Paracetamol combinations

Paracetamol can be combined with codeine or dihydrocodeine, with both medicines are in a single tablet.

Codeine and dihydrocodeine are opioids. They are sometimes called ‘weak opioids’ but are strong pain medications.

To show the combination the name starts with co-. Paracetamol combined with codeine is called co-codamol. Paracetamol combined with dihydrocodeine is called co-dydramol.

Each co-codamol, or co-dydramol, has the same amount of paracetamol as one standard paracetamol 500mg tablet.

You may use both paracetamol and a paracetamol combination tablet to help manage your pain. You can take both types of medicine but;

• Do not take more than 2 paracetamol containing tablets at a time.
• Leave 4-6 hours between doses.
• Do not take more than 8 paracetamol containing tablets in 24 hours

Only take stronger pain medication when your pain is at its worst. This gives the best pain control with the least side effect. It reduces the risk of tolerance and dependence from opioids.

Table 1 shows how you can combine standard paracetamol with combination co-codamol (or co-dydramol).

Table 2 shows different strengths available.

Are there any side effects?

All medicines can cause side effects but not everyone will get them. A full list is in the patient information sheet provided with the medicine.

Paracetamol rarely causes side effects. It does not cause sleepiness. There is no risk of addiction.

Common side effects of opioids are feeling sick, constipation, dizziness and sleepiness. Less common side effects are itching, sweating, dry mouth, diarrhoea or rash.

If a medicine makes you sleepy, do not driving or operating machinery. It is an offence to do so whilst unsafe due to medicines. Alcohol may make the sleepiness worse.

Some side effects can be reduced by slowly building up the dose. Others may pass after the first few doses. If side effects are a problem, talk to a doctor or pharmacist.

Reducing your dose

It is best not to take opioids regularly long term. They can cause tolerance, dependence and addiction.

Do not stop opioids suddenly as this may cause withdrawal effects. Reducing the dose slowly will stop this happening. A doctor or pharmacist can advise.

Table 3 shows how to reduce combination pain medicine.

It is best to reduce at a time when your pain is stable, and you are not under extra stress.

Table 1

How you can combine standard paracetamol with combination (co-codamol or co-dydramol) pain medication.

Take mainly paracetamol when pain is more controlled. Step up to combination pain medicine when pain is less well controlled.

Approx timings	Morning 7-8am	Lunchtime 12-1pm	Teatime 5-6pm	Night 10-11pm
Pain controlled by paracetamol alone	2 paracetamol 500mg	2 paracetamol 500mg	2 paracetamol 500mg	2 paracetamol 500mg
Pain slightly worse, add opioids Pain slightly better, remove opioids	2 co-codamol	2 paracetamol	2 paracetamol	2 co-codamol
	or
	1 paracetamol + 1 co-codamol	1 paracetamol + 1 co-codamol	1 paracetamol + 1 co-codamol	1 paracetamol + 1 co-codamol
	or
	1 paracetamol + 1 co-codamol	2 paracetamol	2 paracetamol	2 co-codamol
	or
	Any combination of the above as long as you don’t exceed the equivalent of 8x paracetamol (4000mg in 24hrs)
Max dose for flare up of pain	2 co-codamol	2 co-codamol	2 co-codamol	2 co-codamol

Remember

How you can combine standard paracetamol with combination (co-codamol or co-dydramol) pain medication.

Take mainly paracetamol when pain is more controlled. Step up to combination pain medicine when pain is less well controlled.

Table 2

Different strengths of co-codamol and co-dydramol. Co-codamol and co-dydramol are available in different strengths. Some of these need a prescription.

co-codamol	Paracetamol per tablet	Codeine per tablet	Other information
Paracetamol 500mg	500mg	none	Available to buy in shops or pharmacies.
Co-codamol 8/500	500mg	8mg	Available to buy in shops or pharmacies. For short term use.
Co-codamol 15/500	500mg	15mg	Prescription required. Also called Codipar®
Co-codamol 30/500	500mg	30mg	Prescription required. Also called Solpadol®, Tylex® and Kapake®

co-dydramol		Paracetamol per tablet		Dihydrocodeine per tablet		Other information
Paracetamol 500mg		500mg		none		Available to buy in shops or pharmacies.
Co-dydramol 7.46/500		500mg		7.46mg		Available to buy in shops or pharmacies. For short term use.
Co-dydramol 10/500		500mg		10mg		Prescription required.
Co-dydramol 20/500		500mg		20mg		Prescription required. Also called Remedeine®
Co-dydramol 30/500		500mg		30mg		Prescription required. Also called Remedeine Forte®
	Morning		Lunch time		Teatime		Night
Week	2 co-codamol		2 co-codamol		2 co-codamol		2 co-codamol
1	2 co-codamol		1 co-codamol + 1 paracetamol		2 co-codamol		2 co-codamol
2	2 co-codamol		1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol		2 co-codamol
3	1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol		2 co-codamol
4	1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol
5	1 co-codamol + 1 paracetamol		2 paracetamol		1 co-codamol + 1 paracetamol		1 co-codamol + 1 paracetamol
6	1 co-codamol + 1 paracetamol		2 paracetamol		2 paracetamol		1 co-codamol + 1 paracetamol
7	2 paracetamol		2 paracetamol		2 paracetamol		1 co-codamol + 1 paracetamol
8	2 paracetamol		2 paracetamol		2 paracetamol		2 paracetamol

If you reduce your co-codamol dose, this can be stepped back up when required for short periods.

The plan can be used for co-dydramol too.

Medication in chronic pain

Medicines are not always helpful for long term pain.

It is best to stop medicines that are not working or cause problems.

It is helpful to find other ways of managing pain.

A doctor or pharmacist can explain more.

Remember

Do not stop medicines suddenly.

Do not share medicines.

Never take more medicine than prescribed.

Let your doctor or pharmacist know if you take other medicines or products.

Read the information sheet given with each medicine.

Keep medicines out of the reach of children.

Store medicines safely.

Return unused medicines to your pharmacy.

If medicines make you drowsy, do not drive.

Discuss any medication concerns with your doctor or pharmacist.