Henley Spracklen, BS
Endurance athletes have a high prevalence of tramadol use in competition.
Tramadol is not considered a performance-enhancing drug.
Dependence on tramadol is possible and has been recorded, but the overall risk is lower than that of other opioids.
Pain is a necessary biologic advantage that signals to the brain that something within the body is wrong. Individuals are often cheered and considered brave when embracing pain and showing grit, particularly in sports. Athletes are praised for putting their bodies through rigorous training cycles in hopes of becoming better at their sport. They are even applauded for fighting through the pain when suffering an injury yet continuing to compete. Many wonder whether the top athletes are simply born with a natural talent for pushing their bodies to the extreme, or whether the hours of grueling training have reconditioned their body and mind.
Several studies have shown that athletes report an increased pain tolerance and higher thresholds to thermal stimuli when compared with non-athletes [1,2]. These studies also demonstrated that the type of sport impacts pain perception as endurance athletes were seen to have improved pain inhibition and tolerability, whereas strength athletes had reduced pain sensitivity . The continuous exposure to low-intensity pain from multiple workouts a day may explain why athletes have been found to respond better to pain than non-athletes. However, Assa et al. stated that while the repetitive pain exposure may help to desensitize athletes, in those suffering from chronic pain, this repetitive exposure could result in pain hypersensitivity. This is due to chronic pain being both unpredictable and uncontrollable .
While athletes have a greater pain tolerance than the average population, many still require the use of pain medication after surgery. A popular option amongst athletes is the synthetic opioid tramadol. When tramadol was first introduced in 1995, it was not considered an opioid. However, over the years it was found to have some addiction potential and since then has been categorized as a Schedule IV drug. Some studies have found that tramadol is associated with a greater risk of chronic use compared to other short-acting opioids (13.7% vs 4.7-8.9%, respectively), and the National Survey on Drug Use and Health (NSDUH) estimated that 1.6 to 1.8 million people in the United States misused tramadol from 2015-2017 [3,4]. Despite this, an analysis of the NSDUH found that tramadol had an overall lower rate of lifetime misuse at 1.5% of individuals compared to 4% and 6% for oxycodone and hydrocodone respectively, demonstrating low addiction potential (Figure 1) .
Figure 1. Percent of US Population reporting any lifetime misuse (at least once) of oral tramadol, morphine, oxycodone, and hydrocodone (2002-2014). Reprinted from Reines SA, Goldmann B, Harnett M, Lu L. Misuse of Tramadol in the United States: An Analysis of the National Survey of Drug Use and Health 2002-2017. Subst Abuse. 2020;14:1178221820930006. doi:10.1177/1178221820930006
Tramadol has become a commonly prescribed opioid among athletes. This is mostly explained by the drug’s fewer adverse effects and its presumed safety compared to other synthetic opioids [3,5]. Another reason for Tramadol’s popularity among athletes is because it is one of the few opioids not included on the World Anti-Doping Agency prohibited list. This allows athletes to treat sport-related aches and pains without fear of failing a drug screen . However, there is some speculation that athletes also take tramadol in hopes of enhancing their performance. Since tramadol suppresses pain and therefore potentially increases pain tolerance, athletes believe that it will allow them to push themselves to even greater extents during the competition . However, due to its potential for enhanced mood and slightly euphoric feeling, the possibility of addiction and dependence remains .
Elite athletes have been found to have an increased risk of opioid overuse and misuse for various reasons including their greater risk of acquiring a musculoskeletal injury, the pressure to perform well despite injury, and the desire to maximize earning potential over a short career span . It has also been noted that the use of opioids at each skill level (i.e., collegiate vs professional) predicts future use and misuse with contact sports having the greatest risk . In a study by Cottler et al. looking at opioid use in retired national football league (NFL) players, 52% had used opioids during their NFL career with 71% reporting misuse (Figure 2) . The study also found that the most prominent risk factors for opioid use during their careers were having an undiagnosed concussion, enduring a career-ending injury, and being an offensive lineman. Additionally, risk factors for continuing opioid use into retirement were unemployment, alcohol abuse, multiple injuries, and an undiagnosed concussion . While the study did not state which opioids were most misused, these findings demonstrate how elite athletes are at risk of opioid misuse, especially those in a contact sport. As for tramadol, it has been estimated that the prevalence of its use in competition is 1.4% overall; with cycling, triathlon, and rowing athletes consuming the greatest amounts (Figure 3) [5,8]. In 2019, tramadol was banned from cycling competitions due to its high rate of misuse as there was a concern for possibly inducing dizziness and drowsiness during racing . While one experiment did find that tramadol allowed cyclists to maintain greater power and cardiorespiratory stress during a twenty-minute time trial, the results could not be replicated suggesting that tramadol does not have an ergogenic effect . Other studies have claimed that tramadol increases ventilatory efficiency, VO2 max, and the overall aerobic contribution to exercise, however, most state that tramadol can be more ergolytic than performance enhancing [5,10,11].
Figure 2. History of prescription opioid use from NFL to present. Reprinted from Cottler LB, Ben Abdallah A, Cummings SM, Barr J, Banks R, Forchheimer R. Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug Alcohol Depend. Jul 1 2011;116(1-3):188-94. doi:10.1016/j.drugalcdep.2010.12.003
Figure 3. A, Urine tramadol concentration and B, percentage of samples with tramadol concentration above 50 ng/mL in each sport. The urine samples were measured in the Madrid doping control laboratory between 2013 and 2017. Reprinted from Baltazar-Martins G, Plata MDM, Munoz-Guerra J, Munoz G, Carreras D, Del Coso J. Prevalence of tramadol findings in urine samples obtained in competition. Drug Test Anal. Apr 2019;11(4):631-634. doi:10.1002/dta.2575
Tramadol use among athletes does not appear to be a major cause for concern unless increased rates of use are found during competition for a specific sport as was the case for cycling. It does not appear to be a performance-enhancing drug, but if misused, can have side effects that can negatively impact performance. Furthermore, there is still the potential for dependence to develop, so tramadol use should continue to be monitored. Future studies investigating athlete attitudes and habits around tramadol would be beneficial to better understanding the extent of use among athletes and sport-specific reasons for its consumption. This would allow for a more accurate assessment of the risk for misuse among a particular population in the case of possible regulatory action.
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3. Reines SA, Goldmann B, Harnett M, Lu L. Misuse of Tramadol in the United States: An Analysis of the National Survey of Drug Use and Health 2002-2017. Subst Abuse. 2020;14:1178221820930006. doi:10.1177/1178221820930006
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7. Cottler LB, Ben Abdallah A, Cummings SM, Barr J, Banks R, Forchheimer R. Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug Alcohol Depend. Jul 1 2011;116(1-3):188-94. doi:10.1016/j.drugalcdep.2010.12.003
8. Baltazar-Martins G, Plata MDM, Munoz-Guerra J, Munoz G, Carreras D, Del Coso J. Prevalence of tramadol findings in urine samples obtained in competition. Drug Test Anal. Apr 2019;11(4):631-634. doi:10.1002/dta.2575
9. Holgado D, Zandonai T, Zabala M, et al. Tramadol effects on physical performance and sustained attention during a 20-min indoor cycling time-trial: A randomised controlled trial. J Sci Med Sport. Jul 2018;21(7):654-660. doi:10.1016/j.jsams.2017.10.032
10. Ionescu AM, Popa R, Manolescu BN, et al. THU0331 Tramadol Effects on Exercise Capacity in Patients with Low Back Pain. Annals of the Rheumatic Diseases. 2014;73(Suppl 2):296-297. doi:10.1136/annrheumdis-2014-eular.1439
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