Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997 - 2007

Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction.
Purpose and Methods: We aimed here at analysing data voluntarily supplied by coroners (1997-2007). All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post mortem toxicology and/or implicated in death were extracted from the database.
Results: DHC, either alone or in combination, was identified in 584 fatalities meeting the selection criteria; in 44% of cases it was directly implicated in the cause of death. . These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early 30s. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases.
Remarks: Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone; buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.