its antinociceptive effects are mediated by a combination of -opioid agonist effects , and norepinephrine and serotonin reuptake inhibition , and it can suppress opioid withdrawal . first marketed in the 1970s , tramadol was said to have a low - abuse potential.[25 ] however , its abuse liability and diversion were soon recognized , with several reports on physical dependence.[612 ] the largest series of tramadol - dependence was reported from a study in sweden , comprising of 104 patients , where the majority were women . in another series 97% of the abusers had a history of abuse of other substances . association with seizures at therapeutic and toxic doses has been reported , as has been the abuse among occupations like physicians and air force personnel . in india , because of the laxity in drug regulation implementation , opioids are often available over - the - counter ; increasing the risk of opioid misuse . however , we could trace only one case report of tramadol - dependence from india . we present a series of seven cases seeking treatment at our centre for tramadol - dependence . the seven cases with tramadol - dependence , diagnosed as per icd-10 , sought treatment at the drug de - addiction and treatment centre , department of psychiatry , pgimer , chandigarh [ table 1 ] . the dose of tramadol , taken on a regular basis , ranged 50 mg to 1500 mg per day . the reported reasons for initiation of tramadol included , as an alternate to other opioids , to counter opioid withdrawal , and being prescribed for headache and opioid detoxification . six of the seven patients had been using other opioids at some point in their lives . four subjects , treated as inpatients and started on oral opioid antagonist naltrexone 50 mg / day , showed poor treatment compliance . one patient , who had earlier relapsed while taking oral naltrexone , was prescribed an oral buprenorphine as an opioid - type analgesic , which exerts its effects through multiple receptor systems , tramadol carries a dependence producing potential . this needs to be taken into consideration when detoxifying the patient from other opioids . in three of our patients , initiation of tramadol use had begun with a prescription of tramadol for detoxification ; they were not able to taper the doses of tramadol as per prescription . thus , tramadol is used by opioids - dependent subjects as a substitute for the unavailable  harder drugs . detoxification of our patients was done largely with oral clonidine and non - steroidal anti - inflammatory drugs ( nsaids ) , as reported by some , but not others who used the buprenorphine  naloxone combination and methadone for tramadol - detoxification . apart from those patients with medical disorders using tramadol ; the drug has the potential for abuse by opioids - dependent subjects . given the easy availability of tramadol from pharmacies in india and some other countries , its abuse and diversion may become a bigger challenge in the future . there is a need to effectively regulate the distribution of this medication , and apply the appropriate safeguards , to prevent diversion . it emphasizes the need for caution before prescribing tramadol to patients , especially those who are opioids - dependent , and to apprise the drug regulatory authorities of such occurrences , for proper scheduling and issue of warnings .
tramadol is an atypical , centrally acting , synthetic analgesic , acting through opioid and non - opioid systems . 
 we present a series of seven cases , all men , who sought treatment at our centre for tramadol - dependence . 
 the majority were using other opioids at some point in their lives . 
 their tramadol use had begun with a prescription of tramadol for opioid detoxification , for headache and body pains , and as an alternative to injectable opioids . 
 the doses of tramadol used varied from 50 to 1500 mg per day . all subjects reported an experience of euphoria with tramadol use . 
 four patients were put on naltrexone , but had poor compliance . 
 this case series underscores the need for caution , while using tramadol in substance - dependent patients .