Single dose oral dihydrocodeine for acute postoperative pain



This is an updated version of the original Cochrane review published in Issue 2, 2000. Dihydrocodeine is a synthetic opioid analgesic developed in the early 1900s. Its structure and pharmacokinetics are similar to that of codeine and it is used for the treatment of postoperative pain or as an antitussive. It is becoming increasingly important to assess the relative efficacy and harm caused by different treatments. Relative efficacy can be determined when an analgesic is compared with control under similar clinical circumstances.


To quantitatively assess the analgesic efficacy and adverse effects of single‐dose dihydrocodeine compared with placebo in randomised trials in moderate to severe postoperative pain.

Search methods

Published reports were identified from electronic databases (MEDLINE, EMBASE, CENTRAL, the Oxford Pain Relief Database in December 2007, the original search was conducted in October 1999). Additional studies were identified from the reference lists of retrieved reports.

Selection criteria

Inclusion criteria: full journal publication, clinical trial, random allocation of participants to treatment groups, double blind design, adult participants, baseline pain of moderate to severe intensity, postoperative administration of study drugs, treatment arms which included dihydrocodeine and placebo and either oral or injected (intramuscular or intravenous) administration of study drugs.

Data collection and analysis

Data collection and analysis: summed pain intensity and pain relief data over four to six hours were extracted and converted into dichotomous information to yield the number of participants obtaining at least 50% pain relief. This was used to calculate relative benefit and number‐needed‐to‐treat‐to‐benefit (NNT) for one participant to obtain at least 50% pain relief. Single‐dose adverse effect data were collected and used to calculate relative risk and number‐needed‐to‐treat‐to‐harm (NNH).

Main results

Fifty‐two reports were identified in the original review as possible randomised trials which assessed dihydrocodeine in postoperative pain. Four reports met the inclusion criteria; all assessed oral dihydrocodeine. Three reports (194 participants) compared dihydrocodeine with placebo and one (120 participants) compared dihydrocodeine (30 mg or 60 mg) with ibuprofen 400 mg. For a single dose of dihydrocodeine 30 mg in moderate to severe postoperative pain the NNT for at least 50% pain relief was 8.1 (95% confidence interval 4.1 to 540) when compared with placebo over a period of four to six hours. Pooled data showed significantly more participants to have reported adverse effects with dihydrocodeine 30 mg than with placebo. When compared to ibuprofen 400 mg both dihydrocodeine 30 mg and 60 mg were significantly inferior. No additional studies were found for this update.

Authors' conclusions

A single 30 mg dose of dihydrocodeine is not sufficient to provide adequate pain relief in postoperative pain. Statistical superiority of ibuprofen 400 mg over dihydrocodeine (30 mg or 60 mg) was shown. Since the last version of this review no new relevant studies have been identified.


R Andrew Moore, Jayne Edwards, Sheena Derry, Henry J McQuay


Plain language summary

Dihydrocodeine in a single dose in the treatment of acute postoperative pain

This review assessed the efficacy of single‐dose dihydrocodeine in adults with moderate/severe postoperative pain using information from randomised placebo controlled trials. There was a lack of data that could be included in the analyses; all assessed the oral form of the drug and none assessed dihydrocodeine 60 mg. The results were not robust. The implication was that single‐dose oral dihydrocodeine 30 mg was more effective than placebo, but was inferior to ibuprofen 400 mg. Dizziness, drowsiness and confusion were commonly reported.


R Andrew Moore, Jayne Edwards, Sheena Derry, Henry J McQuay

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

The update of this review has not identified any further information to provide evidence for or against the use of single dose dihydrocodeine for acute postoperative pain. Based on the limited amount of information in the available studies, a 30 mg dose of dihydrocodeine is not sufficient to provide good pain relief and higher doses are required. When compared with ibuprofen 400 mg, fewer participants benefited with dihydrocodeine (30 mg and 60 mg).

Implications for research 

The annual prescriptions for dihydrocodeine in the UK alone indicate it to be a commonly used drug. To date, there is not enough high quality data available, especially for dihydrocodeine 60 mg, on which to make policy decisions.

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