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Is tramadol stronger than codeine?

Medically reviewed by Carmen Fookes, BPharm. Last updated on Aug 22, 2022.

Official answer


Both tramadol and codeine are prescription opioid painkillers, and they seem to be equally effective in terms of pain relief. There is no evidence that tramadol is any stronger than codeine at relieving pain.

On the analgesic ladder, tramadol is considered a “weak opioid” and sits alongside codeine and dihydrocodeine as a prescribing option. Research has suggested tramadol's effectiveness at relieving acute pain after dental surgery was similar to that of 60 milligrams of codeine, but less than that of a recommended dose of NSAIDs or a codeine combination (eg, acetaminophen/codeine). A large retrospective study of 368 960 participants concluded that tramadol, compared with codeine, was significantly associated with a higher risk of cardiovascular events, fractures, and death from any cause, but there was no difference in the risk of opioid abuse or dependence, constipation, delirium, falls, or sleep disorders; however, the authors urged caution when interpreting the results because of confounding (other factors possibly distorting the results).

There are some differences between the two drugs’ side effect profiles:

  • Tramadol is associated with less risk of respiratory depression and generally less constipation than codeine, but has an increased risk for serotonin toxicity, especially when combined with other drugs that also increase the brain chemical serotonin. Symptoms of serotonin toxicity may include sweating, shaking and headaches
  • Tramadol can lower the seizure threshold, which means people with a history of seizures should not take tramadol for pain relief. For the same reason, tramadol can’t be taken with a class of older antidepressant drugs known as monoamine oxidase inhibitors (MAOIs).

Tramadol and codeine are prescribed to treat moderate pain. In addition to pain relief, codeine is also used as a cough suppressant. Both medications may be combined with other ingredients such as acetaminophen.

Codeine comes from the poppy plant like many other narcotics, while tramadol is man-made.

Side effects of both drugs may include:

  • Potential for addiction
  • Dizziness
  • Confusion
  • Sedation
  • Constipation

Although these two drugs are weaker than other opioids, tramadol and codeine are still habit-forming and can cause severe withdrawal symptoms if they are stopped abruptly.

  1. World Health Organization (WHO). WHO Analgesic Ladder: Which weak opioid to use at step 2? Available at: [Accessed August 22, 2022].
  2. U.S. National Library of Medicine MedlinePlus. Tramadol. January 15, 2022. Available at: [Accessed August 22, 2022].
  3. U.S. National Library of Medicine MedlinePlus. Codeine. December 15, 2020. Available at:,of%20symptoms%20or%20speed%20recovery. [Accessed August 22, 2022].
  4. Prescribing tramadol appropriately. 26 February 2018. BPAC NZ.
  5. Moore P. A. (1999). Pain management in dental practice: tramadol vs. codeine combinations. Journal of the American Dental Association (1939), 130(7), 1075–1079.

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