‘ We ’ re looking at medieval levels of life expectancy within this patient population , which is why we need to be exploring all the available treatment options to support the complex needs of this group .’
There had been no drug-related deaths among anyone engaged in the programme , with the majority now abstinent from street heroin . ‘ Some individuals may slip up , but in terms of their overall level of heroin use it ’ s a dramatic reduction , and there ’ s been significant reduction in harm .’ People who had been regularly visiting hospital for wounds and infections were no longer attending , and clients had reduced their overall consumption of other substances . There was also 100 per cent engagement in non-mandatory psychosocial interventions by month ten .
‘ There ’ s been a dramatic improvement in physical and psychological health , and a real increase in everybody ’ s social stability ,’ he said . People who were street homeless had managed to get into secure housing , with those in supported accommodation able to move to independent living . There was also a 60 per cent reduction in both criminal behaviour and its severity , he said . ‘ But we ’ re pushing for research into savings to the wider economy because we think they ’ re far greater .’
In terms of other areas launching similar programmes , ‘ I think the appetite is there ,’ he said . ‘ I know services that want to get involved .’ There was resistance , however , mainly from the public health argument that only a small number of people were impacted . ‘ But that forgets that by targeting a particular group it ’ s been shown to be cost-effective . I think it ’ s about us as a sector shouting that this is an evidence-based intervention . We ’ re talking about world-class treatment , so why haven ’ t we got this available for anybody who needs it ?’ DDN
While the will to offer diamorphine is there , a crisis in supply makes for difficult choices says Dr David Bremner
The diamorphine shortage is not a conspiracy but a very real concern , with patients increasingly unable to get their prescriptions filled as and when they are needed .
Despite what some advocates , pharmacies , manufacturers and distributors might say about supposed stock levels , prescribing processes dictate that promises of plenty do not always result in medication in hand . And when prescriptions can ’ t be filled , patients face undue risks , something my team and I always aim to avoid .
As an organisation , Turning Point are quick to use depot buprenorphine injections – cost does not dictate . The limited numbers of people on diamorphine is not a significant cost burden to my organisation , which has never challenged me or my formulary for including it . But supply is unreliable .
It is hard to swap out diamorphine in an emergency and therefore getting harder and harder to justify prescribing it . As many of the recipients tell me , not having prescribed diamorphine is a strong push back to ever more toxic street heroin .
Supply disruption is well documented – medicines supply notifications , supply disruption permanent actions , clear legislation around use of split dosing and finally , the cessation of production of 500mg ampoules . There are few 5mg and 10mg ampoules , over utilised 30mg and 100mg ampoules and no more 500mg ampoules .
Advice to swap to something more readily available has been met with ‘ I will take my chances ’ from most recipients , but what are we letting people take their chances with ?
The second shortage of 2021 was sudden , hours before a bank holiday , making re-titration onto alternatives tricky and slow . Some swapped medications , getting a generic methadone conversion that holidays and pharmacy opening hours permitted , some went without . Travel plans and family occasions were impacted . We managed but this should have been done electively and in a planned way .
What is the clinician ’ s role in this ? Should we keep prescribing a drug that faces multiple shortages a year when the emergency provision for an alternative has proven to be so inadequate and the consequences , as foretold by the patient , are threatened to be fatal ? Or do we not allow people to ‘ take their chances ’ and undergo a safer elective swap in medication while trampling on patient choice ?
This is our sometime rock and hard place , the constant balance of patient safety and patient choice .
Dr David Bremner is group medical director at Turning Point
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