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Opioid Use Disorders Attributed to Tramadol Among Egyptian University

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DOI: 10.1097/ADM.0000000000000380

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ORIGINAL RESEARCH

Opioid Use Disorders Attributed to Tramadol Among

Egyptian University Students
Medhat M. Bassiony, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry),
Mohamed Abdelghani, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry),
Ghada M. Salah El-Deen, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry),
Mervat S. Hassan, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry),
Hayam El-Gohari, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry),
and Usama M. Youssef, MBBCh, MSc (Neuropsychiatry), MD (Psychiatry)

investigate the causal relationship between tramadol use, smoking,

Background: Tramadol use is an overwhelming problem in Egypt
with tremendous medical and social consequences especially among
youth. Use liability among Egyptian university students is under-
evaluated. This study aimed to estimate the prevalence and associ-
ated correlates of tramadol use among students from Zagazig
University, Egypt.
Methods: A cross-sectional study included a total of 1135 under-
graduate students, from 10 colleges in Zagazig University. Partic-
ipants were randomly selected and assessed for tramadol use using
The Drug Use Disorders Identification Test (DUDIT) and The Drug
Use Disorders Identification Test—Extended (DUDIT-E).
Results: The prevalence of tramadol use was 12.3% among univer-
sity students, with higher prevalence in male (20.2%) than female
students (2.4%). The average age at onset of tramadol use was
17.6  2.1. Only 15% of the students with substance use were using
tramadol alone whereas the rest (85%) were using at least 1 drug plus
tramadol. One-fifth of these students started with tramadol as their
first drug. Smoking, cannabis, and alcohol use predict tramadol use.
About 60% of students who use tramadol had drug-related problems
and 30% had dependence. Treatment readiness for tramadol use is
negatively correlated with smoking and its duration.
Conclusions: Tramadol use was common among university stu-
dents, with higher prevalence among males. There is a considerable
relationship between tramadol use, smoking, and use of other sub-
stances. Further population-based longitudinal studies need to
From the Department of Psychiatry, Faculty of Medicine, Zagazig University,
Zagazig, Egypt.
Received for publication August 9, 2017; accepted November 23, 2017.
This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors for the conduct of the
research and/or preparation of the manuscript.
The authors declare no conflicts of interest.
Send correspondence to Medhat M. Bassiony, MBBCh, MSc (Neuropsychia-
try), MD (Psychiatry), Psychiatry Department, Faculty of Medicine,
Zagazig University, Zagazig, Sharkia Governorate, Egypt.
E-mail: mbassiony@hotmail.com
Copyright ß 2018 American Society of Addiction Medicine
ISSN: 1932-0620/16/0000-0001
DOI: 10.1097/ADM.0000000000000380
and use of other substances.
Key Words: Egypt, tramadol use, university students, Zagazig
(J Addict Med 2018;xx: xxx–xxx)
D rug use is a devastating crisis in Egypt, raising chal-
lenging alarms to both the community and government
(Okasha, 2004). The United Nations Office on Drugs and
Crime reported that 6% to 8% of adult Egyptians used
cannabis (World Health Organization, 2012). Moreover, the
prevalence of other illicit drugs was seriously increasing,
particularly following the Arab Spring, 2011 (Viney, 2017).
The most affected age group, according to the national
addiction survey, was the Egyptians between 20 and 45 years,
leading them to several educational, medical, and socioeco-
nomic consequences (Hamdi et al., 2013).
Among all used drugs, tramadol, a centrally acting
analgesic (Grond and Sablotzki, 2004), was the most heavily
used illicit drug in the last decade, considered by some as
‘‘youth plague’’ not only in Egypt but also in the neighboring
countries (Fawzi, 2011). According to the Ministry of Health
report on drug addiction in Cairo, 1.4 million people were
addicted to drugs, particularly heroin and/or tramadol (Viney,
2017). Another recent Palestinian study revealed a shift in
drug use from psychotropic drugs to tramadol among youth
over the past few years (Al-Afifi et al., 2012). This alleged
heavy use can be attributed to tramadol’s apparent reputation
as a remedy for alleviating pain (Raffa et al., 1992), reducing
stress and depression (Barber, 2011) and improving sexual
performance (Salem et al., 2008). In addition, despite being
officially announced as a schedule I (highly addictive) con-
trolled drug since 2012 (Egyptian Ministry of Health, 2012),
patients with tramadol use can easily access to tramadol at
relatively low prices and without prescription (Fawzi, 2011).
Although tramadol is a weak opioid with a controversial
risk of dependency when briefly used, its long-term use may
result in a wide array of psychiatric and physical symptoms
including, psychosis, personality changes, indecisiveness,
incoordination during walking, dried mouth (Langley et al.,

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Bassiony et al.
2010), convulsions (Shadnia et al., 2012), and death
(Mayor, 2013). Deaths due to tramadol rose from 83 in
2008 to 154 in 2011 in the UK (Mayor, 2013). Tramadol-
related fatalities were reported also in Sweden (Tjäderborn
et al., 2007) and in Iran (Iravani et al., 2010). Not so far, Egypt
has one of the worst mortality records due to road accidents
whose tramadol use was associated with 18.7% of them
(Fawzi, 2011).
Despite the impact of early drug use on the future of the
youth, tramadol use among university students remains an
underreported issue. The early exposure to illegal drugs often
predicts future drug use and other psychiatric disorders (Gil
et al., 2004). Adolescent drug use was found to be associated
with numerous functioning difficulties at age 30, some of
which appear to be related to recurrent drug use, comorbid
adolescent disorders, or functioning problems already evident
in adolescence (Rohde et al., 2007). Also, the rarity of
accurate and detailed data on tramadol use among university
students in Egypt and neighboring Middle East countries
would reduce the probability of success of any future inter-
ventions aimed at controlling this problem.
To our knowledge, this study would be one of the first
studies that thoroughly investigated tramadol use among
youth in Egypt. Most of the previous research on tramadol
use among youth in Egypt had focused on ‘‘ever versus never’’
use, rather than including detailed information regarding the
interrelation between tramadol and smoking as well as other
drugs, pros, and cons for tramadol use and readiness for
treatment. The aim of the study was to estimate the preva-
lence, sociodemographic and clinical correlates, and personal
attitudes for and motivation of tramadol use among Egyptian
university students.
METHODS
Study Design and Sample Selection
This was a cross-sectional study, which was carried out
in Zagazig University located in Zagazig city, Sharkia Gov-
ernorate, Egypt in 2012–2013. Zagazig University was
founded in 1970 to be the first university in the Eastern Nile
Delta. Zagazig University provides educational services to
more than 100,000 undergraduate students through 33 col-
leges and institutes in different specialties spreading over a
wide regional area in Sharkia. We used systematic random
method, which involves selecting items from an ordered
population using a skip or sampling interval, because we
have tight budget and it is better than random sampling when
data do not exhibit patterns and there is a low risk of data
manipulation by a researcher and this is case in our study. In
addition, we hypothesized that male students are using drugs
more than female counterparts depending on the results of
previous studies. Six practical colleges namely medicine,
pharmacy, veterinary medicine, science, engineering, and
agriculture and 4 theoretical colleges namely arts, commerce,
education, and physical education were selected. The sample
size included in the study was 1173 undergraduate students
from different grades according to EPI-INFO version 6
(Centers for Disease Control and Prevention, Atlanta, GA)
(Dean and Dean, 1994). Students were met in their
2 ß
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med  Volume 00, Number 00, Month/Month 2018
classrooms, to explain the study objectives, confirm confi-
dentiality, and get their consent for participation.
Data Collection and Measures
Screening Questionnaire
Students were given a questionnaire, which included
sociodemographic data (age, gender, type of college, the
number of years of education, and residence) and clinical
data (current smoking status, current tramadol use, types of
substances used alongside tramadol, age at onset of tramadol
use, and age at onset of smoking). After screening, partic-
ipants were assessed for tramadol and other substance use
problems and dependence using The Drug Use Disorders
Identification Test (DUDIT) and The Drug Use Disorders
Identification Test—Extended (DUDIT-E).
The Drug Use Disorders Identification Test
The DUDIT (Berman et al., 2004) was developed to help
screening for drug use problems and was parallel to the Alcohol
Use Disorders Identification Test (Saunders et al., 1993) devel-
oped by the World Health Organization (WHO). This ques-
tionnaire has 11 items about the frequency of drug use, harmful
consequences of drug use, and symptoms of dependence.
DUDIT serves as an effective screening instrument detecting
individuals who have a drug problem or dependence. Drug-
related problems are identified at a cutoff score of 6 points or
more for males and 2 or more for females. Dependence is
identified at a score of 25 or more (Berman et al., 2004).
The Drug Use Disorders Identification Test—
Extended
The DUDIT-E (Berman et al., 2007) was developed to
acquire detailed information about patients’ attitudes toward
their drug use.
The rationale for focusing on patients’ perceptions of
positive and negative aspects of drug use is that these per-
ceptions are assumed to be critical to patient’s motivation to
either continue or cease using drugs. The DUDIT-E is not
explicitly linked to any theory of motivation but relates to both
the decisional balance part of the trans-theoretical model and
expectancy theory (Berman et al., 2010).
DUDIT-E is used after identification of a drug problem
by DUDIT. The first section of DUDIT-E is a 17-item test,
investigating the positive incentives for drug use. This section is
labeled P (positive) section. The second section of the ques-
tionnaire explores negative aspects of drug use and is so labeled
N section. The third and final section has 10 items on treatment
readiness and is labeled the T section. Separate scores can be
calculated for each section of the DUDIT-E. By multiplying the
negative (N) and treatment readiness (T) scores and dividing
that by the positive (P) score, the ‘‘motivational index’’ is
achieved. The assumption behind the motivational index is
that a relatively negative view of the consequences of drug use
will potentiate treatment readiness, whereas a positive view will
diminish it (Berman et al., 2007). An investigator translated the
test into Arabic (after permission of the authors), another
investigator translated it back to English and then a third one
translated the test into Arabic again.
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J Addict Med  Volume 00, Number 00, Month/Month 2018 Tramadol Use Among University Students

TABLE 1. Sociodemographic and Clinical Distributions of Study Participants

Pure Tramadol With Other No X2 or
Tramadol Use other Substances Use Substances Use Substance Use ANOVA, P
N ¼ 1173 (%) 21 (1.8) 123 (10.5) 120 (10.2) 909 (77.5)
Age (M, SD) 20.43 (1.12) 20.82 (1.89) 20.68 (2.12) 20.19 (1.67) 6.8, <0.001
Gender
Male 16 (76.2) 117 (95.1) 114 (95.0) 427 (47.0) 169.5, <0.001
Female 5 (23.8) 6 (4.9) 6 (5.0) 482 (53.0)
College type
Practical 13 (61.9) 42 (34.1) 35 (29.2) 678 (74.6) 156.9, <0.001
Theoretical 8 (38.1) 81 (65.9) 85 (70.8) 231 (25.4)
Years of Education (M, SD) 14.6 (1.28) 14.7 (1.24) 14.5 (1.19) 14.6 (1.21) 1.1, 0.357
Residence
Urban 15 (71.4) 64 (52.0) 57 (47.5) 422 (46.4) 11.3, 0.010
Rural 6 (28.6) 59 (48.0) 63 (52.5) 487 (53.6)
Smoking 13 (61.9) 118 (95.9) 110 (91.7) 104 (11.4) 638.3, <0.001
Bold text indicates statistical significance where P < 0.05.
Students with polysubstance (with and without tramadol) were more likely to be older males with more theoretical education and smoking than students who used pure tramadol and
control group (no substance). Students with pure tramadol were more likely to be males with more smoking and from urban residence than the control group as shown in Table 4.
ANOVA, analysis of variance.

Data Processing and Statistical Analysis
The collected data were reviewed and coded. SPSS
(Statistical Package for Social Science) statistical software
version 16.0 (SPSS Inc, Chicago, IL) was used for data
analysis. Quantitative data were represented as arithmetic
means and standard deviations (mean  SD); the analysis
of variance test was used for comparison between 2 groups
and Mann-Whitney U test for data not normally distributed.
Qualitative data were represented as frequencies and percen-
tages; Chi-square test (x2) was carried out for calculating
significant relations between the groups. Pearson correlation
coefficient was used to evaluate the degree of relationship
between 2 variables that had a linear relationship. Logistic
regression models were used to obtain odds ratios and 95%
confidence intervals to determine the association between
tramadol use and sociodemographic and clinical variables.
All results were considered statistically significant when the
significant probability was less than 5% (P < 0.05).
RESULTS
(range 6–22 years). Other substances’ use included alcohol,
cannabis, and others: 107 (9.1%), 220 (18.7%), and 18 (1.5%),
respectively. A total of 345 (29.3%) students were smokers.
The age at onset of smoking was 16.78  2.71 (range 6–25).
Tramadol Use Correlates
Sociodemographic and clinical variables are displayed in
Table 1. All variables were statistically significant except years
of education. However, separate comparisons between each 2
different subgroups showed various results. When compared
with other substance use students, pure tramadol users were
more likely to be younger (20.43  1.12 vs 20.68  2.12,
P < 0.001), more females (23.8% vs 5%, P < 0.001), of practi-
cal education (61.9% vs 29.2%, P < 0.001), from urban areas
(71.4% vs 47.5%, P ¼ 0.01, and less smokers (61.9% vs 91.7%,
P < 0.001) as shown in Table 1.
With further logistic regression of all statistically sig-
nificant variables predicting tramadol use, smoking followed
by cannabis and alcohol use were the only significant pre-
dictors of tramadol use among students, as shown in Table 2.

Sociodemographic and Clinical Characteristics

This study included 1173 University students, 674 TABLE 2. Logistic Regression of Tramadol Use Predictors
(57.3%) males, 768 (65.5%) practical colleges’ students, Among Study Participants
615 (52.4%) from rural areas, the mean age was
Tramadol Use
20.32  1.76 years (range 17–34 years) and the mean years
of education was 14.63  1.21 (range 13–17). A total of 144 P OR (95% CI)
(12.3%) of participants used tramadol at least once during Age 0.425 0.9 (0.8–1.1)
their lives. Among students who used tramadol, 21 (14.6%) Gender (male) 0.445 1.0
were using tramadol alone whereas 123 (85.4%) were using Female 0.7 (0.3–1.6)
College type (practical) 0.699 1.0
more than 1 drug (cannabis, alcohol, or other substances Theoretical 1.1 (0.7–1.9)
alongside tramadol). Among all university students, the prev- Years of education 0.071 1.3 (0.9–1.7)
alence of cannabis was 18.8%, alcohol was 9%, and other Residence (urban) 0.083 1.0
substances were 1.5% [opium (12 students, 1.02%), alprazo- Rural 0.7 (0.4–1.1)
Smoking <0.001 6.8 (3.1–15.3)
lam (5 students, 0.43%), antihistaminic (1 student, 0.09%)]. Alcohol use <0.001 3.4 (2.0–5.8)
Among students with substance use, tramadol was Cannabis use <0.001 5.3 (2.9–9.6)
reported as the first substance used by 21%, the second Use of other substances 0.756 1.2 (0.4–3.8)
substance used by 35%, and the third substance used by Bold text indicates statistical significance where 95% confidence intervals do not
41%. The age at onset of tramadol use was 17.55  2.07 include the null value (1.00).

ß 2018 American Society of Addiction Medicine 3

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Bassiony et al. J Addict Med  Volume 00, Number 00, Month/Month 2018

TABLE 3. Correlations Between DUDIT Score and Sociode- Positive and Negative Thoughts, Treatment
mographic and Clinical Characteristics of Tramadol Using Readiness and Motivational Index Among
Study Participants Students With Tramadol Use
As displayed in Table 4, positive thoughts about tra-
DUDIT Score Pearson Correlation (r) P
madol were positively correlated with male gender, studying
Age 0.03 0.762 in theoretical colleges, polysubstance tramadol use, and can-
Years of education 0.10 0.258
Age of first tramadol use 0.19 0.079
nabis use, while inversely correlated with the mean age at
Age of onset of smoking 0.32 0.005 onset of tramadol use. Treatment readiness correlation was
Gender (M, SD) MWU test, P inversely correlated with smoking (treatment readiness mean
Male 19.6 (9.3) 344.0, 0.171 for smoking (47.4) was much less than nonsmoking mean
Female 14.9 (9.3) (72.8); z ¼ 2.17 and P ¼ 0.03) and positively correlated with
College type
Practical 14.9 (10.5) 1112.0, <0.001 the mean age of smoking onset.
Theoretical 21.9 (7.6)
Residence DISCUSSION
Urban 20.1 (9.7) 1833.0, 0.255 The current study revealed that the prevalence of tra-
Rural 18.5 (8.9)
Smoking 19.9 (9.1) 276.5, 0.015
madol use among Zagazig University students was 12.3%.
Pattern of tramadol use This result is consistent with a previous study conducted in
Pure tramadol use 13.8 (10.5) 595.5, 0.027 Egypt about the prevalence of tramadol use among students of
Polysubstance use 20.12 (8.95) Mansoura University, which was 12.6% (Mahgoub et al.,
Use of other substances 2016). It is also consistent with a study done in another
Alcohol 20.7 (9.7) 1787.0, 0.169
Cannabis 20.5 (8.8) 957.5, 0.015 Middle Eastern country in Hamadan (Iran), which was
Others 23.1 (9.4) 425.5, 0.135 12.5% (Bashirian et al., 2014).
Bold text indicates statistical significance where P < 0.05.
However, in Scotland, the frequency of tramadol use
DUDIT, Drug Use Disorders Identification Test. was 2.5% in 2010 (Ruscitto et al., 2015), which was so much
far from that of our study. This discrepancy can be in part
explained on the basis that there is a tramadol black market in
Egypt where patients can get it without a prescription (Fawzi,
Drug-related Problems and Dependence 2011), despite the official declaration of tramadol as a control
Among students with tramadol use, 86 students drug (Egyptian Ministry of Health, 2012). Moreover, there are
(59.7%) had drug-related problems (DUDIT score 6 numerous cheap forms of tramadol that are of unknown
in males and 2 in females) and 43 (29.9%) had origin, and probably manufactured away from the legally
dependence (DUDIT score 25). Those who were studying registered pharmaceutical companies. Also, patients, espe-
in theoretical colleges, smokers, of a younger age of smoking cially youth, were used to having tramadol for various arrays
onset, used polysubstance, tramadol, or cannabis, were more of symptoms either physical like pain and premature ejacula-
likely associated with drug-related problems as shown in tion or psychological like mood or sleep-related problems
Table 3. (Lord et al., 2011).

TABLE 4. Correlations Between Drug Use Disorders Identification Test—Extended Scores and Sociodemographic and Clinical
Characteristics of Tramadol Using Study Participants
DUDIT-E Score
Positive Negative Treatment Readiness Motivational Index
Pearson correlation (r), P
Age 0.01, 0.956 1.54, 0.128 0.00, 0.981 0.03, 0.765
Years of education (M, SD) 1.50, 0.137 0.21, 0.051 0.03, 0.788 0.05, 0.621
Age of first tramadol use 0.26, 0.051 0.19, 0.167 0.03, 0.813 0.01, 0.971
Age of onset of smoking 0.17, 0.225 0.04, 0.786 0.278, 0.049 0.01, 0.947
MWU test, P
Gender 152.0, 0.006 348.5, 0.881 257.5, 0.417 187.5, 0.075
College type 552.0, 0.001 699.5, 0.082 650.0, 0.056 693.0, 0.125
Residence 1264.0, 0.946 1029.5, 0.225 1117.0, 0.671 1155.0, 0.885
Smoking 289.0, 0.593 263.0, 0.847 130.0, 0.030 205.0, 0.308
Pattern of tramadol use 331.0, 0.033 359.5, 0.180 382.5, 0.297 434.5, 0.661
Use of other substances
Alcohol 984.5, 0.051 1040.5, 0.261 1060.5, 0.410 1161.0, 0.931
Cannabis 498.0, 0.004 626.0, 0.174 699.0, 0.521 672.5, 0.384
Others 183.0, 0.051 270.0, 0.503 246.0, 0.330 218.5, 0.178
Bold text indicates statistical significance where P < 0.05.
DUDIT-E, Drug Use Disorders Identification Test—Extended; MWU

4 ß 2018 American Society of Addiction Medicine

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J Addict Med  Volume 00, Number 00, Month/Month 2018
Addressing the relationship between tramadol and other
substances as well as smoking was a critical issue in our study
due to their proposed bidirectional influence in relation to
severity, impairment or treatment readiness. In our study, all
proposed risk factors except cigarette smoking, cannabis, and
alcohol use failed to predict tramadol use among university
students. Moreover, the majority of students with tramadol
use were using other substances (at least 1 drug alongside
tramadol). In addition, students with tramadol use who were
smokers, smoking at a younger age and using other substances
alongside tramadol were more likely involved in drug-related
problems and dependence. These relationships were previ-
ously assessed in numerous studies. A study about monitoring
tramadol use in the United States found that around 95% of
tramadol use patients used at least 1 illicit substance during
their lives (Cicero et al., 1999). In an Egyptian sample of
tramadol use patients admitted for detoxification, researchers
reported a bidirectional association between heavy smoking
and severity of tramadol dependence. Moreover, they con-
cluded that reducing cigarette smoking would help tramadol
dependents reduce their tramadol intake (Shalaby et al.,
2015). In addition, an Iranian study found that smoking
and illicit drug use predicted tramadol use among Iranian
university students (Fathi et al., 2012). Even among adoles-
cents, tramadol use was associated with a higher risk of
using substances like alcohol, cannabis, and amphetamines
(Nazarzadeh et al., 2014), and most of the adolescents with
tramadol use started their tramadol after smoking (Bassiony
et al., 2015).
Our study found the mean age of onset of tramadol use
was the latest (18 years) after tobacco smoking, alcohol, and
cannabis (16.8, 17.5, and 17.7 years, respectively). In addi-
tion, tramadol was reported as the first ‘‘earliest’’ substance
used in only about one-fifth of substance use students, which
was much lesser than that of cannabis (66% of substance use
students). Consistent with our findings, an American study
conducted among university students found that alcohol,
tobacco then cannabis were the earliest substances of expo-
sure (Arria et al., 2008). Interestingly, these drugs were
followed by prescription drugs (stimulants and analgesics).
This pattern of various substance uses is quite similar to that of
Egyptian university students in our study if we consider the
easiness of getting cigarettes by adolescents and the religious
prohibition of alcohol use in Egypt as a country with a
majority of Muslims. Moreover, the mean age of onset of
use of all substances including tramadol (after age 17), apart
from tobacco, reflects the age of transition from the secondary
school to college where availability of illicit substances as
well as lesser parental supervision would ease access to these
substances. Also, this age can permit students to dispense
prescription drugs or even easily get them as well as other
substances from drug dealers enhancing the probability of
their first use of drugs.
The drug-related problems and dependence are consid-
ered a further step toward progression from merely accidental
or experimental drug use to drug use. Our study found the
frequency of tramadol use (referred here as drug-related
problems and dependence) among participants was 11%. This
finding reflects the growing risks and consequences that
ß 2018 American Society of Addiction Medicine
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Tramadol Use Among University Students
tramadol results in among youth, and how tramadol is differ-
ently recognized among students as a pure drug of use, not
merely a prescribed drug that is medically dispensed with
strict regulations as in western countries. An Iranian study
reported consistent results; frequency of lifetime tramadol use
was 12.5% (Bashirian et al., 2014). However, another study
found that only 2% of Iranian medical students used pre-
scribed opioid drugs (Abbasi-Ghahramanloo et al., 2015). The
researchers, in the last study, did not investigate each pre-
scribed drug separately and ignored other sources of tramadol
supply. In Egypt, the widespread of tramadol use is—in part—
related to its easy availability without prescription (Fawzi,
2011).
Various perceptions of patients with drug use to their
own drug use can be considered as an indicator for future
prognosis and motivation for drug abstinence (Laudet and
Stanick, 2010). Our study found that male and students with
polysubstance use (especially cannabis use) are more likely to
perceive tramadol as an acceptable drug while smokers
(especially old smokers) are less likely to be ready for
treatment. Men usually tend to justify their drug use even
during abstinence (Stocker, 1998). Male students often use
tramadol for its pleasant ‘‘high’’ effect (Lord et al., 2011) or as
a remedy for premature ejaculation (Salem et al., 2008).
Consistent with our findings, polysubstance patients can
hardly decrease their rate of use over time (Kuo et al.,
2014) and smoking was associated with poor prognosis of
abstinence of alcohol (Friend and Pagano, 2005) and stimu-
lants (Weinberger and Sofuoglu, 2009). Therefore, targeting
use of other substances and smoking among students with
tramadol use can help reducing their satisfaction with trama-
dol use and enhance their readiness for treatment.
Clinical Implications
This study found that tramadol use is common among
Egyptian university students. It would be advisable that
undergraduate students undergo tramadol toxicological
screening upon university admission for early detection and
management. It is also advocated that management programs
targeting smoking and associated substance use especially
cannabis would enhance tramadol abstinence among univer-
sity students. The findings of this study might shed the light on
the importance of more authority surveillance regulations for
dispensing tramadol, especially for youth.
LIMITATIONS
Our findings cannot be interpreted apart from few study
limitations. First, this study was cross-sectional survey study,
so future longitudinal studies need to be done to identify the
causal nature of the associations between tramadol use and its
predictors. Second, the survey was subjectively answered by
the students, which might lead to both selection and recall
biases. Third, despite the large sample size, the apparent low
response rate might limit the generalizability of the findings.
Despite these limitations, our study is one of the most
recent and few studies to estimate the prevalence of and
personal attitudes toward tramadol use among university
undergraduate students. These students represent the corner-
stone of any future national development plans; therefore,
5
CE: A.M.; JAM-D-17-00126; Total nos of Pages: 6;
JAM-D-17-00126
Bassiony et al.
these findings can help addressing the size of this devastating
problem and identifying its predictors, which were not thor-
oughly analyzed in the previous studies targeting these
populations.
CONCLUSIONS
Tramadol use was common among university students.
Tramadol use was correlated with smoking and its duration,
and polysubstance use. Gender, smoking, and polysubstance
use influence the students’ attitudes toward their tramadol use.
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