Venlafaxine and tramadol: taking an antidepressant with a strong painkiller

Venlafaxine is a type of antidepressant called a serotonin and noradrenaline reuptake inhibitor, or SNRI. The NHS says it is mainly used to treat depression, but is sometimes used for anxiety, panic attacks and menopause symptoms such as hot flushes in women with breast cancer. It is thought to work by increasing the level of serotonin and noradrenaline.

Tramadol is a strong painkiller from the opioid group. The NHS says it is used for moderate to severe pain, often when weaker painkillers have not helped, that it usually starts working in 30 to 60 minutes, and that it is possible to become addicted to it. Long-term pain and low mood often go together, so it is common for the same person to be prescribed both.

The question this page answers is therefore not whether anyone ever takes the two together, but what extra care is needed when they do.

The NHS tramadol page tells you to say, before taking tramadol, if you are already taking medicines that treat depression or other mental health problems, relieve pain, help you sleep, reduce tension or anxiety, treat allergy symptoms, help prevent blood clots or treat an infection. It says that some medicines can affect the way tramadol works and increase the chance of side effects.

The NHS venlafaxine page lists medicines that may not mix well: anticoagulants such as warfarin and apixaban, anti-inflammatory painkillers such as aspirin and ibuprofen, MAOI antidepressants, and the herbal supplement St John's wort. Tramadol is not named on the venlafaxine page. For citalopram, a related antidepressant, the NHS does name strong painkillers such as tramadol and buprenorphine, which shows that this class of painkiller is one that prescribers think about with serotonin-acting antidepressants.

In other words, the NHS pages do not forbid the combination, and they do not describe it as routine. They ask that the prescriber knows about both.

Both medicines have serious-effect lists that can overlap in practice, so it helps to keep the signs in one place.

The NHS lists a seizure or fit as an emergency on the tramadol side-effects page. The venlafaxine page says it may not be suitable if you have epilepsy, along with diabetes, heart disease, glaucoma, a bleeding disorder or a history of mania. A person with a seizure history or epilepsy should therefore make sure that anyone prescribing either medicine knows about it.

The NHS pages do not state how the risk changes when both are used, and this guide does not either. What can safely be said is that two separate pages each carry a seizure-related caution, which is why the question is worth putting directly to the prescriber.

Both medicines can make people drowsy or dizzy, and the NHS advises against driving, riding a bike or using machinery if you feel dizzy or drowsy. Alcohol adds to tramadol sleepiness according to the NHS, so the safest approach is to avoid it or to discuss it with your prescriber.

The NHS tramadol page says not to take medicines containing codeine with tramadol, including co-codamol, ibuprofen and codeine products such as Nurofen Plus, and Solpadeine, because side effects are more likely. It says it is safe to take tramadol with paracetamol, ibuprofen or aspirin, although the venlafaxine page names the last two among medicines that may not mix well with venlafaxine, so ask a pharmacist which painkillers to add.

Useful questions for a GP or pharmacist are: which warning signs matter most for me, what should I do if a dose is missed, how long is tramadol meant to be used, and how will the antidepressant dose be reviewed if the pain plan changes. Do not stop venlafaxine suddenly; the NHS says to speak to your doctor first because the dose is reduced gradually over several weeks or months.