Tramadol Relieves Neuropathic Pain

Clinical Question

Is tramadol (Ultram) safe and effective for the treatment of neuropathic pain?

Evidence-Based Answer

Tramadol is an effective treatment for neuropathic pain. One out of four patients who take the medication achieves at least 50 percent pain relief.

Practice Pointers

Tramadol is a unique pain reliever that is thought to work via a weak effect on opioid receptors and by limiting reuptake of serotonin and norepinephrine, an effect occurring with many antidepressants. This systematic review identified six randomized controlled trials of tramadol for the treatment of neuropathic pain. Four studies (337 total patients) compared tramadol with placebo. All four studies were double-blinded, and three of the four studies (including 302 of the patients) adequately concealed allocation from participants and accounted for patients lost to follow-up.

The review found a clinically significant benefit with tramadol (number needed to treat to achieve at least 50 percent pain relief = 3.8; 95% confidence interval [CI], 2.8 to 6.3). One small, unblinded study (21 total patients) found no difference between tramadol and clomipramine (Anafranil). Another study (40 total patients) found no clear difference between tramadol and morphine in patients with cancer-related pain. However, these studies were too small and too poorly designed (i.e., unblinded with many dropouts) to draw firm conclusions.

Between 5 and 15 percent of patients discontinued the study medication because of adverse effects. In the two studies that provided adverse effects data, the combined number needed to harm was 7.7 (95% CI, 4.6 to 20). Although no life-threatening adverse effects were reported, tramadol can lower the seizure threshold and should not be given to patients with a history of seizure. An evidence-based guideline from the Institute for Clinical Systems Improvement recommends tramadol as a treatment option for neuropathic pain,¹ and an expert panel recommends it as a first-line treatment.²