Tramadol, initially introduced in Germany in 1977, is a synthetic analgesic and appears to have a dual mechanism of action; a weak μ-opioid receptor agonism and a reuptake inhibition of serotonin and noradrenaline. It is marketed in Tunisia since 2001. Generally, Tramadol is considered to have a very low risk of dependence and abuse, but rare cases of tramadol dependence have been described in patients without prior substance abuse history. We describe one such case in a relatively young, otherwise healthy patient.

Mr AR, a 47-year-old man, presented to get help with tramadol addiction. He had no previous history of illicit drug use, did not smoke cigarettes or drank alcohol.

Mr AR was started on tramadol treatment about 2 years earlier for back pain. He did have better pain control with tramadol, but he gradually started taking more and more. Ultimately, his pain resolved but he was unable to stop taking tramadol: he was taking up to 1700 mg/d of tramadol and had made multiple efforts to stop. When he stopped taking tramadol, he had dysphoria, muscle cramps, anxiousness, restlessness, and a sensation of insects crawling all over his body. His withdrawal symptoms were severe enough to interfere with his work and family life.

Tramadol dependence is very rare but can happen in a patient without substance abuse history. We, as medical practitioners, should be open to the possibility of tramadol dependence and should resort to optimal and judicious use of such a substance.