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To the Editor: Obsessive-compulsive disorder (OCD) affects 1.9% to 3.3% of the general population in the United States (1). Specific selective serotonin reuptake inhibitors (SSRIs) are often effective in the treatment of OCD (1). However, these medications are slow to act, and many patients have an inadequate response. Opiates have been noted to be efficacious in treatment-refractory OCD (2–4). We describe using the analgesic tramadol in an attempt to provide rapid symptom remission in a previously untreated patient with OCD. Tramadol is an analgesic that binds to opioid receptors and inhibits the reuptake of norepinephrine and serotonin (5).
Ms. A was a 27-year-old white woman with a 10-year history of OCD. She presented approximately 5 weeks after giving birth to a healthy child. There was no history of tic disorder or OCD in her family. Because of the pain from a fourth-degree perineal tear requiring surgical repair, Ms. A was given a dose of the opiate oxycodone. She observed that her obsessions ceased entirely for several hours immediately following administration of the oxycodone. Following the birth of her child, Ms. A’s symptoms worsened. For example, she developed time-consuming rituals around the preparation of her child’s formula and spent hours smoothing out wrinkles in crib sheets to prevent her baby from succumbing to sudden infant death syndrome. She required constant reassurance from her spouse and other family members.
At the time of presentation, Ms. A had a Yale-Brown Obsessive Compulsive Scale (6) score of 26. Because of her previous response to opiates, a regimen of tramadol was initiated. Within 24 hours, she reported by telephone that her obsessions and compulsions had diminished significantly with the tramadol, 50 mg b.i.d. A week later, her Yale-Brown Obsessive Compulsive Scale score had dropped to 19. A dose of fluoxetine, 20 mg daily, was then added (after a discussion of possible serotonergic syndrome). Three weeks later, the fluoxetine dose was increased to 40 mg daily. During the first month of treatment, Ms. A required up to 350 mg p.r.n. daily of tramadol in divided doses (50 mg–100 mg q.i.d.) to diminish her OCD symptoms; her doses of tramadol were increased by approximately 50 mg–100 mg increments weekly over the first 3 weeks because of her tolerance to the anti-obsessive effects. Side effects of tramadol consisted only of initial nausea and mild sedation. Six weeks after the initiation of the two medications, Ms. A found that she no longer required the as-needed doses of tramadol, and her Yale-Brown Obsessive Compulsive Scale score had dropped to 10.
The efficacy of SSRIs in the treatment of OCD has been well established. Tramadol may represent a useful initial treatment for patients with OCD because it has low abuse potential, low physical dependency, and mild tolerance (5), and it may provide rapid symptom reduction during SSRI titration. Controlled studies are required to demonstrate tramadol’s effectiveness in the treatment of OCD.
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