Diamorphine
hydrochloride is a full
opiate agonist in its
salt form, making it
injectable. It’s used as an
analgesic for severe pain,
especially in end-of-life
care for cancer sufferers...
It was the mainstay of
prescribing for decades
under the ‘British system’
and was a successful
frontline treatment until
Dole and Nyswander’s
methadone model
arrived in the UK
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me. It worries me because the one thing worse
than no diamorphine prescribing is poor
diamorphine prescribing that will limit future
prescribing and, more importantly, fail its users.
What concerns most regarding the future
direction of diamorphine programmes is their
increasing medicalisation, and accessibility. The
new programmes are following in the baleful
path of the highly dubious RIOTT trial, and I’m
not quite sure what the point of RIOTT was. At
its inception there was already an evidence base
proving diamorphine’s efficacy in treatment,
so if you’re of a cynical disposition you might
assume RIOTT was an attempt to kick the whole
issue into the long grass.
Whether RIOTT was needed or not, it seems
to have had a significant impact on the direction
of diamorphine programmes. The worrying new
direction of travel can be clearly seen in RIOTT’s
stated aims, which were trumpeted as ‘a heroin
prescribing programme with on-site supervised
consumption’. This was a huge change from
earlier programmes, and most definitely not a
change for the better for service users. It turned
a community/pharmacy-based approach into a
medicalised, high-threshold service. It appears
on-site consumption along with increased
surveillance and control are the new way, and for
many users it’s the wrong way. I doubt I’d have
survived long at RIOTT with its requirement for
frequent attendance and rigid control protocols,
which are one thing in a trial setting but quite
another when used as the norm.
Of course if you were cynical you’d question
why the change? Listening to the aims and
aspirations of the new programmes could offer
a clue. They cite cutting drug-related deaths, HIV
and acquisitive crime – all laudable goals, but
where does diamorphine fit into their aims?
Every service user is unique, with their
own story and their own needs, but there’s
an understandable urge to create and label
subsets of users – and the new diamorphine
programmes seem to be confusing their
subsets. In the past diamorphine programmes
were aimed at an older user group who’d
already struggled with methadone and other
treatment options, but had the discipline to
manage diamorphine usage in the community
and craved stability and the opportunity to
rebuild their lives.
If you want to cut deaths, HIV and crime
you’d primarily address another subset – a
much more chaotic, poly drug using high-
risk group who are often homeless and with
a high percentage of dual diagnosis. So, I
presume they’re the target cohort of the new
programmes.
That’s two very different groups of people,
with very different sets of needs. Maybe
the use of the medicalised RIOTT model will
work with the chaotic, polydrug using cohort
and maybe it won’t. The problem is I’m not
sure the providers of the new programmes
have even considered this, never mind
planned accordingly, and this would set their
programmes up to fail.
Diamorphine is often misunderstood. It’s
not a wicked, dangerous drug and it’s not a
panacea or the holy grail of opiates. It’s just
another drug, but it’s a drug that can give
hope, a drug that can save users by making
treatment viable when other options have
failed. Every user should have the chance to
access diamorphine maintenance if needed.
Diamorphine programmes need to be
implemented carefully. There need to be clear
aims and objectives, simple user protocols and
highly skilled staff. None of this comes cheap,
but it’s cheaper than burying people. The horrific
rise in drug-related deaths makes increasing
access to diamorphine a sane, reasonable
response, but some thought needs to go into
extending programmes rather than the usual
regressive knee jerk reactions that policy makers
and treatment providers tend to favour.
There’s been too much needless death
already. We need to get diamorphine provision
right.
Nick Goldstein is a service user
FEBRUARY 2020 • DRINK AND DRUGS NEWS • 15