Does Suboxone block tramadol? Can you take tramadol with Suboxone?

It is NOT recommended to use buprenorphine/naloxone (Suboxone) after taking tramadol as this might precipitate withdrawal. 

Tramadol is considered a weak opioid, so it is less likely to precipitate withdrawal than full opioids. However, it still should not be taken with Suboxone. 

If you are taking Suboxone and need tramadol to manage pain, talk to your doctor about alternatives.

What Is Tramadol?

Tramadol is an opioid medication that is used to treat moderate to severe pain.[1] It is considered a mixed-mechanism opioid drug, and it has chemical effects that are different from full opioid agonist drugs like heroin or methadone.[2]

When tramadol was first approved for use in 1995, it was not classified as an opioid medication.[3] This is because despite the fact it does activate opioid receptors in the brain, its effects are weaker, and it is believed to have other mechanisms besides its opioid agonist effects by which it reduces pain.   Furthermore, it was not considered a medication with a high risk for abuse when it first came out, and for this reason was not considered a controlled substance that needed higher monitoring by the drug enforcement agency (DEA).

As a prodrug, tramadol has a low affinity for the mu-opioid receptors.[4] As a result, it is not considered as dangerous as full opioid drugs. 

However, repeated reports of tramadol misuse and diversion prompted the DEAto reassess its status. In 2014, the DEA classified tramadol as a Schedule IV controlled substance.[5] 

Schedule IV substances are deemed to have a low abuse potential but to still require some monitoring. Schedule I substances, like heroin, are considered to have the greatest risk of abuse, requiring the most monitoring and caution. 

Despite this lighter scheduling of tramadol as compared to heroin, one recent study found that people who used tramadol were more likely to engage in prolonged use of that medication than those using other opioid medications like oxycodone or hydrocodone.[6] This suggests that tramadol isn’t necessarily less dangerous than other opioids when it comes to misuse and addiction potential.  Another study found that tramadol was associated with a two times higher risk of death compared to anti-inflammatory pain medications such as naproxen, and a comparable risk of death as compared to opioid pain medications such as codeine.

As a narcotic, tramadol comes with risks for misuse and dependence, leading to substance use disorder (SUD). 

Why You Shouldn’t Use Suboxone With Tramadol

Suboxone contains buprenorphine and naloxone. Buprenorphine has a high affinity for the mu-opioid receptors in the brain, occupying them and keeping opioid withdrawal symptoms and cravings at bay. 

Buprenorphine can also displace other opioids from the receptor, and if it is consumed too close in time to a full-agonist opioid, like oxycodone or heroin, it can trigger withdrawal symptoms. This will immediately trigger withdrawal symptoms in a process known as precipitated withdrawal. Suboxone should only be initiated in collaboration with a heath-care provider.

Naloxone is another ingredient in Suboxone that might trigger withdrawal symptoms in people who are tolerant to opioids. With proper use, the naloxone in Suboxone remains inactive. If Suboxone is abused, however, it is activated. Once activated, naloxone attaches to opioid receptors in the brain, displacing other opioids and blocking their effects, and for this reason it can also trigger withdrawal if opioids are still present when Suboxone is consumed.[7] 

If you take Suboxone soon after taking tramadol, this process of precipitated withdrawal may occur, too., because tramadol has some weak opioid agonist effects.

Taking Suboxone with tramadol is less likely to precipitate withdrawal than if you take Suboxone with full opioids like heroin, hydrocodone, or oxycodone, but the risk is still present.

What Happens if You Mix Suboxone & Tramadol

If you mix Suboxone and tramadol, the main risk is precipitated withdrawal. 

If you are taking tramadol for pain-relief purposes, because of its tendency to occupy opioid receptors and kick opioid agonists off the receptors, Suboxone will also prevent tramadol from working correctly and addressing your pain. 

Ideally, you should stop taking tramadol 24 hours before you begin taking Suboxone.[8] This will prevent precipitated withdrawal. 

Communicate with your treatment team regarding your tramadol dosing schedule to best determine when you should begin taking Suboxone. Do not take Suboxone until you have discussed an induction schedule and guidelines with your healthcare provider.

How to Manage Pain While Taking Suboxone

If you have chronic pain, talk to your doctor about other methods for managing it. Tramadol and other opioid medications are not the ideal choice for pain control in people with a co-occurring opioid or other substance use disorder. 

Non-narcotic medications like acetaminophen or ibuprofen, may be appropriate for you, and a treatment plan should be developed with your health-care provider as the ideal medications  to address pain while you take Suboxone will depend on the source of the pain. 

Your treatment team may suggest other ways to manage pain that don’t involve medication. Physical therapy, massage, neurostimulation, and exercise can all be effective, non-pharmacological approaches to manage pain.[9]

SOURCES

1. Tramadol. American Society of Health-Systems Pharmacists. https://medlineplus.gov/druginfo/meds/a695011.html. January 2022. Accessed April 2022.
2. Full Opioid Agonists and Tramadol: Pharmacological and Clinical Considerations. Anesthesia and Pain Medicine. https://pubmed.ncbi.nlm.nih.gov/34692448/. August 2021. Accessed April 2022.
3. Is Tramadol a Risky Pain Medication? Harvard Health Publishing. https://www.health.harvard.edu/blog/is-tramadol-a-risky-pain-medication-2019061416844. July 2019. Accessed April 2022.
4. Pharmacology of Tramadol. Drugs. https://pubmed.ncbi.nlm.nih.gov/9190321/. 1997. Accessed April 2022.
5. Tramadol. U.S. Food and Drug Administration. https://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf. March 2020. Accessed April 2022.
6. Historically ‘Safer’ Tramadol More Likely Than Other Opioids to Result in Prolonged Use. Mayo Clinic. https://www.sciencedaily.com/releases/2019/05/190514090953.htm. May 2019. Accessed April 2022.
7. Naloxone DrugFacts. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugfacts/naloxone. January 2022. Accessed April 2022.
8. Buprenorphine. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine. March 2022. Accessed April 2022.
9. Management of Pain Without Medications. Stanford Health Care. https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf?sfvrsn=16224bc2_0. Accessed April 2022.