Codeine and Tramadol Dosages for Pain Management
For pain management, tramadol is typically dosed at 50-100 mg every 4-6 hours with a maximum daily dose of 400 mg, while codeine is usually prescribed at 15-60 mg every 4-6 hours with a maximum daily dose of 360 mg. 1, 2
Tramadol Dosing
- Standard immediate-release formulation: 50-100 mg every 4-6 hours, not to exceed 400 mg daily 1, 2
- Modified-release formulation: 100-150-200 mg tablets with duration of effectiveness of 12 hours 1
- Available forms include drops (100 mg/ml) and capsules (50 mg) 1
- For opioid-naïve patients, start with 50 mg and titrate as needed 2
- Clinical trials have shown that a 10-day titration schedule (increasing by 50 mg every 3 days) results in fewer discontinuations due to side effects than more rapid titration 2
Codeine Dosing
- Standard dosage: 15-60 mg every 4-6 hours 1
- Duration of effectiveness: 4-6 hours 1
- Maximum daily dose: 360 mg 1
- Often combined with acetaminophen or other non-opioid analgesics for enhanced pain relief 3
Comparative Efficacy
- Tramadol 100 mg provides analgesia roughly equivalent to codeine 60 mg alone 2, 4
- Both medications are classified as weak opioids (WHO level II) 1
- Tramadol has a relative effectiveness of 0.1-0.2 compared to oral morphine 1
- Codeine has lower analgesic efficacy than combinations of aspirin/codeine or acetaminophen/codeine 4
Formulations and Combinations
- Tramadol is available as immediate-release and modified-release formulations 1
- Codeine is commonly combined with acetaminophen or aspirin for enhanced analgesia 3, 5
- Tramadol/acetaminophen combinations (37.5 mg/325 mg) have shown comparable efficacy to codeine/acetaminophen (30 mg/300 mg) for chronic pain management 3
Side Effects and Precautions
- Common side effects of tramadol include dizziness, nausea, dry mouth, and sedation 6
- Codeine more frequently causes constipation (21%) and somnolence (24%) compared to tramadol combinations 3
- Tramadol has dual mechanisms of action: weak mu-opioid receptor binding and inhibition of norepinephrine and serotonin reuptake 6
- When converting between opioids, start with a substantially lower dose (25-50% reduction) to avoid overdose due to incomplete cross-tolerance 7
Special Considerations
- For elderly patients (≥75 years) and those with hepatic or renal dysfunction, consider lower starting doses and slower titration 7
- Tramadol has shown limited indication for acute dental pain management compared to NSAIDs or codeine combinations 8
- For chronic pain management, daily doses of approximately 250 mg tramadol in divided doses are generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg daily 2
Monitoring
- Carefully reassess benefits and risks before increasing total opioid dosage to ≥50 morphine milligram equivalents (MME) per day 7
- Increase doses by the smallest practical amount if necessary 7
- Monitor for common opioid side effects including constipation, nausea, vomiting, and central nervous system toxicity 1