Can co-codamol (paracetamol and codeine) and tramadol be taken together?

From the Guidelines

You should not take co-codamol and tramadol together without medical supervision. Both medications contain opioids that work in similar ways in the brain, and combining them significantly increases the risk of serious side effects including excessive sedation, respiratory depression, and even overdose. Co-codamol contains codeine (an opioid) plus paracetamol, while tramadol is a different opioid medication. Taking these medications together essentially doubles your opioid intake, which can be dangerous. The combination can cause extreme drowsiness, confusion, slowed or difficult breathing, and potentially life-threatening complications.

According to the most recent guidelines, such as those from the American Society of Clinical Oncology (ASCO) in 2023 1, the use of opioids like tramadol and codeine should be carefully considered due to their limitations and potential interactions. Tramadol, for instance, has a low threshold for neurotoxicity and potential interactions with other drugs at the level of cytochrome P450.

If you're experiencing pain that isn't adequately controlled by your current medication, consult your doctor who can adjust your treatment plan safely. They might recommend alternating between medications, adjusting dosages, or prescribing a different pain management approach altogether. Never adjust pain medications on your own or combine prescribed medications without medical guidance, as this can lead to severe consequences, including those affecting morbidity, mortality, and quality of life.

Key considerations include:

• The potential for increased risk of serotonin syndrome when combining tramadol with other serotonergic medications 1.
• The need for caution when using tramadol in patients with a risk of epilepsy or when used in combination with antidepressants 1.
• The importance of selecting the appropriate opioid based on factors such as pharmacokinetic properties, cost, and the patient's specific needs 1.

Given the potential risks and the availability of more recent and comprehensive guidelines, it's crucial to prioritize medical supervision when managing pain with opioids like co-codamol and tramadol.

From the FDA Drug Label

ADVERSE REACTIONS Tramadol hydrochloride was administered to 550 patients during the double-blind or open-label extension periods in U. S. studies of chronic nonmalignant pain. Of these patients, 375 were 65 years old or older. The overall incidence rates of adverse experiences in these trials were similar for tramadol hydrochloride and the active control groups, TYLENOL with Codeine #3 (acetaminophen 300 mg with codeine phosphate 30 mg), and aspirin 325 mg with codeine phosphate 30 mg

The FDA drug label does not directly answer whether you can take cocodamol and tramadol together, but it does provide information on the comparison of tramadol to other pain medications, including those containing codeine and acetaminophen, which are components of cocodamol. Key points:

• Tramadol has been compared to TYLENOL with Codeine #3 in clinical trials.
• The overall incidence rates of adverse experiences were similar between tramadol and the active control groups. However, the label does not provide direct information on the safety of taking tramadol and cocodamol together. 2

From the Research

Combination of Cocodamol and Tramadol

• There is no direct evidence to suggest that taking cocodamol and tramadol together is safe or effective 3, 4, 5, 6, 7.
• Cocodamol is a combination of paracetamol and codeine, while tramadol is a weak opioid analgesic 3, 6.
• Studies have shown that combining paracetamol with a weak opioid like codeine or tramadol may increase the risk of adverse effects, but may not necessarily increase the analgesic effect 3, 6.
• Tramadol has been shown to have a higher risk of drug interactions and adverse effects, such as respiratory depression, compared to codeine 4, 5, 6.
• One study compared the analgesic efficacy and tolerability of tramadol-paracetamol with codeine-paracetamol in patients with moderate-to-severe low back pain, and found that codeine-paracetamol was slightly more effective and better tolerated 7.

Adverse Effects and Interactions

• The combination of cocodamol and tramadol may increase the risk of adverse effects, such as nausea, vomiting, dizziness, headache, drowsiness, and constipation 6.
• Tramadol has been shown to have a higher risk of serious adverse effects, such as respiratory depression, especially when combined with other medications or in patients with certain medical conditions 4, 5.
• The use of tramadol with other medications, such as opioids, benzodiazepines, or antidepressants, may increase the risk of adverse effects and interactions 4.

Clinical Use

• The decision to use cocodamol and tramadol together should be made on a case-by-case basis, taking into account the individual patient's medical history, current medications, and potential risks and benefits 3, 4, 5, 6, 7.
• Patients should be closely monitored for adverse effects and interactions when using this combination, and the dosage and duration of treatment should be carefully managed 4, 5, 6.