Tramadol Use in United States Emergency Departments 2007-2018



      Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids.


      Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018.


      We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates.


      Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018.


      Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mazer-Amirshahi M
        • Mullins PM
        • Rasooly I
        • van den Anker J
        • Pines JM.
        Rising opioid prescribing in adult U.S. emergency department visits: 2001-2010.
        Acad Emerg Med. 2014; 213: 236-243
        • Hedegaard H
        • Warner M
        • Miniño AM
        Drug Overdose Deaths in the United States, 1999–2016.
        National Center for Health Statistics, 2017 (NCHS Data Brief, no. 294)
      1. Available at Accessed May 20, 2020.
        • Poon SJ
        • Greenwood-Ericksen MB.
        The opioid prescription epidemic and the role of emergency medicine.
        Ann Emerg Med. 2014; 64: 490-495
        • Barnett ML
        • Olenski AR
        • Jena AB.
        Opioid-prescribing patterns of emergency physicians and risk of long-term use.
        N Engl J Med. 2017; 376: 663-673
        • Cantrill SV
        • Brown MD
        • Carlisle RJ
        • et al.
        Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department.
        Ann Emerg Med. 2012; 60: 499-525
        • Cohen V
        • Motov S
        • Rockoff B
        • et al.
        Development of an opioid reduction protocol in an emergency department.
        Am J Health Syst Pharm. 2015; 7223: 2080-2086
        • Duncan RW
        • Smith KL
        • Maguire M
        • Stader 3rd, DE
        Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction.
        Am J Emerg Med. 2019; 371: 38-44
        • Rui P
        • Santo L
        • Ashman JJ.
        Trends in Opioids Prescribed at Discharge from Emergency Departments among Adults: United States, 2006–2017.
        National Center for Health Statistics, 2020 (National Health Statistics Reports, no. 135)
        • Chaparro LE
        • Furlan AD
        • Deshpande A
        • Mailis-Gagnon A
        • Atlas S
        • Turk DC.
        Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review.
        Spine (Phila Pa 1976). 2014; 39: 556-563
        • Sonis J.
        Tramadol for acute pain: a review of the evidence.
        Am Fam Physician. 2005; 72: 1964-1966
        • De Decker K
        • Cordonnier J
        • Jacobs W
        • Coucke V
        • Schepens P
        • Jorens PG.
        Fatal intoxication due to tramadol alone: case report and review of the literature.
        Forensic Sci Int. 2008; 175: 79-82
        • Miotto K
        • Cho AK
        • Khalil MA
        • Blanco K
        • Sasaki JD
        • Rawson R.
        Trends in tramadol: pharmacology, metabolism, and misuse.
        Anesth Analg. 2017; 124: 44-51
        • Kirchheiner J
        • Keulen JT
        • Bauer S
        • Roots I
        • Brockmöller J.
        Effects of the CYP2D6 gene duplication on the pharmacokinetics and pharmacodynamics of tramadol.
        J Clin Psychopharmacol. 2008; 28: 78-83
        • Stamer UM
        • Musshoff F
        • Kobilay M
        • Madea B
        • Hoeft A
        • Stuber F.
        Concentrations of tramadol and O-desmethyltramadol enantiomers in different CYP2D6 genotypes.
        Clin Pharmacol Ther. 2007; 82: 41-47
        • Moss MJ
        • Hendrickson RG
        • Toxicology Investigators Consortium
        Serotonin toxicity: associated agents and clinical characteristics.
        J Clin Psychopharmacol. 2019; 39: 628-633
        • DeMik DE
        • Carender CN
        • Shamrock AG
        • Callaghan JJ
        • Bedard NA.
        Opioid use after total knee arthroplasty: does tramadol have lower risk than traditional opioids? [published online ahead of print January 28].
        J Arthroplasty. 2020;
        • Groenewald CB
        • Zhou C
        • Palermo TM
        • Van Cleve WC.
        Associations between opioid prescribing patterns and overdose among privately insured adolescents.
        Pediatrics. 2019; 1445e20184070
        • Koo H
        • Lee MT
        • You SH
        • et al.
        Duplicated tramadol use in chronic low back pain: a nationwide cross-sectional study.
        Basic Clin Pharmacol Toxicol. 2020; 1263: 226-235
        • Bigal LM
        • Bibeau K
        • Dunbar S.
        Tramadol prescription over a 4-year period in the USA.
        Curr Pain Headache Rep. 2019; 2310: 76
        • Pitts SR
        • Niska RW
        • Xu J
        • Burt CW.
        National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.
        Natl Health Stat Report. 2008; 7: 1-38
        • Zeng C
        • Dubreuil M
        • LaRochelle MR
        • et al.
        Association of tramadol with all-cause mortality among patients with osteoarthritis.
        JAMA. 2019; 32110: 969-982
        • Hirst A
        • Knight C
        • Hirst M
        • Dunlop W
        • Akehurst R.
        Tramadol and the risk of fracture in an elderly female population: a cost utility assessment with comparison to transdermal buprenorphine.
        Eur J Health Econ. 2016; 172: 217-227
        • Wei J
        • Lane NE
        • Bolster MB
        • et al.
        Association of tramadol use with risk of hip fracture [published online ahead of print February 5].
        J Bone Miner Res. 2020;
      2. Bush DM. Emergency Department Visits for Adverse Reactions Involving the Pain Medication Tramadol. The CBHSQ Report. Substance Abuse and Mental Health Services Administration; 2013.

        • West NA
        • Severtson SG
        • Green JL
        • Dart RC.
        Trends in abuse and misuse of prescription opioids among older adults.
        Drug Alcohol Depend. 2015; 149: 117-121
        • Dunn KE
        • Bergeria CL
        • Huhn AS
        • Strain EC.
        A systematic review of laboratory evidence for the abuse potential of tramadol in humans.
        Front Psychiatry. 2019; 10: 704
        • Cicero TJ
        • Ellis MS
        • Paradis A
        • Ortbal Z.
        Role of key informants and direct patient interviews in epidemiological studies of substance abuse.
        Pharmacoepidemiol Drug Saf. 2011; 20: 308-312
        • Skipper GE
        • Fletcher C
        • Rocha-Judd R
        • et al.
        Tramadol abuse and dependence among physicians.
        JAMA. 2004; 292: 1818-1819
        • Musich S
        • Wang SS
        • Schaeffer JA
        • Slindee L
        • Kraemer S
        • Yeh CS.
        Safety events associated with tramadol use among older adults with osteoarthritis [published online ahead of print March 2].
        Popul Health Manag. 2020;
        • Dunn KE
        • Bergeria CL
        • Huhn AS
        • Strain EC.
        A systematic review of laboratory evidence for the abuse potential of tramadol in humans.
        Front Psychiatry. 2019; 10: 704
        • Salm-Reifferscheidt L.
        Tramadol: Africa's opioid crisis.
        Lancet. 2018; 391: 1982-1983
        • Nakhaee S
        • Hoyte C
        • Dart RC
        • et al.
        A review on tramadol toxicity: mechanism of action, clinical presentation, and treatment.
        Forensic Toxicol. 2021; 39: 293-310