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Patients who order tramadol online must be transparent with their doctors about all other substances they are consuming, including herbal supplements and alcohol. Mixing tramadol with alcohol is extremely dangerous and can lead to fatal respiratory depression or profound sedation. There are also dangerous interactions with SSRIs, SNRIs, and other opioids which can complicate the metabolic process in the liver. Since tramadol is metabolized by the liver into a stronger opioid metabolite known as M1, individual genetics play a large role in how effectively—or how dangerously—the drug works. Those who are "ultra-rapid metabolizers" may experience dangerously high levels of the drug in their system, making professional medical oversight and regular check-ups an absolute necessity for safety.