Codeine may be a safer bet than tramadol for chronic non-cancer pain, according to a new study from Spain.

Tramadol is increasingly used to manage chronic non-cancer pain, but few safety studies have compared it with other opioids, say researchers from the Foundation University Institute for Primary Health Care Research, Barcelona, in JAMA.

They analysed 10 years of linked primary-care and pharmacy-claims data and used propensity-score matching to create a cohort of nearly 369,000 adults who received an initial prescription for either tramadol or codeine.

Compared with a new prescription for codeine, a new prescription for tramadol was associated with a significantly higher risk of all-cause mortality, cardiovascular events and fractures, the researchers reported