How should a patient be treated when tapering from tramadol?

basically, this was a situation that happened 10 years ago, and I feel that the doctors responsible for this person's care did just about everything wrong that they could possibly do wrong. Could any GPs/doctors who may see this, tell me how you would treat this situation?

Ok so imagine the patient is a female who had been prescribed Tramadol for 9 months for abdominal pain (8 x 50mg pills per day, every day for 9 months) (should never have happened in the first place) but she becomes pregnant unexpectedly so she shows up at your surgery one morning and tells you she's pregnant and thus needs to stop her tramadol prescription.

You tell her that yes, she'll need to come off it, but it won't be as simple as just stopping taking it because she's been taking it for so long her body will be dependent on it.

So you arrange a tapering plan with her. She tells you that in the previous few weeks she had been having to take extra pills because the dose she'd been taking for 9 months hadn't been working as well (surprise surprise after 9 months!) so she'd been taking up to 12 x 50mg pills per day instead of the prescribed 8 - and now she's desperate to come off the tramadol as soon as possible for the sake of her baby.

So you arrange a tapering plan with her, down to 11 x pills per day for 1 week, 10x per day for the next week, 9x per day for the next week, etc. She does this with little trouble, until she's at the point, weeks later, of going from 5 per day to 4 per day.

That's where the problems start.

She comes back saying the withdrawal is still not over at the end of the week and it's started giving her panic attacks. so you keep her on 4 per day for an extra week, and she then goes down from 4 to 3 a week later.

to cut a long story short, the withdrawal gets unbearable for this girl. she forces herself down to 3 per day, although it takes a few extra weeks, and then even manages to get down to 2 per day - and that's the point where she can't take it anymore - she comes to the surgery begging for a sleeping pill or some anti anxiety medication. she hasn't slept more than 2 hours per night for 6 weeks because of the restless legs, the sweating and shaking, the agitation and panic attacks caused by the withdrawal, the effects of such long term insomnia and the worry that her baby will be born in withdrawal if she can't get off those final two pills per day before it's born. all through those 6 weeks of 0-2 hours sleep per night, she's fought through it and refused to give in and go back to taking more than 2 per day, even though she knew it would take away the insomnia and the anxiety etc and make her feel normal again. she's begging you to give her either a short term small amount of diazepam or a sleeping pill, that will make her sleep so she can then titrate from 2 to 1 pill per day and then 1 to 0 before her baby is born. she says she feels like she's going crazy and suffering in a way that's inhumane

as a doctor, what would you do in this situation, how would you treat this patient, which treatment options would you recommend and which if any medications would you prescribe?

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