Can You Take Codeine or Tramadol While Breastfeeding?
Key takeaways:
In 2017, the FDA recommended that people who are breastfeeding avoid codeine and tramadol (ConZip, Qdolo).
Codeine and tramadol can pass into breast milk. This is most dangerous when the person who is breastfeeding metabolizes (breaks down) codeine or tramadol more quickly than the average person.
It’s best to avoid most opioids while breastfeeding. Still, low doses of some opioids are considered safe while breastfeeding. It’s best to take the lowest dose for the shortest amount of time — and to avoid codeine and tramadol.
Table of contents
In 2017, the FDA warned against taking codeine or tramadol (ConZip, Qdolo) for people who are breastfeeding. The warning stated that taking these medications while breastfeeding can cause serious side effects in the breastfed infant.
What are codeine and tramadol?
Codeine and tramadol are opioid medications that treat pain. Opioids are generally only taken when other pain relievers don’t work. Codeine is also used in some cough medications.
All codeine products are prescription-only. For treatment of general pain, codeine is available as codeine sulfate. It also comes as oral tablets and liquid in combination with acetaminophen.
Search and compare options
For tension headaches, butalbital / acetaminophen / caffeine / codeine (Fiorcet with Codeine) and butalbital / aspirin / caffeine / codeine capsules are available. For cough, codeine is available in combination productions, such as:
Promethazine / codeine oral syrup
Promethazine / phenylephrine / codeine oral syrup
Codeine / chlorpheniramine extended-release tablets (Tuxarin ER)
Tramadol is also prescription-only. It’s available in a few different forms, including:
Generic immediate-release tablets
Generic extended-release tablets
Brand-name oral liquid (Qdolo)
Brand-name ER capsules (ConZip)
Celecoxib / tramadol tablets (Seglentis)
Acetaminophen / tramadol tablets (Ultracet)
Are codeine and tramadol controlled substances?
Yes, all opioid medications are controlled substances. Opioids have a higher likelihood of causing dependence and misuse than other medications and can lead to opioid use disorder.
Codeine sulfate is a Schedule 2 controlled substance. Schedule 2 prescription medications are more likely to cause dependence and misuse than controlled substances in lower schedules, like Schedule 3, 4, or 5.
Tramadol and codeine products used for cough have a lower risk of misuse than many other opioids, including codeine sulfate. So they are in lower schedules.
Do codeine and tramadol pass into breast milk?
Yes, codeine and tramadol can pass into breast milk, but it may not be in large amounts.
Codeine and tramadol are metabolized in the liver. Liver enzymes (proteins) turn these medications into their “active” forms. Codeine’s active form is morphine. Tramadol’s active form is O-desmethyltramadol (M1). Tramadol itself also has pain-relieving effects, but M1 is stronger.
Once the medications are broken down in the liver, the active forms of codeine and tramadol enter the bloodstream. These active forms can then pass into breast milk, but it’s usually in low amounts. Some breastfed infants, however, may be exposed to higher levels of these medications depending on how quickly they’re metabolized.
What does it mean to be an ultra-rapid metabolizer of codeine and tramadol?
Some people have liver enzymes that metabolize codeine and tramadol more quickly and fully than the average person. These people are “ultra-rapid metabolizers.”
After taking codeine or tramadol, ultra-rapid metabolizers may experience higher than normal levels of these substances in their bloodstream. The medication can then pass into breast milk and result in unsafe levels of codeine and tramadol for the breastfed infant.
Why should you avoid codeine and tramadol during breastfeeding?
There have been several cases of opioid overdose in breastfed babies whose mothers took codeine. Opioid overdose is thought to occur most frequently in babies who are breastfed by ultra-rapid metabolizers of codeine. There weren’t incidents like this with tramadol. But tramadol carries the same risk as codeine; it can be metabolized too quickly by some people.
Most people don’t know if they’re ultra-rapid metabolizers of codeine or tramadol. So a person who is breastfeeding likely won’t know if their baby is at greater risk for an opioid overdose. For this reason, it’s recommended that codeine and tramadol are avoided altogether while breastfeeding.
What if you’re currently taking codeine or tramadol and breastfeeding?
If you’re currently breastfeeding, or planning to breastfeed, talk to your healthcare provider about whether you should continue taking codeine or tramadol.
If you’ve been taking one of these medications for a long time, it’s not a good idea to stop taking it abruptly, because this can lead to opioid withdrawal. But there may be a safer medication for you and your baby. And your healthcare provider can help you make the switch safely.
What are the symptoms of opioid overdose in infants?
Common symptoms of opioid overdose in infants include:
Trouble breastfeeding
Increased sleepiness
Difficulty breathing
Limpness
If you notice these symptoms in your infant, call 911 or head to the nearest emergency room. Opioid overdose is serious and can be life-threatening.
Also, keep in mind that if you’re seeing symptoms of opioid overdose in your breastfed infant, it’s possible that you’ll experience the symptoms yourself. If this happens, you should call 911 or head to the nearest emergency room.
Are other opioids safe during breastfeeding?
Opioids are sometimes taken by people during labor and delivery and in the early postpartum phase. Short-term opioid use during these times is generally considered safe.
Still, it’s best to avoid opioids while breastfeeding if possible. If you need pain medication after giving birth (as many people do), talk to your healthcare provider about other options. These may include ibuprofen (Advil, Motrin) and acetaminophen (Tylenol).
If treatment with an opioid is necessary, it’s usually best to avoid codeine or tramadol. And taking the lowest dose of the opioid for the shortest amount of time is recommended. If long-term opioid treatment is necessary, both the person breastfeeding and the infant should both be closely monitored.
If you need to take a low dose of an opioid while breastfeeding, “pumping and dumping” isn’t usually necessary. This is when you pump out breast milk and throw it away instead of saving it for your baby.
The bottom line
Codeine and tramadol (ConZip, Qdolo) aren’t recommended for people who are breastfeeding. This is because some people metabolize these opioid medications quickly. This can lead to high levels of the medication in the blood and breast milk, which can cause an opioid overdose in the breastfed infant.
It’s best to avoid opioids in the postpartum phase if possible. Taking other pain relievers, like ibuprofen or acetaminophen, is usually preferred.
Still, some people may require opioids to treat their pain. Low doses of opioids (besides codeine and tramadol) are generally considered safe for breastfeeding parents and infants. But it’s best to take the lowest dose for the shortest amount of time possible.
Why trust our experts?
References
American College of Obstetricians and Gynecologists. (2017). Leading women’s health organizations recommend strategies to enable adequate pain control and continued breastfeeding.
Athena Bioscience, LLC. (2022). Qdolo [package insert].
Drugs and Lactation Database. (2022). Codeine.
Drugs and Lactation Database. (2023). Tramadol.
Ito, S. (2018). Opioids in breast milk: Pharmacokinetic principles and clinical implications. The Journal of Clinical Pharmacology.
NuCare Pharmaceuticals, Inc. (2023). Tramadol hydrochloride [package insert].
Preferred Pharmaceuticals Inc. (2022). Tramadol hydrochloride [package insert].
U.S. Drug Enforcement Administration. (2018). Drug scheduling.
U.S. Food and Drug Administration. (2018). FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; Recommends against use in breastfeeding women.
U.S. Food and Drug Administration. (2019). Use of codeine and tramadol products in breastfeeding women - Questions and answers.
Vertical Pharmaceuticals, LLC. (2022). ConZip [package insert].
