Inert substance vs. Tramadol in Opioid withdrawal pain- A Comparison Study

BACKGROUND: Heroin, a short-acting opioid presents with withdrawal symptoms within hours of the last dose in patients. Pain is among the most troublesome of the withdrawal symptoms, where routine analgesics are difficult to work. Enhanced use of tramadol and buprenorphine to overcome the withdrawal pain resulted in tramadol abuse and buprenorphine dependence. The placebo (normal saline 2ml), an inert compound was used in addition to routine management in heroin withdrawal to avoid the risk of iatrogenic drug dependence. MATERIAL AND METHODS: We enrolled a total of 42 male patients with mild to severe withdrawal as per the COWS score in the study. The placebo (normal saline 2ml) and tramadol injection (50mg) was administered intramuscularly in 24 and 18 patients respectively when routine treatment failed to resolve the withdrawals. Both groups were matched for age, gender, and self-reported average quantity of heroin use per day. The inertness of placebo was explained to patients before and quality reassurance was given regarding its beneficial effects on pain. A numerical rating scale for pain was administered 1 hour after receiving placebo and tramadol. RESULTS: 24/42 patients who were in mild to moderately severe withdrawals received placebo and 18/42 patients received tramadol. The mean score of pain before receiving placebo or tramadol was 4.916±1.8 and 6.277±2.0 respectively while as after receiving placebo or tramadol, the mean score of pain was 1.708±1.9 and 1.111±1.9 respectively. There was a significant reduction in both mild to moderate pain with placebo and tramadol. However, tramadol was much more effective in severe pain compared to a placebo. The results of the placebo and tramadol groups were compared; an unpaired sample t-test was administered. The difference between the two groups was statistically insignificant (p=0.3296) CONCLUSION: Management of opioid withdrawal is a challenge and its dependence not only impacts the drug user but also imposes a significant economic burden on society by increasing health costs, unemployment rates, absenteeism and premature mortality. These preliminary data suggest that a placebo may be used in place of tramadol in the management of mild to moderately severe heroin withdrawal. Placebo being inert in action is understudied but can aid in cases of emergency where other options are limited or if used risk of abuse liability is high.