Indications and dose
Show For dihydrocodeine tartrate
Moderate to severe pain for dihydrocodeine tartrate
By mouth using immediate-release medicines
- Child 4–11 years
- 0.5–1mg/kg every 4–6hours (max. per dose 30mg).
- Child 12–17 years
- 30mg every 4–6hours.
- Adult
- 30mg every 4–6hours as required.
By deep subcutaneous injection, or by intramuscular injection
- Adult
- Up to 50mg every 4–6hours if required.
Chronic severe pain for dihydrocodeine tartrate
By mouth using modified-release medicines
- Child 12–17 years
- 60–120mg every 12hours.
- Adult
- 60–120mg every 12hours.
Show For DF118 Forte®
Severe pain for DF118 Forte®
By mouth
- Child 12–17 years
- 40–80mg 3 times a day; maximum 240mg per day.
- Adult
- 40–80mg 3 times a day; maximum 240mg per day.
Unlicensed use
Unlicensed use For dihydrocodeine tartrate
In children:
Most preparations not licensed for use in children under 4 years.
Important safety information
Important safety information For all opioids
MHRA/CHM advice: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression (March 2020)
The MHRA reminds healthcare professionals that opioids co-prescribed with benzodiazepines and benzodiazepine-like drugs can produce additive CNS depressant effects, thereby increasing the risk of sedation, respiratory depression, coma, and death. Healthcare professionals are advised to only co-prescribe if there is no alternative and, if necessary, the lowest possible doses should be given for the shortest duration. Patients should be closely monitored for signs of respiratory depression at initiation of treatment and when there is any change in prescribing, such as dose adjustments or new interactions. If methadone is co-prescribed with a benzodiazepine or benzodiazepine-like drug, the respiratory depressant effect of methadone may be delayed; patients should be monitored for at least 2 weeks after initiation or changes in prescribing. Patients should be informed of the signs and symptoms of respiratory depression and sedation, and advised to seek urgent medical attention should these occur.
MHRA/CHM advice: Opioids: risk of dependence and addiction (September 2020)
New safety recommendations have been issued following a review of the risks of dependence and addiction associated with prolonged use (longer than 3 months) of opioids for non-malignant pain.
Healthcare professionals are advised to:
- discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to dependence and addiction;
- agree a treatment strategy and plan for end of treatment with the patient before starting opioids;
- counsel patients and their carers on the risks of tolerance and potentially fatal unintentional overdose, as well as signs and symptoms of overdose;
- provide regular monitoring and support to patients at increased risk, such as those with current or history of substance use disorder (including alcohol misuse) or mental health disorders;
- taper dosage slowly at the end of treatment to reduce the risk of withdrawal effects associated with abrupt discontinuation (tapering high doses may take weeks or months);
- consider hyperalgesia in patients on long-term opioid treatment who present with increased pain sensitivity;
- consult product literature for the latest advice and warnings for opioid use during pregnancy (see also Pregnancy).
The MHRA has also issued a safety leaflet for patients—see Patient and carer advice.
Contra-indications
Contra-indications For all opioids
Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus
Cautions
Cautions For all opioids
Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack); central sleep apnoea; convulsive disorders; current or history of mental health disorder; current or history of substance use disorder; debilitated patients (reduced dose is recommended) (in adults); diseases of the biliary tract; elderly (reduced dose is recommended) (in adults); hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease); inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders; prostatic hypertrophy (in adults); shock; urethral stenosis
Cautions, further information
Dependence and addiction
Prolonged use of opioid analgesics may lead to drug dependence and addiction, even at therapeutic doses. There is an increased risk in individuals with current or history of substance use disorder or mental health disorders. See also Important safety information.
Central sleep apnoea
Opioids cause a dose-dependent increased risk of central sleep apnoea, consider total opioid dose reduction. M
Palliative care
In the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to the use of opioid analgesics. M
Elderly
In adults:
Prescription potentially inappropriate (STOPP criteria):
- if prescribed a strong, oral or transdermal opioid (i.e. morphine, oxycodone, fentanyl, buprenorphine, diamorphine, methadone, tramadol, pethidine, pentazocine) as first-line therapy for mild pain (WHO analgesic ladder not observed)
- if used regularly without concomitant laxative (risk of severe constipation)
- if prescribed a long-acting (modified-release) opioid without a short-acting (immediate-release) opioid for breakthrough pain (risk of persistence of severe pain)
See also Prescribing in the elderly.
Cautions For dihydrocodeine tartrate
Pancreatitis; severe cor pulmonale
Interactions
View interactions for dihydrocodeine
Side-effects
Side-effects For all opioids
Common or very common
Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions; urinary retention; vertigo; vomiting (more common on initiation); withdrawal syndrome
Uncommon
Drug dependence; dysphoria
Side-effects, further information
Respiratory depression
Respiratory depression is a major concern with opioid analgesics and it may be treated by artificial ventilation or be reversed by naloxone.
Dependence, addiction, and withdrawal
Long term use of opioids in non-malignant pain (longer than 3 months) carries an increased risk of dependence and addiction, even at therapeutic doses. At the end of treatment the dosage should be tapered slowly to reduce the risk of withdrawal effects; tapering from a high dose may take weeks or months. See also Important safety information.
Overdose
Opioids (narcotic analgesics) cause coma, respiratory depression, and pinpoint pupils. For details on the management of poisoning, see Opioids, under Emergency treatment of poisoning and consider the specific antidote, naloxone hydrochloride.
Side-effects For dihydrocodeine tartrate
General side-effects:
Frequency not known
Dysuria; mood altered; postural hypotension
Specific side-effects:
Frequency not known
With oral use
Biliary spasm; bronchospasm; hypothermia; sexual dysfunction; ureteral spasm
Pregnancy
Pregnancy For all opioids
Respiratory depression and withdrawal symptoms can occur in the neonate if opioid analgesics are used during delivery; also gastric stasis and inhalation pneumonia has been reported in the mother if opioid analgesics are used during labour.
Breast feeding
Breast feeding For dihydrocodeine tartrate
Specialist sources indicate caution—use the lowest effective dose for the shortest possible duration; monitor infant for adverse effects, including sedation, breathing difficulties, constipation, difficulty feeding and poor weight gain.
Hepatic impairment
Hepatic impairment For dihydrocodeine tartrate
Manufacturer advises caution; consider avoiding.
Dose adjustments
Manufacturer advises dose reduction, if used.
Renal impairment
Renal impairment For dihydrocodeine tartrate
Avoid use or reduce dose; opioid effects increased and prolonged and increased cerebral sensitivity occurs.
Treatment cessation
Treatment cessation For all opioids
Avoid abrupt withdrawal after long-term treatment; they should be withdrawn gradually to avoid abstinence symptoms.
Prescribing and dispensing information
Prescribing and dispensing information For all opioids
The Faculty of Pain Medicine has produced resources for healthcare professionals around opioid prescribing:http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware
Patient and carer advice
Patient and carer advice For all opioids
MHRA safety leaflet: Opioid medicines and the risk of addiction
https://www.gov.uk/guidance/opioid-medicines-and-the-risk-of-addiction
Driving and skilled tasks
Drowsiness may affect performance of skilled tasks (e.g. driving); effects of alcohol enhanced. Driving at the start of therapy with opioid analgesics, and following dose changes, should be avoided.
For information on 2015 legislation regarding driving whilst taking certain controlled drugs, including opioids, see Drugs and driving under Guidance on prescribing.
Profession specific information
Profession specific information For dihydrocodeine tartrate
Dental practitioners' formulary
Dihydrocodeine tablets 30mg may be prescribed.
Medicinal forms
There can be variation in the licensing of different medicines containing the same drug.
Forms available from special-order manufacturers include: oral suspension, oral solution.
View all medicinal forms and pricinginformation
Or jump straight to:
- Tablet
- Modified-release tablet
- Oral solution
- Analgesics
Other drugs in class
Other drugs in classOpioids
- Alfentanil
- Aspirin with codeine
- Bupivacaine with fentanyl
- Buprenorphine
- Buprenorphine with naloxone
- Co-codamol
- Codeine phosphate
- Diamorphine hydrochloride
- Dihydrocodeine with paracetamol
- Dipipanone hydrochloride with cyclizine
- Fentanyl
- Hydromorphone hydrochloride
- Meptazinol
- Methadone hydrochloride
- Morphine
- Oxycodone hydrochloride
- Oxycodone with naloxone
- Paracetamol with buclizine hydrochloride and codeine phosphate
- Pentazocine
- Pethidine hydrochloride
- Remifentanil
- Tapentadol
- Tramadol hydrochloride
- Tramadol with dexketoprofen
- Tramadol with paracetamol