Tramadol acts via μ-opioid receptor agonism and monoamine reuptake inhibition but is clinically limited by metabolic dependence, interindividual variability, and addiction risks. Structural modification aims to resolve these limitations. This review systematically summarizes tramadol’s structure–activity relationships and mechanisms, focusing on key strategies for structural optimization. Major advances include: (i) synergistic strategies, such as tramadol–celecoxib cocrystals (tramadol and celecoxib coexist in the supramolecular crystal network at a 1:1 molar ratio), achieving multimodal analgesia at lower doses; (ii) mechanism-balancing strategies such as tapentadol (derivatives of tramadol with a dual mechanism of action), which enhance μ-opioid agonism and norepinephrine reuptake inhibition while attenuating serotonergic effects to improve efficacy; (iii) metabolic optimization utilizing M1 analogues to circumvent CYP2D6 polymorphisms (tramadol is metabolized by this enzyme into the active metabolite M1 to exert analgesic effects); and (iv) pharmacophore optimization leveraging tramadol–morphine homology and “message–address” concepts to design selective ligands. Novel derivatives demonstrate improved potency and metabolic stability but continue to face challenges regarding opioid risks and clinical translation. Future research should integrate rational drug design, delivery systems, and personalized medicine to facilitate the development of safer next-generation analgesics.
Wang et al. (Thu,) studied this question.