Hear my song: auditory hallucinations with tramadol hydrochloride

Abstract

Tramadol hydrochloride is a weak opioid with effects on seratoninergic and adrenergic neurotransmission. 1 It is reported to have fewer opioid adverse effects than conventional opioid analgesia. 2 We report an unusual but important adverse effect not previously reported with the drug. Case reportA 74 year old man with lung cancer was referred to the palliative care team for symptom control. He had pain in the left side of his chest and was advised to take tramadol hydrochloride 50 mg four times daily at home. Soon after starting the tramadol, he began to experience auditory hallucinations. These were particularly vivid and took the form of "two voices singing, accompanied by an accordion and a banjo, singing songs, songs by Josef Locke-old songs." They were distressing, making him feel as though he was going mad. Because of these symptoms we admitted the patient for inpatient care.He was also taking aspirin 75 mg, digoxin 250 g, prednisolone 15 mg, frusemide 40 mg, omeprazole 20 mg, and codanthramer 20 ml, each once daily, and Voltarol 75 mg twice daily, and he was using a Combivent (salbutamol/ipratropium) nebuliser 2.5 ml four times daily, but all these had been unchanged for some weeks before the onset of the auditory hallucinations. The patient had no other adverse effects or signs of toxicity attributable to opioids.We discontinued the tramadol and instead gave two tablets of co-proxamol (dextropropoxyphene 32.5 mg, paracetamol 325 mg) four times daily, with which his cancer pain was well controlled. Two days later the hallucinations ceased. A computed tomographic brain scan around the time of admission showed only established diffuse ischaemic change with no major focal cerebral lesion. There was no history of hallucinations or mental illness. We reported this adverse reaction to the Committee on Safety of Medicines through the yellow card scheme.

Psychosis among substance users

“…Although there are some case reports of psychoses following administration of opioid analgesics for different medical conditions (e.g. [55][56][57]), psychoses among opioid abusers seem to be rare. Hardly any report on 'opioid-induced psychoses' is found.…”

The clinical spectrum of musical hallucinations

“…If a certain treatment was reported, most of the cases resolved by treating the underlying cause, for example stopping a causative medication [32,61,68,94], treating Hashimoto's encephalopathy [101] or Lyme disease [102], or ameliorating hearing [36]. Roberts et al [93] described the case of a 61-year-old woman in whom musical hallucinations disappeared after clipping of two small aneurysms.…”

“…In seven cases, we found concomitant focal brain lesions not incriminated to be the main cause of the musical hallucinations [12,26,33,92,93]. In another 34 of the reported cases, general brain atrophy or not localized pathology could be suspected to act as a cofactor in the aetiology of musical hallucinations [12,27,28,30,[32][33][34]37,46,47,49,51,54,[58][59][60][61]64,65,69,73,78,79,94].…”

“…We included reports of patients in whom intoxication or inflammatory encephalopathy seemed to be the underlying cause [25,28,61,65,68,81,82,94,99,100,101,102] and another seven cases in whom intoxication seems to at least support the aberrant perception [2,28,32,33,36,56,57]. One case did not present with enough information for inclusion in this review [103].…”

Can “Steroid Switching” Improve Steroid-Induced Musical Hallucinations in a Patient with Terminal Cancer?

“…Reported causes of druginduced musical hallucinations include tricyclic antidepressants, carbamazepine, cannabinoids, paracetamol, phenytoin, baclofen, ketamine, and opioids (tramadol and oxycodone) which are often used in palliative care. [17][18][19][20][21] Treatment with steroid-taper should be considered for steroid-induced psychiatric symptoms. 3 There is a report of the effectiveness of ''steroid switching'' in sterioid induced psychosis.…”