Which statement about tramadol counseling is NOT correct?

• A. Must be tapered when discontinuing tramadol
• B. Beware of concomitant use with serotonergic agents (SNRIs, SSRIs, MAOIs)
• C. CYP3A4 and CYP2C9 are substrates of tramadol
• D. REMS is not required for tramadol

Answer: (D)

Tramadol counseling focuses on safety and how the drug works in the body to prevent common problems. Because stopped abruptly tramadol can cause withdrawal or a rebound increase in pain, it should be tapered gradually rather than suddenly discontinued. Its serotonin-related activity means it can interact with SSRIs, SNRIs, or MAO inhibitors to raise the risk of serotonin syndrome, so concurrent serotonergic medications require caution and monitoring. In terms of metabolism, tramadol is processed by CYP enzymes (notably CYP2D6 for the active metabolite and CYP3A4 for other pathways), so drugs that inhibit or induce these enzymes can alter tramadol’s effect or risk profile. Importantly, there is a REMS program for tramadol, so the statement that REMS is not required is not correct.