Is dihydrocodeine the ideal opioid for use after discharge from hospital?

Abstract

It is now recognised that there is a global prescribed opioid crisis, and that this crisis has many causes. One of these causes is the benevolent action of medical staff in treating patients with acute pain, who then transition to chronic opioid users/misusers. To try and prevent this transition, there are multiple guidelines that now promote opioid stewardship to mitigate the harms from prescribed opioids. And whilst they all promote the regular administration of simple analgesics, there is no consensus on the ideal opioid to be used on discharge from hospital. This is probably due to the complexity of the issue, and the heuristics of prescribers. However, it is acknowledged that various pharmacological properties of the opioids increase the risk of opioid dependence and other adverse drug events. These properties are multiple and can be categorised (Table 1). Conversely, the opioid must also be effective, and prodrugs that are subject to genetic polymorphism for activation and have an unpredictable analgesic activity should probably be avoided. This is because the individual patient may not experience the intended analgesic benefit. No single opioid is devoid of all these adverse properties. However, from an academic exercise it does appear that dihydrocodeine 30 mg in a pack size of 28 tablets has the least number of intrinsic pharmacological adverse properties. Furthermore, dihydrocodeine is the recommended opioid for lactating mothers on discharge from hospital after operative delivery. This is because it is minimally metabolised to further active compounds, unlike codeine and tramadol, and it causes less neonatal sedation than codeine, tramadol and oxycodone. It is also noteworthy that following a literature review, dihydrocodeine became an essential component of the discharge medication for day-case lower limb arthroplasty service at a major London teaching hospital. An additional advantage of dihydrocodeine 30 mg is that it is a schedule 5 CD. This means that it can be stocked and dispensed from clinical areas such as Accident and Emergency, the delivery ward, day surgery units and other surgical wards, thus facilitating patient flow. Nevertheless, whichever opioid is prescribed, the prescriber has a responsibility to ensure that the principles of opioid stewardship are adhered to and that the patient is presented with both verbal and written information. This information includes having a plan for discontinuation; safe disposal of unused opioids; the promotion of a short duration of opioid use; and the avoidance of drug driving, repeat prescriptions and opioid diversion. This important patient safety