Introduction

We describe a patient with severe tramadol withdrawals who dramatically responded to combination of clonidine, baclofen and ibuprofen (NSAID).

Tramadol is a weak mu receptor agonist. It increases secretion of endorphin, dopamine and serotonin in the brain. It is usually prescribe as a moderate pain killer for a short period [11. Sadock B, Sadock V, Ruiz P (2015) (Editors) Kaplan & Sadock's Synopsis of Psychiatry: Lippinott Wiliams and Wilkins, Philadelphia (USA).].

In Iran some patients use tramadol to treat their premature ejaculation, to increase their sexual desire and to enhance their sexual function.

Psychiatric and psychological problems have been growing disorders in the world including Iran [22. Ahmadi J, Toobaee S, Alishahi M (2004) Depression in nursing students. J Clin Nurs 13: 124. -2424. Ahmadi J, Pridmore S, Ekramzadeh S (2015) Successful Use Of Electro Convulsive Therapy In The Management Of Methamphetamine Induced Psychosis With Onset During Intoxication. J Addict & Depend 1: 1­2.]. In psychiatric diseases, substance related disorders, especially stimulants induced disorders have been considered as progressive worldwide problems. At the present time, patients with stimulants abuse and stimulants induced psychiatric disorders referred to clinics and hospitals are growing [2525. Ahmadi J (2015) The Effect of Buprenorphine and Bupropion in the Treatment of Methamphetamine Dependency and Craving. Br J Med & Med Res 10: 1­4.-5757. Ahmadi J, Benrazavi L (2002) Substance use among Iranian cardiovascular patients. Eur J Med Res 7: 89­92].

The approved FDA (Food and Drug Association) use of clonidine (alpha 2 adrenergic receptor agonist) is for the treatment of hypertension, baclofen for the treatment of spasticity and NSAIDS for the reduction of pain [11. Sadock B, Sadock V, Ruiz P (2015) (Editors) Kaplan & Sadock's Synopsis of Psychiatry: Lippinott Wiliams and Wilkins, Philadelphia (USA).].

Now we are using combination of clonidine (for the treatment of diarrhea, lacrimation, rhinorrhea and nausea), baclofen and ibuprofen (NSAID) as a new approach for the treatment of severe tramadol withdrawals and craving.

We ourselves made a reliable and valid scale to evaluate the withdrawal craving according to DSM-5 (Diagnostic Statistical Manual of Mental Disorders; edition 5) criteria for tramadol craving only, ranging from 0 to 10 (0 means no craving at all and 10 means severe craving and temptation all the time).

Craving scale: 0-1-2-3-4-5-6-7-8-9-10.

To our understanding and knowledge we could not find enough controlled published study on this matter.

Therefore, study of this case could represent a new result.

Case Presentation

AJ was a single, 26 year old worker with high school education. He lived with his parents in Shiraz city of Fars province in southern Iran.

AJ began drinking of alcohol at age of 17 and after several months he became a regular daily drinker. Since three years Prior To Admission (PTA) due to severe migraine headache, he stopped drinking alcohol and began abuse of tramadol. After a couple of months he increased the dosage of tramadol to 2000 mg per day. Because of tramadol induced convulsions, and depression, he was admitted in psychiatric ward. During hospitalization he received clonidine 0.3 mg, baclofen75 mg and ibuprofen 1200 mg per day for the treatment of tramadol withdrawals. He also received olanzapine 20 mg and sodium valproate 400 mg per day for the treatment of depression and migraine headache. He was improved and discharged after two weeks of hospitalization. With the exception of sodium valproate, all other medications (clonidine, baclofen, ibuprofen and olanzapine) were discontinued. He was asked to continue sodium valproate 400 mg daily for treatment of headache. AJ was in good condition for five months, then (one month before the second hospital admission) AJ again began tramadol abuse and shortly increased the dosage to 2000 mg per day. He also reported occasional abuse of methadone since three years PTA.

Because of tramadol dependency, tramadol induced convulsion, agitation and depression He was admitted again.

In psychiatric interview and examinations he was depressed, restless and agitated. In exact physical and neurological examinations we could not find any abnormal findings. Urine drug screening tests were positive for tramadol and methadone. Serology for viral markers (HIV, HCV and HB Ag) was normal. He reported that his two brothers were opium and heroin dependent in the past.

According to DSM-5 criteria, and also complete medical, psychiatric, and substance use history AJ was diagnosed as “opioid (tramadol) dependent and opioid induced mood disorder”

During second hospitalization we began clonidine 0.3 mg, baclofen75 mg and ibuprofen 1200 mg per day for the treatment of severe tramadol withdrawals and craving. In addition we began olanzapine 20 mg and sodium valproate 400 mg per day for the treatment of depression and chlorpromazine 200 mg daily for management of insomnia and agitation.

He was closely interviewed for signs and symptoms of withdrawal every day. 

He was especially monitored and interviewed for tramadol withdrawals and craving, 3 times a day (morning, afternoon, evening).

AJ was taking medications and his condition was improving every day.

Based on the interview and closely monitoring (3 times a day), he experienced much more tramadol withdrawals and craving before taking medication than after taking medication.

Discussion

Our study elucidates that clonidine 0.3, baclofen 75 mg and ibuprofen 1200 mg per day is very effective in the reduction and cessation of tramadol withdrawal and craving. Therefore this study is a considerable addition to the literature.

Conclusions

Low doses of clonidine, baclofen and ibuprofen is very useful in the management of opioids withdrawal. This finding is fascinating.