Tramadol Side Effects and When to Get Help

Maybe you just started a new prescription and feel foggy and queasy. Maybe you have taken it for months and catch yourself watching the clock for your next dose. Or maybe you are worried about someone you love.

You deserve straight answers. Tramadol side effects run from the expected and manageable to the rare and dangerous, and this drug carries risks other opioids do not. Here is how often each one happens, which ones need a 911 call, and how to tell when use has become dependence or misuse.

What is tramadol?

Tramadol is a prescription opioid pain reliever, not a muscle relaxer. The FDA approves it for adults whose pain is severe enough to need an opioid when other treatments fall short. It also blocks the reuptake of serotonin and norepinephrine, the same brain chemicals many antidepressants act on. Much of its opioid effect comes from a metabolite called M1, which your liver makes with an enzyme called CYP2D6. M1 binds opioid receptors roughly 200 times more strongly than tramadol does. The DEA has classed tramadol as Schedule IV since August 2014.

What are the most common side effects of tramadol?

The FDA label tracked side effects in trials lasting up to 90 days, and the numbers are cumulative. Constipation hits 24% of people in week one and 46% by day 90, which makes it the most common side effect of tramadol. Dizziness is slightly more common in week one, but over three months it trails both constipation and nausea.

Does tramadol make you sleepy (or keep you awake)?

Usually sleepy: 25% of people in the label trials. Between 1% and 5% reported a sleep disorder or nervousness instead, which fits tramadol’s serotonin and norepinephrine activity. The label’s boxed warning says combining opioids with alcohol, benzodiazepines or other sedatives can cause profound sedation, slowed breathing, coma and death. Our post on whether hydrocodone makes you sleepy explains opioid drowsiness in more depth.

Why tramadol causes constipation and nausea, and what helps

Opioid receptors line your gut as well as your brain. Tramadol slows the bowel and dries out stool, and unlike drowsiness, constipation rarely eases as your body adjusts to the drug. Start water, fiber and a daily walk on day one, and ask your pharmacist which stool softener or laxative fits you before you are days in and miserable. Tell your prescriber if nausea keeps you from eating or drinking.

What are the worst side effects of tramadol?

They are uncommon, but they are why tramadol deserves respect even at prescribed doses.

Serotonin syndrome and which drugs raise the risk

Serotonin syndrome happens when too much serotonin builds up. The label lists agitation, hallucinations, a racing heart, swings in blood pressure, high body temperature, overactive reflexes, muscle stiffness, poor coordination, nausea, vomiting and diarrhea. It can be life-threatening.

The FDA label flags SSRI and SNRI antidepressants (sertraline, fluoxetine, duloxetine, venlafaxine), tricyclics, MAO inhibitors, migraine triptans, anti-nausea drugs such as ondansetron, and certain muscle relaxants. Mirtazapine and trazodone raise the same concern. If you take any of these, every prescriber and your pharmacist should know.

Seizures

Seizures have been reported in people taking tramadol within the recommended dose range. The risk goes up with antidepressants, other opioids, antipsychotics, a history of epilepsy or a head injury, and, according to postmarketing reports, doses above the recommended range.

Slowed breathing and overdose signs

Like every opioid, tramadol can slow breathing dangerously. The CDC lists these overdose signs:

• Can’t be woken up, or is unconscious
• Slow or shallow breathing, or trouble breathing such as choking sounds
• Discolored skin, especially the lips and nails
• Small, pinpoint pupils that don’t react to light

Call 911 and give naloxone (Narcan) if you have it. Naloxone is sold over the counter in all 50 states. Lay the person on their side to prevent choking and stay with them until help arrives. The CDC advises watching for at least four hours to make sure breathing returns to normal. For confidential, 24/7 treatment referral, the SAMHSA National Helpline is 1-800-662-4357.

Can tramadol cause low blood sugar or low sodium?

Tramadol’s label carries specific warnings about low blood sugar and low sodium, and in studies the risk was highest early in treatment.

Low blood sugar (hypoglycemia). A study of 334,034 people with noncancer pain, published in JAMA Internal Medicine in 2015, compared tramadol with codeine. Tramadol users had 1.52 times the odds of being hospitalized for low blood sugar overall (95% CI 1.09 to 2.10). In the first 30 days the odds were 2.61 times higher (95% CI 1.61 to 4.23). The FDA label notes most reported cases involved people with risk factors such as diabetes.

Low sodium (hyponatremia). A 2015 study in The American Journal of Medicine followed 332,880 people starting tramadol or codeine. In the first 30 days, tramadol roughly doubled the risk of hospitalization for low sodium (adjusted hazard ratio 2.05; 95% CI 1.08 to 3.86): 4.6 versus 1.9 cases per 10,000 person-months. The FDA label notes most cases occurred in women over 65, within the first week of treatment. The label tells prescribers to watch for confusion and disorientation.

Both are rare. If you or a parent feels confused or unwell in the first weeks, ask for a blood sugar and sodium check rather than writing it off as grogginess.

Why don’t doctors like to prescribe tramadol?

Many prescribers do use it, but cautiously, and genetics is a big part of the reason. Tramadol has to be converted to M1 by CYP2D6, and people inherit very different versions of that enzyme. “Ultra-rapid metabolizers” turn tramadol into M1 fast, which pushes opioid levels higher than expected. The FDA estimates this applies to 1% to 10% of White people, 3% to 4% of Black people and 1% to 2% of East Asian people, and possibly more than 10% of people with Oceanian, North African, Middle Eastern, Ashkenazi Jewish or Puerto Rican ancestry. Children have died after receiving tramadol, and in at least one case the child was an ultra-rapid metabolizer. That is why it is contraindicated for anyone under 12 and for anyone under 18 after tonsil or adenoid surgery.

Add the serotonin interactions, the seizure risk and the blood chemistry effects, and tramadol is harder to manage than its “mild opioid” reputation suggests. For how it compares, see our posts on hydrocodone side effects and oxycodone vs. hydrocodone.

Who is more likely to have tramadol side effects?

Older adults

The label calls slowed breathing the chief risk for older patients, especially after large first doses, and sets a lower daily ceiling for people over 75 (300 mg rather than 400 mg). Add the low sodium risk in women over 65, and sudden confusion in an older parent deserves a phone call, not a wait-and-see.

Women

Most low sodium cases in the label occurred in women over 65. Long-term use during pregnancy can cause neonatal opioid withdrawal syndrome in the baby (a boxed warning), and the label does not recommend breastfeeding on tramadol. If you are pregnant, planning to be or nursing, talk with your prescriber.

People with kidney or liver problems

About 30% of each dose leaves the body unchanged in urine, so weak kidneys let tramadol build up. For severe kidney impairment the label directs prescribers to space doses 12 hours apart with a 200 mg daily maximum. Severe liver disease slows how the body breaks down both tramadol and M1. Make sure your prescriber knows about either condition before you start.

How long do tramadol side effects last?

It depends on the side effect. Drowsiness and dizziness track each dose: tramadol peaks in the blood about 2 hours after you take it and M1 about 3 hours after. Constipation tends to last as long as you keep taking it. The blood sugar and sodium risks are highest in the first week to month. Anything severe, new or worsening is worth a call to your prescriber.

How long does tramadol stay in your system?

The FDA label puts tramadol’s average half-life (the time your body takes to clear half of it) at 6.3 hours, and M1’s at 7.4 hours. Pharmacologists usually count about five half-lives for a drug to be mostly gone, which means roughly a day and a half after your last dose for a healthy adult. Kidney or liver impairment stretches that window.

Is tramadol addictive?

Yes, it can be. Tramadol’s label carries the same boxed warning about addiction and misuse as other opioids. In the 2024 National Survey on Drug Use and Health, cited by the DEA, 0.4% of Americans 12 and older misused tramadol in the past year. Among the 7.6 million people who misused any prescription opioid, 16.2% misused tramadol products.

Three terms get mixed up here:

• Physical dependence: your body has adapted, so stopping suddenly brings withdrawal. It can happen to anyone taking tramadol daily as prescribed.
• Misuse: extra doses, someone else’s pills, or taking it for mood or sleep.
• Opioid use disorder: what most people mean by addiction. Use continues despite harm and gets hard to control.

Dependence alone is not addiction, but it is the ground addiction grows in, so talk with your prescriber about how long you will stay on tramadol. If use has already moved past that point, painkiller addiction treatment is built for this situation.

What are tramadol withdrawal symptoms?

Tramadol withdrawal looks like other opioid withdrawal. The label lists restlessness, watery eyes, runny nose, yawning, sweating, chills and muscle aches as common symptoms. Others can follow, such as anxiety, irritability, stomach cramps, insomnia, nausea, vomiting, diarrhea and a faster heart rate.

If you have taken it regularly, do not stop suddenly. The label tells prescribers to taper gradually on an individual plan, so call yours first. When tapering at home is not safe or has already failed, RRTC coordinates detox placement with accredited partner facilities in Massachusetts, then plans your handoff back into our outpatient programs.

When side effects are a sign of something bigger

Watch for these patterns in yourself or someone close to you:

• Running out early or asking for refills ahead of schedule
• Taking extra doses on hard days, or for stress or sleep instead of pain
• Feeling sick, anxious or achy between doses, then better after the next one
• Hiding pills or getting defensive about them

If you are a family member, pick a calm moment, describe what you have seen rather than labeling it, and offer to sit in on the call to the doctor or a treatment center. You do not need certainty to start that conversation.

At Rockland Recovery, you do not need to be sure before you reach out. Our opioid addiction treatment includes partial hospitalization, day and evening intensive outpatient, and virtual care, with locations in Braintree, Quincy, Sharon and Bedford. Medication-assisted treatment is available too: Suboxone (buprenorphine and naloxone) to reduce cravings and withdrawal, or Vivitrol (naltrexone) to block the effects of opioids. If tramadol started with real pain, tell the admissions team so your plan accounts for it.

Recovery from opioid use disorder is possible, and it usually starts with one honest conversation. You can check your insurance online in about two minutes, and a member of the admissions team will contact you with your results and next steps.

Frequently asked questions

What is the number one side effect of tramadol?

Constipation, which affected 46% of people over 90 days in the FDA label trials. Dizziness is slightly more common in the first week, but constipation keeps building the longer you take tramadol.

Is 50 mg of tramadol stronger than extra strength Tylenol?

They are not comparable by milligrams. Extra strength Tylenol is 500 mg of acetaminophen, a non-opioid. Tramadol is an opioid reserved for pain that other treatments have not controlled, and it carries risks acetaminophen does not, such as dependence, seizures and slowed breathing.

Can you take tramadol with antidepressants?

Only with your prescriber’s knowledge. SSRIs, SNRIs, tricyclics and MAO inhibitors raise the risk of serotonin syndrome and seizures. Some antidepressants, such as fluoxetine, paroxetine and bupropion, also block CYP2D6 and change how much active M1 your body makes. Never stop an antidepressant on your own to make room for tramadol.

Is tramadol a muscle relaxer?

No. Tramadol is an opioid pain reliever. It can ease pain from a muscle injury, but it does not relax muscles the way cyclobenzaprine does.

Does tramadol show up on a drug test?

Not on a standard opiate screen. The opiate immunoassay in basic panels is built to catch morphine and codeine and does not detect tramadol. It shows up only when a tramadol-specific test is ordered.

Is tramadol safer than other opioids?

Not in every way. Tramadol is Schedule IV and oxycodone and hydrocodone are Schedule II, so the DEA rates its misuse potential lower. But it adds risks those drugs do not have: serotonin syndrome, seizures at normal doses, low blood sugar and low sodium, and wide genetic variation in how strongly it works.