Which is stronger, codeine or tramadol?

From the Guidelines

Tramadol is generally considered stronger than codeine for pain relief. Tramadol works as both an opioid agonist and by inhibiting the reuptake of serotonin and norepinephrine, giving it a dual mechanism of action 1. Codeine, on the other hand, is a prodrug that must be converted to morphine in the liver to be effective, and about 10% of people lack the enzyme (CYP2D6) needed for this conversion, making codeine ineffective for them 1. In terms of potency comparison, 50mg of tramadol is roughly equivalent to 60mg of codeine. However, strength isn't the only consideration when choosing between these medications. Tramadol carries risks of serotonin syndrome when combined with certain medications and may cause seizures in some individuals 1. Both medications can cause side effects including nausea, constipation, dizziness, and respiratory depression, though tramadol typically causes less respiratory depression than other opioids. Both can be habit-forming with potential for dependence and withdrawal, so they should be used at the lowest effective dose for the shortest duration necessary 1.

Some key points to consider when choosing between tramadol and codeine include:

• Tramadol's dual mechanism of action may provide more effective pain relief for some patients
• Codeine's effectiveness may be limited by the need for conversion to morphine in the liver
• Tramadol carries a risk of serotonin syndrome and seizures, particularly when combined with certain medications
• Both medications can cause side effects and have the potential for dependence and withdrawal
• The most recent and highest quality study, published in 2023, recommends considering factors such as pharmacokinetic properties, bioavailability, route of administration, half-life, neurotoxicity, and cost when selecting an opioid for pain treatment 1.

Overall, tramadol is likely a stronger option for pain relief than codeine, but the choice between the two medications should be based on individual patient needs and medical history, and made with caution and careful consideration of the potential risks and benefits 1.

From the FDA Drug Label

Tramadol hydrochloride has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol hydrochloride Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250 mg of tramadol hydrochloride in divided doses were generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg (TYLENOL with Codeine #3) daily, five doses of aspirin 325 mg with codeine phosphate 30 mg daily, or two to three doses of acetaminophen 500 mg with oxycodone hydrochloride 5 mg (TYLOX® ) daily A dose of 100 mg tramadol hydrochloride tended to provide analgesia superior to codeine sulfate 60 mg, but it was not as effective as the combination of aspirin 650 mg with codeine phosphate 60 mg.

Comparison of Codeine and Tramadol:

• A dose of 100 mg tramadol hydrochloride was found to provide analgesia superior to codeine sulfate 60 mg.
• However, the combination of aspirin 650 mg with codeine phosphate 60 mg was more effective than 100 mg tramadol hydrochloride. Based on the information provided, tramadol 100 mg appears to be stronger than codeine 60 mg, but the combination of aspirin 650 mg with codeine 60 mg is more effective than tramadol 100 mg 2.

From the Research

Comparison of Codeine and Tramadol

• Codeine and tramadol are both opioid analgesics used to treat pain, but they have different potencies and mechanisms of action 3, 4, 5.
• Tramadol is a synthetic analogue of codeine, but it has a lower affinity for opioid receptors compared to morphine 4.
• The analgesic potency of tramadol is about 10% of that of morphine following parenteral administration 5.
• Codeine and tramadol can have similar dose-dependent adverse effects as morphine, including respiratory depression 6.
• There is no evidence that codeine or tramadol is less risky than morphine at its lowest effective dose, and they require at least as much vigilance as morphine 6.

Efficacy of Codeine and Tramadol

• Oral tramadol is as effective as codeine for acute dental pain 3.
• Tramadol is effective for treating moderate to moderately severe chronic pain, and it has been shown to reduce pain and improve sleep parameters, joint stiffness, and physical function in patients with osteoarthritis 7.
• Tramadol may be a suitable alternative for patients with inadequate analgesic response or contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors 7.

Safety and Tolerability

• Tramadol has a low potential for abuse and is generally well-tolerated, but it can cause adverse effects such as dizziness, nausea, dry mouth, and sedation 3, 4, 5.
• Tramadol can also cause serious adverse effects, including respiratory depression, serotonin syndrome, hypoglycaemia, hyponatraemia, and seizures 6.
• The safety and efficacy of tramadol have been established in clinical studies, and it is a viable therapeutic option for the management of chronic/persistent nonmalignant pain in some patients 7.