The Differences Between Toradol and Tramadol
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TramadolMedically reviewed by Alex Yampolsky, PharmD
Toradol (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID) that treats pain and inflammation.
Tramadol, often referred to by its brand name Ultram, is an opioid medication used to treat pain.
This article will provide detailed information about both U.S. Food and Drug Administration (FDA)-approved prescription drugs.
What Is Toradol?
Toradol contains ketorolac, a nonsteroidal anti-inflammatory drug (NSAID).
Toradol is FDA-approved for the following uses:
Short-term treatment of moderately severe acute pain requiring strong (opioid-level) pain management
After surgery to control pain
Toradol is always started as an injection into a:
Vein (intravenous or IV), or
Muscle (intramuscular or IM)
It may then be continued as an oral (by mouth) treatment.
Toradol has associated risks and can only be used for five days.
Sometimes, healthcare providers prescribe a medication for a use that is not FDA-approved. This is called off-label prescribing. Toradol is only FDA-approved for use in adults 18 years and older.
Sometimes healthcare providers prescribe this medication off-label for the following:
Moderate to severe pain in children
Pain due to cancer that has metastasized (spread) to the bones
Acute migraine pain treatment in the emergency room setting
Common side effects of Toradol include, but are not limited to:
Nausea
Stomach pain
Indigestion
Headache
How Does Toradol Work?
The way Toradol works is not entirely understood.
It's thought to prevent the body from producing prostaglandins.
Prostaglandins are substances that cause pain and inflammation.
So, by preventing the production of prostaglandins, Toradol helps reduce symptoms of pain and inflammation.
What Is Tramadol?
Ultram (tramadol) is an opioid pain medication for severe pain.
The FDA approved its use in adults to treat pain severe enough to require opioid pain medicine.
It is a controlled substance, which means there is potential for abuse and dependence.
Due to these risks, tramadol should only be used when non-opioid medications:
Are not strong enough to relieve the pain
Cannot be tolerated
Tramadol is sometimes prescribed off-label to treat the following:
Osteoarthritis pain
Postherpetic neuralgia (skin pain after a shingles infection)
Diabetic neuropathy (nerve damage associated with diabetes)
Common side effects of tramadol include, but are not limited to, the following:
Dizziness
Vertigo (a spinning sensation)
Nausea
Vomiting
Constipation
Headache
Sleepiness
Itching
How Does Tramadol Work?
The way tramadol works is not completely understood.
It's thought to work by binding to opioid receptors.
It also inhibits the reuptake of neurotransmitters in the brain that carry messages such as:
This results in pain relief.
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TramadolDosage: Toradol vs. Tramadol
Toradol
Toradol (ketorolac) is an injectable medication that can be used IV or IM.
It is also available as a 10 milligrams oral tablet taken by mouth.
The oral tablet should only be taken after the medication is injected.
Toradol is only approved in adults. It is not approved for children or teenagers under 18 years old. However, some healthcare providers prescribe it off-label in these populations.
After an injection, oral Toradol can be taken as 10 milligrams by mouth every 4 to 6 hours with food as needed for pain.
Sometimes, a one-time oral dose of 20 milligrams will be given before the 10 milligram dose is started.
Toradol should be prescribed at the lowest effective dose and for the shortest possible period.
The total time that someone should take this medication, including by injection or mouth, is a maximum of five days.
Older adults or individuals who weigh less than 110 pounds may be prescribed a lower dosage.
Tramadol
Tramadol is available as:
Immediate-release tablets (50 milligrams and 100 milligrams)
Extended-release tablets (100 milligrams, 200 milligrams, and 300 milligrams)
Extended-release capsules (100 milligrams, 150 milligrams, 200 milligrams, and 300 milligrams)
An oral liquid that contains 5 milligrams per 1 milliliter
The dosage varies based on the formulation as well as other individual factors.
However, a typical dosage of immediate-release tramadol is 50 to 100 milligrams by mouth every 4 to 6 hours as needed for pain.
As with Toradol, the lowest effective dose of tramadol should be prescribed for the shortest time.
Older adults may be prescribed a lower dose.
The drug should be slowly tapered when stopping tramadol to avoid withdrawal symptoms.
Your healthcare provider will provide you with a tapering schedule.
Help Is available
Because tramadol is a controlled substance, it has the potential for abuse and dependence. Talk to your healthcare provider about safe opioid use, and make sure you have a prescription for Narcan, which can save your life in an overdose. If you need help, you can make a free, confidential call to the SAMHSA National Helpline at 1-800-662-HELP (4357).
Alternatives for Chronic Pain Management
Ask your healthcare provider if you are interested in the following alternatives for chronic pain management. Many of the following can be combined with your prescribed medication:
Acupuncture: An extensive review of studies found that acupuncture was helpful for pain due to chronic musculoskeletal, headache, and osteoarthritis pain. The effects lasted for some time.
Anti-inflammatory diet: An anti-inflammatory diet has helped reduce pain and improve quality of life. Consult a registered dietitian (RD or RDN) for more information.
Biofeedback: Biofeedback is a type of mind-body therapy that allows you to control some of your body's functions. It may help with pain management.
Exercise: Regular (not fatiguing) physical activity has helped with chronic pain. Consult your healthcare provider before beginning any new exercise program.
Hypnosis: Some studies suggest that hypnosis helped with pain relief.
Meditation: Meditation has helped with pain, quality of life, and symptoms of depression.
Osteopathic spinal manipulation: Some evidence showed visceral spinal manipulation reduced pain and disability in people with chronic non-cancer pain.
Tai chi: Some studies found tai chi helped with chronic pain.
Transcutaneous electrical nerve stimulation (TENS): Studies show less pain during and after TENS treatment.
Yoga: Yoga may help with pain by stretching, strengthening muscles, and regulating your nervous system.
Black Box Warnings
Both Toradol and tramadol have a black box warning, which is the most serious warning required by the FDA.
Toradol Black Box Warning
The Toradol black box warning informs healthcare providers and people of the following risks/considerations:
Toradol (ketorolac) should only be used for up to five days to treat moderately severe acute pain.
Oral ketorolac should only be used to continue treatment after IV or IM Toradol when necessary.
The maximum of five days applies to a combined duration of the IV or IM and oral Toradol.
Toradol is not approved for use in children.
Toradol should not be used for minor or chronic (ongoing) pain.
The maximum daily dose of oral Toradol tablets is 40 milligrams. A higher dose will not help pain but can increase the risk of severe side effects.
Toradol may cause gastrointestinal (GI; stomach and intestinal) bleeding, perforation (holes), and ulcers (sores). These complications can be severe and may cause death - and can occur at any time during Toradol use and without warning. Toradol should not be used in individuals with certain gastrointestinal conditions (see next section). Older adults are at higher risk for serious GI complications.
NSAIDs, including Toradol, increase the risk of severe heart events, including heart attack and stroke, which can cause death.
Toradol should not be used before or after heart bypass surgery (CABG).
Toradol should not be used in people with severe kidney problems or at risk for kidney failure.
Because Toradol affects platelets, it should not be used in individuals with bleeding or clotting conditions.
Toradol should not be used to prevent pain before major surgery.
Toradol should not be used during labor and delivery.
Toradol should not be used in people who take aspirin or another NSAID.
Specific individuals will need lower dosages of Toradol. This includes adults aged 65 years or older, adults under 110 pounds, and people with elevated serum creatinine.
Tramadol Black Box Warning
The tramadol black box warning informs healthcare providers and people of the following risks/considerations:
Tramadol is a Schedule IV controlled substance. It has a risk of abuse and dependence, which can lead to overdose and death. Individuals should be assessed for risk before taking tramadol and regularly monitored during treatment.
Slowed and ineffective breathing could occur, which can be severe, life-threatening, or cause death. Individuals should be closely monitored, especially when treatment starts or the dose increases.
If a child accidentally takes tramadol, an overdose may occur that can cause death. Life-threatening respiratory depression (slowed, ineffective breathing) and death have occurred in children who took tramadol. Some cases occurred after a tonsillectomy and/or adenoidectomy (surgically removing the tonsils and/or adenoids). In these cases, tramadol may have been prescribed off-label because it is not approved in this age group.
Tramadol is not approved for use in anyone under 18 years old. Tramadol should be avoided in anyone under 12 or children under 18 after a tonsillectomy and/or adenoidectomy.
Using tramadol during pregnancy can result in a life-threatening condition for the baby called neonatal opioid withdrawal syndrome. Pregnant individuals should discuss risks and benefits with their healthcare provider before using tramadol.
Tramadol is known as a central nervous system (CNS) depressant. It causes a slowing down of nervous system activity. Therefore, tramadol should not be combined with alcohol or other CNS depressants like sleeping medication, anxiety medicine, or other opioids except when necessary and under close monitoring.
Who Should Avoid Toradol or Tramadol?
Toradol
Toradol is not appropriate for everyone.
Before taking Toradol, tell your healthcare provider about your:
Medical conditions
Medical history
Family history
You should not take this medication if you are allergic to ketorolac, any NSAID, or any of the inactive ingredients in Toradol.
Other people who should not take Toradol include the following:
People with aspirin-induced or NSAID-induced asthma or hives
People with Samter's triad (a condition where the individual has all three conditions: Asthma, sinus condition with nasal polyps, and aspirin sensitivity)
People who are going to have (or have just had) CABG surgery
People who are going to have any major surgery
People with severe kidney problems
People with active bleeding
People with a blood clotting disorder
People with a history of GI bleeding or ulcers
People with cerebrovascular hemorrhage (stroke due to brain bleeding)
People who are volume-depleted (low plasma)
Individuals who are pregnant (Toradol should never be used starting at 30 weeks of pregnancy, and at other times during pregnancy, your healthcare provider should weigh risks and benefits)
Individuals in labor and delivery
In some people, Toradol may be prescribed cautiously only if the healthcare provider determines it is safe.
There are many conditions where the healthcare provider will weigh risks and benefits to determine if Toradol is safe.
If Toradol is prescribed, you will be closely monitored.
Some examples include people with heart, liver, and specific GI problems.
Tramadol
Tramadol is not appropriate for everyone.
Before taking tramadol, tell your healthcare provider about your:
Medical conditions
Medical history
Family history
You should not take this medication if you are allergic to tramadol, any opioids, or any of the inactive ingredients in this medication.
Other people who should not take tramadol include the following:
People who have taken an MAO inhibitor medicine in the past 14 days
People who are ultra-rapid CYP2D6 metabolizers (these people break down certain medicines very quickly)
Children and teenagers under 18 years old
People with electrolyte abnormalities
People with GI obstruction (blockage)
People with respiratory depression
People with acute or severe asthma
People who are intoxicated (from drugs or alcohol)
People who are having suicidal thoughts or behaviors
People with a history of addiction
Anyone who is in a coma or impaired consciousness
People in circulatory shock
Additionally, people with severe kidney or liver problems should not take the extended-release form of tramadol.
Tramadol may be prescribed with caution in some people only if the healthcare provider determines it is safe.
There are many conditions where the healthcare provider will weigh risks and benefits to determine if tramadol is safe.
If tramadol is prescribed, you will be closely monitored.
Some examples include people with particular heart, liver, or lung conditions.
Interactions for Toradol and Tramadol
Both medications have lengthy lists of potential drug interactions.
The following will cover some of the major drug interactions.
Before taking Toradol or tramadol, tell your healthcare provider about all of the medicines you take, including:
Prescription and over-the-counter (OTC) medicines
Vitamins
Supplements
While taking Toradol or tramadol, do not start any new medications without approval from your healthcare provider.
Talk to your healthcare provider for more information about drug interactions and how they may affect you.
Toradol Interactions
Avoid alcohol while taking Toradol.
Alcohol combined with Toradol can increase the risk of stomach and intestinal bleeding. This can cause death.
Some examples of drug interactions with Toradol include, but are not limited to:
Blood thinners like Jantoven (warfarin)
Other NSAIDs
Diuretics ("water pills") such as Lasix (furosemide) or hydrochlorothiazide
ACE inhibitors such as lisinopril or ramipril
ARBs such as olmesartan or valsartan
Certain anticonvulsants like Dilantin (phenytoin)
SSRI antidepressants such as Lexapro (escitalopram) or Prozac (fluoxetine)
SNRI antidepressants such as Effexor (venlafaxine)
Tramadol Interactions
Ask your healthcare provider if you should avoid grapefruit juice while taking tramadol.
Avoid alcohol while taking tramadol.
Alcohol combined with tramadol can cause various complications including:
Very low blood pressure
Fainting
Impairment
Slowed breathing
Coma
Death
Some examples of drug interactions include, but are not limited to:
Jantoven; Coumadin (warfarin)
Diuretics
Lithium
Methotrexate
ACE inhibitors
ARBs
Benzodiazepines like Valium (diazepam) or Xanax (alprazolam)
Antidepressants
MAO inhibitors (must separate use by at least 14 days)
Triptans for migraine, such as Imitrex (sumatriptan)
Muscle relaxants like Flexeril (cyclobenzaprine)
Other opioids like oxycodone
Sleeping medications like Ambien (zolpidem)
Macrolide antibiotics such as Biaxin (clarithromycin) or Zithromax (azithromycin)
Antifungals such as Diflucan (fluconazole)
Summary
Toradol and tramadol are both FDA-approved prescription medications used to treat pain.
Toradol is a nonsteroidal anti-inflammatory drug used to treat acute pain for five days or less, while tramadol is an opioid medication used to treat severe pain.
Both drugs have warnings and drug interactions to be aware of - in fact, the prescribing information for each medication is so extensive that it is impossible to list all of the information provided.
Therefore, your healthcare provider can only determine the most appropriate drug for you based on your unique medical history.
Frequently Asked Questions
What is an NSAID?
NSAID stands for nonsteroidal anti-inflammatory drug. Toradol (ketorolac) is an NSAID. NSAIDs work by reducing the body's production of substances called prostaglandins, which cause pain and inflammation.
Does tramadol cause addiction?
Tramadol is an opioid pain medication and is a controlled substance, so it does have the potential for abuse and dependence. Before prescribing an opioid pain medication, the healthcare provider will assess your risk of dependence and monitor you carefully during treatment. Individuals who need help should call the free and confidential SAMHSA hotline at 1-800-662-HELP (4357).
What is the best pain medication?
The best medication for pain depends on many factors, including the type and severity of symptoms, age, other medical conditions, and potential drug interactions. Consult your healthcare provider for medical advice on the best medication for you.
