A patient with Tramadol dependence and predictable provoked epileptic seizures
The patient was a 24-year-old high school educated, married male farmer by occupation, who initially started chewing tobacco at the age of 17 years in the company of his friends. He developed dependence in the form of tolerance, withdrawal, and craving over a period of 6-8 months. At the age of 18 years, he took 2-3 tablets of Tramadol (as a combination preparation of 37.5 mg with Paracetamol 375 mg) on the advice of some friends who used the same to allay fatigue after working in the fields. These were freely available without prescription at the neighborhood pharmacy. The patient found it beneficial to allay fatigue and felt elated after its use and started to take it on a regular basis. Over the next 6-8 months, he developed tolerance and had to take 5-6 tablets/day to derive the same benefit and he experienced a craving to consume these tablets and would often start his day with these tablets. He also started to experience symptoms, of that he claimed were non-specific such as headache and fatigue when he did not take the regular dose of these tablets. This would be relieved on taking the tablets. Over the next 4-6 months, he also started to consume Alprazolam at the dose of 1-2 mg/day, again on the advice of friends who claimed it would help him relax. This too was available freely locally. Over a period of 1 year, he developed dependence to Alprazolam as well. After about 3 years of regular use of Tramadol and Paracetamol combination tablets, he once consumed 15-16 tablets on advice of a friend who claimed it would enable him to sustain an erection for longer duration sexual intercourse. His usual dose was 7-8 tablets of Tramadol–Paracetamol and 2 mg/day of Alprazolam. After about 1h of intake, the patient had an episode of unresponsiveness characterized by tonic–clonic movement of both upper and lower limbs for about 1 min, associated with clenching of teeth and frothing from mouth, following which he remained confused for about half an hour. He was at home at this time and did not take any particular treatment for the same. Gradually, however, he started to notice that whenever he took a higher than usual dose of Tramadol–Paracetamol combination, he would feel jittery and uncomfortable and then he would have an epileptic seizure. This, however, he could prevent by taking a higher than normal dose of Alprazolam at the dose of about 3-4 mg, which he would take concurrently with Tramadol–Paracetamol. He also observed that he could sustain an erection and withhold ejaculation for longer than was usual for him during intercourse whenever he took this higher than usual dose of Tramadol–Paracetamol. Therefore, whenever he planned for having sex, he would use a higher than usual dose of Tramadol–Paracetamol and then prevent the expected seizure with a higher than usual dose of Alprazolam. Whenever he got this combination wrong, he would either be dissatisfied with his sexual experience or have a seizure. Eventually, he was persuaded by family members to seek treatment for his drug taking and seizures. He took treatment from some private de-addiction centers without much relief. His usual pattern was to take 7-8 tablets of Tramadol–Paracetamol in the morning and 3-4 tablets in evening, which he would increase to 13-15 tablets in case he had to perform sexual intercourse and 7-8 tablets of 0.5 mg of Alprazolam daily in two divided doses. On admission and on quitting from his usual drugs, he complained of premature ejaculation and headache. His withdrawal symptoms were largely non-specific and the typical opioid withdrawal symptoms were not observed. His ward stay was essentially uncomplicated and a non-contrast computed tomography (CT) scan of the head and electroencephalography (EEG) were reported normal.