months. I did this as my usual beginning of the day but the pain felt like it fort back angrily. It was excruciating and now as I have stopped taking the IR before I suffer every morning. Have I finally gone mad.
for a

Kobus   11/05/2020 7:41:23 PM

Thanks for a very straightforward and easy to understand analysis, I've been on oxycodone for sometime now and it's ceased to be effective except at doses that are becoming way in excess of what I'm comfortable with, my pain specialist wants to shift me over to Tapentadol but I like to research these things before I agree to it... your comparison has been the clearest I've read thus far.

Paula   18/05/2020 5:28:01 AM

Been on 100mg SR Tramadol for about 9yrs due to chronic back pain from horse riding accidents. started taking 50mg as needed got to needing it everyday just to be able to get out of bed without back spasms. thank god it works, doesnt leave me feeling like a zombie which simple paracetamol does these days. 1 of them flattens me for 4hrs but i feel drugged up for a couple of days. Not game to try this other drug for fear of it not working and being in constant pain again. Aint broke dont fix it i say.


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