Tramadol: prohibited in cycling, why?

[Mis à jour le 18 août 2022 à 10h22] Wednesday August 17, the Colombian runner Nairo Quintana has been disqualified from the Tour de France 2022 due to two controls positive for Tramadol. Since March 1, 2019, the use of tramadol in competition is prohibited in all disciplines of cycling, recalls the International Cycling Union (UCI). “The ban is intended to preserve the health and safety of the runner in light of side effects tramadol, in all disciplines and for all categories” argues the organization. “Besides the risk of dependence and addiction, Commonly reported side effects of tramadol are dizziness, drowsiness and loss of attention, which is incompatible with the practice of competitive cycling and endangers other participants (risk of falling, editor’s note) ” details the UCI Medical Regulations. What does Tramadol contain? What are its side effects? What precautions to adopt if taking ?

What is Tramadol?

Tramadol is a synthetic opioid analgesic (a painkiller) prescribed for treatment of moderate to severe pain. It belongs to level 2 of the pain treatment scale proposed by the World Health Organization (WHO). Its action is central, it influences the way the brain and the nervous system respond to pain.

Doping: why is it prohibited in cycling?

Wednesday August 17, 2022, the Colombian runner Nairo Quintana has been disqualified from the Tour de France 2022 due to two controls positive for Tramadol. Since March 1, 2019, the use of tramadol in competition is prohibited in all disciplines of cycling, recalls the International Cycling Union (UCI). “The ban is intended to preserve the health and safety of the runner in light of side effects tramadol, in all disciplines and for all categories” argues the organization. “Besides the risk of dependence and addiction, Commonly reported side effects of tramadol are dizziness, drowsiness and loss of attention, which is incompatible with the practice of competitive cycling and endangers other participants (risk of falling, editor’s note) ” details the UCI Medical Regulations.

What medicines contain Tramadol?

• Tramadol alone: Biodalgic®, Contramal®, Monoalgic®, Monocrixo®, Orozamudol®, Takadol®, Topalgic®, Zamudol®, Zumalgic® and Generic Tramadol.
• In combination with paracetamol : Ixprim®, Zaldiar®, generic Tramadol/Paracetamol.
• In combination with dexketoprofen: Skudexum®.

> View Tramadol medications

What are the side effects of Tramadol?

If opioids are consumed less than non-opioid analgesics (paracetamol, aspirin, NSAIDs) and have “a major interest and indisputable in the management of the pain“ , their misuse increases. With the key to more poisonings and deaths. According to figures published in 2019 by theANSMthe consumption of tramadol alone has increased by +68% between 2006 and 2017 (the tramadol/paracetamol combination has been decreasing since 2011). Tramadol is the first analgesic opioid reported in reports ofproblematic use of the addictovigilance network, the first also implicated in deaths of the “Toxic Deaths by Analgesics (DTA)” survey.

Among the side effects of tramadol:

• constipation, drowsiness (this is a level 2 analgesic so be careful driving!), nausea, vomiting, headaches, confusion, dry mouth.
• in case of overdose : central nervous system depression (drowsiness, coma), respiratory depression with a decrease in the respiratory rate, convulsions and constriction of the pupil. Respiratory depression can cause respiratory arrest and therefore death. Even more so when the person also takes alcohol, sedative drugs, antidepressants or even antihypertensives. “This problem mainly affects patients who consume an opioid analgesic to relieve pain, and who develop a primary dependence on their treatment, and sometimes divert it from its initial indication” notes the ANSM. Women are mostly affected.
• risk of addiction.
• risk hepatic when taking tramadol+paracetamol in addition to paracetamol alone.

A study** published in August 2019 in the journal Scientific Reports showed that tramadol could promote hypoglycaemia (abnormally low blood sugar levels). American authors have recommended “of monitor glucose levels when initiating tramadol or methadone in diabetic and non-diabetic patients” and to favor other safer opioid or non-opioid analgesics for patients at risk of hypoglycaemia or complications associated with hypoglycaemia.

What medications should you avoid if you take Tramadol?

Tramadol should not be taken simultaneously with other medications. For instance :

• With some tranquilizerssleeping pills, analgesics such as morphine or codeine (increased risk of drowsiness or feelings of fainting).
• With some anti coagulants : the effects of coumarin-derived anticoagulants, which thin the blood, may be increased (risk of haemorrhage).
• With medication serotonergic such as SSRI antidepressants (selective serotonin reuptake inhibitors such as Prozac®) or MAO inhibitors taken during depression.
• With carbamazepine, nalbuphine, buprenorphine, pentazocine, ondansetron, bupropion or triptans (migraine).
• With other opiate drugs (analgesics, cough suppressants).

Is tramadol authorized in children?

Tramadol can be prescribed to the child from 3 years, with a fixed dosage according to weight. He is currently showing up in drinkable form in dropper bottle (100mg/ml). In September 2021, the National Medicines Agency (ANSM) reported “medication errors with tramadol in oral solution (…) whose serious consequences involved the vital prognosis of the patient”. In agreement with the ANSM, the Sanofi and Grünenthal laboratories will edit boxes of their specialties Topalgic and Contramal 100 mg/mL based on tramadol, in oral solution, by adding two boxes to avoid overdose :

It can also be prescribed from 12 or 15 years old in oral form. The injectable form of tramadol is contraindicated before 15 years.

To avoid any medication errors, the authorities remind parents:

• to follow the doctor’s prescription,
• to seek medical advice in case of doubt about the prescription or the operation of the dropper bottle,
• to keep the medicine out of reach and sight of children,
• to consult a doctor or emergency service immediately in the event of the appearance of signs of overdose: vomiting, impaired consciousness, breathing difficulties, etc.

In view of the increase in the use of analgesic opioids in France and the complications that can be very serious, the health authorities are taking action to control the supervision of these drugs in terms of prescription and dispensing conditions, prohibition advertising to the general public, information for health professionals. They carefully monitor their consumption and the associated risks.

*codeine, dextropropoxyphene, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, tapentadol, tramadol.

Can you get Tramadol without a prescription?

Tramadol is listed on the list I of poisonous substances. It can only be obtained on medical prescription. Since April 15, 2020drugs based on tramadol taken orally cannot be prescribed for more than 3 months, without new order. This decision taken by the director of the French Medicines Agency (ANSM) aims to limit the misuse of these drugs as well as the addiction risk.

What precautions should be taken if taking Tramadol?

For safe use of tramadol-based medicines:

• Respect the dosage indicated on the prescription, as well as the duration of treatment.
• If the pain is not sufficiently or quickly relieved by your treatment, consult your doctor again.
• Do not suddenly stop your treatment: your doctor or pharmacist will tell you the procedure which consists in gradually reducing the doses.
• It must be delivered in the smallest possible packaging, adapted to the prescription.

What are the dangers of Tramadol?

Developed in the 1970s, this drug dethroned the codeine after withdrawal of dextropropoxyphene (Di-Antalvic®) in 2011. Today is:

• 1^er opioid analgesic cited in a 2018 survey on problematic uses both among drug users but also in the general population for the treatment of pain.
• 1^er analgesic implicated in deaths related to taking analgesics, ahead of morphine (DTA* survey).
• 2^th analgesic most frequently found on falsified prescriptions presented in pharmacies, behind codeine (OSIAP survey**.

Sources:

Topalgic 100 mg/mL and Contramal 100 mg/mL oral solution (Tramadol) – Reminders of proper use and development of boxes to limit the risk of overdose. ANSM. September 17, 2021

Toxic Deaths by Analgesics (2017 data): survey which collects cases of death linked to the taking of analgesics and reported to expert toxicologists, volunteer analysts and to the addictovigilance network.

**Retrospective analysis reveals significant association of hypoglycemia with tramadol and methadone in contrast to other opioids. Tigran Makunts, Andrew U, Rabia S. Atayee & Ruben Abagyan Scientific Reports. volume 9, Article: 12490 (2019).