Into, Tramadol question (manage loss of libido)

Quick intro and question:

I am in my mid-30s and have chronic pain from related treatment for Ewing's Sarcoma (pelvis), mostly from radiation therapy. My pain is not too specific in location and is a combination of soft-tissue, bone, and nerve pain in my pelvic, hip, leg, and lower-back area. Since 1988 I have tried physical therapy, a range of NSAIDS, and opiates. Recently, I was on Vicodin 5/500 to manage pain. I have settled on Vicodin because it seems to balance drowsiness and constipation with pain management best. It worked so-so in that it would beat back the majority of it so that I could function without feeling miserable. My dosage was 1 - 2 tablets every six-hours (the 7.5/750 worked better at the cost of being slightly more drowsy). I am a graduate student and to keep myself from getting too sleepy I'd limit myself to ~1 tablet per six hours (2-worked better, but would make me sleepy). I had moved to a new town in 2006 for my graduate studies and had a hard-time establishing relationships with my new primary care doctors and specialists to maintain my pain management protocol (even with substantial documentation from my previous doctors). Basically, they put me through all the previous non-opiate pain medications I had tried in the past that didn't work for me, mostly NSAIDS but I did try Lyrica (which didn’t work well for me after ~8 weeks). After about 1-year of jumping through those hoops and being completely miserable I was put on Tramadol (50mg 4 x day). It has really changed my life. For me, it is more effective than the vicodin and about as effective as Oxycontin (which I had taken several years ago). For the most part, the side-effects have been manageable except for one, sexual dysfunction. My sex drive has taken a nose dive while on Tramadol. Occasionally it will comeback to normal, but those days seem very rare. I have read that this has to do with the SNRI action of Tramadol, in-fact off-label use is to treat pre-mature ejaculation.

So, my question revolves around alternatives to Tramadol, or how others manage/improve this side-effect of Tramadol. I'd hate to stop taking it because it works so well, but the sexual side-effect is affecting my quality of life (me and my wife are a bit frustrated).

I've read that drugs like Wellbutrin can be used with SSRI's to reduce the sexual side-effects of SSRI's and am wondering if anyone has been on a Tramadol + Wellbutrin combo? Although, other anti-derpessents are contraindicated with tramadol...so this may not be possible.

Has anyone tried "Tapentadol"? It's similar to Tramadol but does not have as strong (or does not have) an effect on Seritonin (which may be producing the majority of the sexual dysfunction effects). I saw an article discussing the positive efficacy of Tapentadol in chronic pain....but I'd like to hear from someone who's actually tried it (or is on it).

Also, there are several refereed articles discussing the combination of standard opiates like vicodin with SNRI's to manage pain. Is anyone on such a regimen? I know that many SNRIs and SSRIs will cause sexual dysfunction, but it sounds like each of them works differently for different patients.

Anyway, any response is appreciated. I have an appointment with my primary care physician to discuss these issues in mid-October. I'd really like to hear other's experiences before then....

FYI, I’ve been on Tramadol for about 7-months now. And the sexual dysfunction has not improved. I am really interested in hearing from those who’ve tried, or are on Tapentadol.

Thanks!

I've tried to ask this question in other forums and have not heard much. I suppose I underestimated peoples willingness to talk about this sort of thing. Anyway, I'll update this thread with anything I discover.

-b

Bomba, Please see my very detailed response to your question about Tapentadol. Tapentadol has much less effect on seratonin levels than tramadol does and would be much better to use if you are having libido problems.

Tramadol is really as much of a problem solver as it is a problem creator sometimes.

Tramadol is actually an analogue of codeine (a T3 replacement in sense), and it undergoes a very similiar process in the liver. Codeine turns into 5 percent morphine, whereas about 20 percent of tramadol is turned into an m1 metabolite that is opioid receptor active (though fairly weak). Only about 1/3 of tramadol's pain killer ability comes from its opioid activity though. What makes its more potent than Codeine is its weak reuptake inhibition of both Norephedrine and Seratonin. SNRIs are known to alter our response to pain. Theres also some evidence that shows that tramadol inhibits dopamine, but to a lesser degree than it does NE and SE.

Anytime you have a medication that inhibits SE, theres a risk seratonin based effects logically. However, medications that raise NE or DP along with SE run a higher risk of SE related effects, since increased levels of NE and DP have the potential to increase seratonin levels as well. With tramadol you have just that, 2 additional reputake effects that can indirectly raise SE levels. The other issue with tramadol and its seratonin effects is that tramadol has a long half life. Tramadol is generally given every 6 to 8 hours vs 4 to 6 hours for other pain medications, and this is because it stays in the system longer. Therefore its SE effects linger on hours after the medication is taken. Good for keeping pain away, but bad for side effects.

I really think the only way to combat the libido issue is to limit the use of the medication or to create a scheduled use that allows time for full system elimination. There does exists some anti-physcotic meds that have seratonin blocking properties, but in my opinion a lot of those medications are risky.