Tramadol is a strong painkiller. It's used to treat moderate to severe pain, for example after an operation or a serious injury.

It's also used to treat long-standing pain when weaker painkillers no longer work.

Tramadol is available only on prescription. It comes as tablets, capsules and liquid drops that you swallow. It can also be given by injection but this is usually only done in hospital.

• Tramadol works by blocking pain signals from travelling along the nerves to the brain.
• The most common side effects of tramadol are feeling sick and dizzy.
• It's possible to become addicted to tramadol, but this is rare if you're taking it to relieve pain and your doctor is reviewing your treatment regularly.
• It's best not to drink alcohol with tramadol as you're more likely to get side effects like feeling sleepy.
• Tramadol is also called by the brand names Invodol, Larapam, Mabron, Maneo, Marol, Maxitram, Oldaram, Tilodol, Tradorec, Tramquel, Tramulief, Zamadol, Zeridame and Zydol.

Tramadol can be taken by adults and children aged 12 and over.

Tramadol is not suitable for some people. Tell your doctor or pharmacist before starting the medicine if you have:

• had an allergic reaction to tramadol or any other medicines in the past
• an illness which causes seizures
• a head injury
• an addiction to alcohol, strong painkillers or recreational drugs
• breathing difficulties
• kidney or liver problems
• had a reaction to other strong painkillers in the past

It's important to take tramadol as your doctor has asked you to.

The dose can vary but you should not normally take more than 400mg a day.

Tramadol doesn't usually upset your stomach, so you can take it with or without food.

Different types of tramadol

Tramadol comes as:

• fast-acting tablets - these contain 50mg of tramadol
• slow-acting tablets - these contain 50mg, 75mg, 100mg, 150mg, 200mg, 300mg or 400mg of tramadol
• fast-acting capsules - these contain 50mg of tramadol
• slow-acting capsules - these contain 50mg, 100mg, 150mg or 200mg of tramadol
• drops that you swallow - these contain 100mg of tramadol in 1ml of liquid
• an injection (usually given in hospital)
• soluble tablets – these contain 50mg of tramadol
• tablets that dissolve in the mouth – these contain 50mg of tramadol
• an injection (usually given in hospital)

Tramadol drops, injections and some tablets and capsules are fast-acting. They start to work within 30 to 60 minutes. They're used for pain that is expected to last for only a short time. You may be told to take fast-acting tramadol only when you need it for pain or on a regular basis. Always follow the instructions given to you by your doctor.

Some tramadol tablets and capsules are slow-release. This means the tramadol is gradually released into your body over either 12 or 24 hours. This type of tramadol takes longer to start working but lasts longer. It's used for long-term pain.

Your doctor will decide the right dose for you, depending on how sensitive you are to pain and how bad your pain is. Your dose may need to be changed several times to find what works best for you. In general, you will be prescribed the lowest dose that relieves your pain.

How much to take

Dosages vary from person to person. Your dose will depend on how bad your pain is, how you've responded to previous painkillers and if you get any side effects.

How to take it

Fast-acting tramadol comes as capsules, drops and 2 different tablets - soluble and dissolve-in-the-mouth tablets:

• capsules: swallow each capsule whole with plenty of water
• drops: mix the drops into a glass of water then drink the whole contents of the glass
• soluble tablets: dissolve each tablet in 50ml (1/2 cup) of water and drink
• dissolve-in-the-mouth tablets: make sure your hands are dry before handling the tablet. Take the tablet out of the blister pack and put it on your tongue. Suck the tablet, do not chew it. After it has melted, swallow or have a drink of water. You can also dissolve the tablet in a glass of water if you prefer.

Slow-release tramadol comes as tablets and capsules. It's important to swallow slow-release tramadol tablets and capsules whole with a drink of water.

When to take it

When to take it depends on the type of tramadol that you have been prescribed:

• fast-acting tablets and capsules - usually 3 to 4 times a day
• drops - usually 3 to 4 times a day
• slow-release tablets and capsules - usually 1 or 2 times a day

If you're 65 and over, or you have liver or kidney problems, you may be asked by your doctor to take tramadol less often.

You can take your tramadol at any time of day but try to take it at the same time every day and space your doses evenly. For example, if you take tramadol twice a day and have your first dose at 8am, take your second dose at 8pm.

What if I forget to take it?

This will vary depending on which type of tramadol you are taking.

If you forget to take a dose, check the information on the patient information leaflet inside the packaging or ask your pharmacist or doctor for advice on what to do.

Never take 2 doses at the same time to make up for a forgotten one.

If you forget doses often, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What will happen if I stop taking it?

If you need to take tramadol for a long time your body can become tolerant to it.

This isn't usually a problem but you could get unpleasant withdrawal symptoms if you stop taking it suddenly.

If you want to stop taking tramadol, talk to your doctor first. Your dose will usually be reduced gradually so you don't get unpleasant withdrawal effects.

Tramadol can cause unpleasant withdrawal symptoms if you come off it suddenly, such as:

• feeling agitated
• feeling anxious
• shaking
• sweating

What if I take too much?

Taking too much tramadol can be dangerous.

If you've taken an accidental overdose you may feel very sleepy, sick or dizzy. You may also find it difficult to breathe. In serious cases you can become unconscious and may need emergency treatment in hospital.

The amount of tramadol that can lead to an overdose varies from person to person.

If you've taken 1 extra dose by mistake, check the information that comes with the medicine packaging or ask your pharmacist or doctor for advice. Generally, you shouldn't get any symptoms and you can take your next dose as usual.

It's safe to take tramadol with paracetamol, ibuprofen or aspirin (aspirin is suitable for most people aged 16 years and over).

Do not take tramadol with codeine-containing painkillers you can buy from a pharmacy. You'll be more likely to get side effects.

Some everyday painkillers that you can buy from pharmacies contain codeine, which is a similar medicine to tramadol. Codeine-containing painkillers that you can buy from pharmacies include co-codamol, Nurofen Plus and Solpadeine.

Like all medicines, tramadol can cause side effects although not everyone gets them. Talk to your doctor or pharmacist if the side effects listed below bother you or don't go away.

Very common side effects

Very common side effects of tramadol happen in more than 1 in 10 people and include:

• feeling sick
• feeling dizzy

Common side effects

Common side effects of tramadol happen in more than 1 in 100 people. They include:

• headaches
• feeling sleepy, tired, dizzy or "spaced out"
• feeling or being sick (vomiting)
• constipation
• dry mouth
• sweating
• low energy

Serious side effects

Serious side effects are rare. Call your doctor straight away if you get:

• breathing difficulty or short shallow breathing
• dizzy, tired and have low energy - these can be a sign of low blood pressure
• hallucinations (seeing or hearing things that are not there)
• confusion
• very sleepy
• trouble peeing or you can't pee at all
• seizures (fits)

If you have a fit go to A&E straight away.

Serious allergic reaction

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to tramadol.

These are not all the side effects of tramadol. For a full list see the leaflet inside your medicines packet.

What to do about:

• headaches - make sure you rest and drink plenty of fluids. It's best not to drink alcohol with tramadol as you're more likely to get side effects like feeling sleepy. Ask your pharmacist to recommend a painkiller. Headaches should usually go away after the first week of taking tramadol. Talk to your doctor if they last longer than a week or are severe.
• feeling sleepy, tired, dizzy or "spaced out" - these side effects should wear off within a week or two as your body gets used to tramadol. Talk to your doctor if they carry on for longer. Do not drink any alcohol as this will make you feel more tired.
• feeling or being sick (vomiting) - stick to simple meals and do not eat rich or spicy food. It might help to take your tramadol after you've eaten a meal or snack. If you're being sick, try small frequent sips of water. If it carries on, tell your doctor. They may be able to prescribe an extra medicine to protect your stomach.
• constipation - try to get more fibre into your diet such as fresh fruit and vegetables and cereals. Also try to drink several glasses of water or another non-alcoholic drink every day. If you can, it may also help to do some gentle exercise like swimming or going for a short walk. Speak to your doctor about medicine to help prevent or treat constipation caused by tramadol if your symptoms don't go away.
• dry mouth - try chewing sugar-free gum or sucking sugar-free sweets. Your doctor may also prescribe an artificial saliva substitute to keep your mouth moist. This comes as a spray, gel or lozenge.
• sweating - try wearing loose clothing, using a strong anti-perspirant and keeping cool using a fan if that is possible. If this doesn't help and you find it unbearable, speak to your doctor as you may need to be treated with a different type of painkiller.
• low energy - speak to your doctor as they may be able to adjust your dose or give you a different painkiller.

Tramadol isn't thought to be completely safe to take during pregnancy.

In early pregnancy, it's been linked to some problems for your unborn baby. If you take tramadol at the end of pregnancy there's a risk that your newborn baby may get withdrawal symptoms.

However, it's important to treat pain in pregnancy. For some pregnant women with severe pain, tramadol might be the best option. Your doctor is the best person to help you decide what's right for you and your baby.

For more information about how tramadol can affect you and your baby during pregnancy, read this leaflet on the Best Use of Medcines in Pregnancy (BUMPS) website.

Breastfeeding and tramadol

It's safe to breastfeed while taking tramadol. Tramadol passes into breast milk in small amounts but it's unlikely to harm your baby.

However, if your baby is premature, had a low birthweight or has an illness, talk to your doctor before breastfeeding.

Some medicines and tramadol interfere with each other and increase the chances of you having side effects.

Tell your doctor if you are taking any medicines:

• for depression
• for mental health problems
• for pain relief
• to help you sleep
• to reduce tension or anxiety
• to treat symptoms of an allergy
• to thin the blood (such as warfarin)
• to treat an infection

Some medicines may weaken and/or shorten the effect of tramadol. Tell your doctor if you're taking:

• carbamazepine (to treat epilepsy)
• buprenorphine (a painkiller)
• ondansetron (to stop you feeling sick)
• rifampicin (an antibiotic)

Mixing tramadol with herbal remedies and supplements

It's not known if complementary medicines and herbal teas are safe to take with tramadol. They're not tested in the same way as pharmacy and prescription medicines. They're generally not tested for the effect they have on other medicines.