New analysis questions tramadol’s role in chronic pain management
A comprehensive data analysis published online in BMJ Evidence Based Medicine raises concerns about the widespread use of tramadol for chronic pain. While the drug is a dual-action opioid used for moderate to severe pain, the study suggests its analgesic effect in chronic conditions is limited and that the potential harms may outweigh the benefits.
What the research looked at
Researchers searched multiple databases for randomized clinical trials up to February 2025 that compared tramadol with placebo in adults with chronic pain, including cancer-related pain. Nineteen trials involving 6,506 participants met the criteria. The conditions studied encompassed neuropathic pain, osteoarthritis, chronic low back pain, and fibromyalgia. Participants averaged around 58 years old, and most trials used tablet formulations of tramadol for treatment periods ranging from 2 to 16 weeks, with follow-up of 3 to 15 weeks.
Key findings: modest pain relief but more harm
The pooled analysis showed tramadol did reduce pain scores slightly, but the effect size was small and below what clinicians consider clinically meaningful. In contrast, the risk of adverse effects during follow-up was higher with tramadol than with placebo. Across eligible trials, tramadol was associated with about a twofold increase in serious harms, including cardiac events such as chest pain, coronary artery disease, and congestive heart failure.
Other safety signals
Beyond cardiovascular events, the study linked tramadol to an increased risk of milder side effects—nausea, dizziness, constipation, and somnolence. There were also signals suggesting a possible rise in some cancers, though the authors cautioned that the short follow-up times limit confidence in that finding.
Limitations and interpretation
The researchers noted a high risk of bias across the included trials, which could exaggerate benefits and underestimate harms. Nevertheless, the balance of evidence points toward a net harm for tramadol in chronic pain management. The authors emphasized that about 60 million people worldwide are affected by opioid addiction, and opioids were implicated in a large share of overdose deaths in recent years. These broader public health concerns underscore the need to reevaluate tramadol’s role in practice.
Implications for guidelines and practice
Given the limited pain relief and increased risk of serious side effects, clinicians and guideline developers may need to reassess tramadol’s position in chronic pain treatment algorithms. The drug remains approved for certain pain indications and is included in several guidelines, partly because of perceptions that it carries a lower risk of adverse events and addiction compared with other short-acting opioids. This new analysis challenges that view, suggesting a more cautious, minimized use approach.
What patients should consider
For individuals currently taking tramadol, a discussion with a healthcare provider is warranted to weigh benefits against risks and to explore alternative therapies. Non-pharmacological interventions, non-opioid medications, and individualized pain management plans may offer safer or more effective options for some patients with chronic pain.
Conclusion
The BMJ Evidence Based Medicine review suggests tramadol’s modest efficacy in chronic pain is overshadowed by a higher risk of serious side effects and other adverse events. While further high-quality research could refine these conclusions, current evidence supports a cautious stance: aim to minimize tramadol use and consider alternative strategies for long-term chronic pain control.
