In the last 20 years, the United States of America (USA) have been facing an opioid crisis that has led to an increase in mortality by overdose and suicide [1]. This crisis is now spreading in Europe [2], as indicated by the rise of opioid prescriptions between 2004 and 2016, especially in Northern and Western European countries [3]. In France, hospitalizations due to opioid overdose increased by 128% and death due to opioid overdose by 161% between 2000 and 2015 [4].

According to data from the USA Centers for Disease Control and Prevention, deaths due to drug overdose and suicide increased from 41,364 in 2000 to 110,749 in 2017, and opioids were implicated in one third of suicides by overdose [5]. This suicide risk increase is not only due to the access to opioids as a lethal mean. Indeed, it has been shown that the suicide risk, whatever the method, is higher among individuals receiving higher opioid doses [6]. Consequently, the Department of Veterans Affairs and Clinical Practice Guidelines for the Management of Opioid Therapy defined high suicidal risk as a contraindication for opioid therapy. Prescription of opioid analgesics (but not of non-opioid analgesics) has been associated with lifetime history of suicide attempt (SA) in cohorts of elderly people from the general population, independently of the physical pain level and health status [7, 8]. Moreover, growing evidence suggests a link between opioid system dysfunction and suicidal behaviors [9].

Besides its analgesic use, recent studies investigated tramadol antidepressant properties for the management of major depressive disorder (MDD) [10,11,12]. Tramadol is a mu-opioid receptor agonist with serotoninergic and noradrenergic activities through norepinephrine and serotonin reuptake inhibition (like done by some antidepressants). Tramadol is often considered to be less addictive and with lower abuse potential than other opioids [13], but this remains debated [14, 15]. Indeed, in Finland, tramadol was implicated in 29.4% of all opioid misuse cases between 2010 and 2011, more than codeine (16.3%), fentanyl (14.5%) and oxycodone (6.9%) [16]. In Ireland, deaths linked to tramadol use increased from 9 to 40% of all deaths linked to drug misuse between 2001 and 2011 [17]. Among adolescents and young adults (10–29 years of age) in Ohio (USA), tramadol was implicated in 24.8% of all intentional opioid poisoning cases between 2002 and 2014 [18].

These findings raise the question of tramadol use as antidepressant and also more generally about its use in view of the high addiction and suicide risks. Here, we present the case of a young adult woman with multiple SA related to tramadol addiction. The purpose of this case report is to alert practitioners about the risk of prescription of Tramadol particularly in patients at risk of suicide. Indeed, Tramadol prescription has increased of 68% between 2006 and 2017 and is now the first opioid prescribed in France but also in some others European countries, such as Germany, Italia, Spain and Danemark [19]. Thus, evaluating potential risk of addiction especially within suicidal patients may be primordial to prevent addiction and worsening of suicidal risk, as we will see in this case report.