Contributor: Aaron Lessen, MD Educational Pearls: Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable 3-10% of people cannot metabolize tramadol and it does not work Some others over-metabolize tramadol and it causes greater effect Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, and it acts to inhibit serotonin reuptake Recent study evaluated all-cause mortality of tramadol compared to codeine and found tramadol had nearly double the all-cause mortality as those prescribed codeine Overall tramadol has many risks and should be critically evaluated before prescribing References Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2021 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/ Association of tramadol vs codeine prescription dispensation with mortality and other adverse clinical outcomes Xie J, Strauss VY, Martinez-Laguna D, et al. JAMA. 2021;326(15):1504-1515. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!