‘One of the questions I often get asked is why Middlesbrough, and why now?’ said Daniel Ahmed,clinical partner at specialist GP practice Foundations and who runs England’s only diamorphine treatment programme in Middlesbrough (DDN, December 2020/January 2021, page 4). ‘We’ve got a perfect storm.’ Not only was Middlesbrough the most deprived local authority in England, it also had the country’s highest number of heroin users per head of population and high rates of drug-related deaths.The average age of patients at Foundations was 38, he said, ‘so a relatively young group of people. But their prevalence of significant health conditions is staggeringly increased compared to the national average. 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.’ In preparation for the diamorphine-assisted treatment programme, he and his colleagues had looked at around 20 people who had been ‘caught in a cycle of failure to benefit from treatment’, sometimes for decades. Managing the group through the criminal justice system alone cost around £2m, he said – a cost that ‘wasn’t improving the outcomes of anyone involved’. All of this meant there was an argument for addressing their needs in a different way, and there was strong evidence that supervised diamorphine as a second-line medication for people failing to benefit from treatment was highly effective. The principle was the same as in any other area of medicine, he said. ‘If you’re treating someone with an antibiotic and it fails to benefit, you might change it for one that’s a bit stronger and more targeted.’ The team began a programme of engagement with the public and media to share the evidence and explain why the intervention was needed. ‘It was relatively successful, although the Daily Mail approached a number of our neighbours and suggested we were giving away free heroin.’ In fact, a key early mistake had been use of the word ‘heroin’, he said. ‘It has connotations for the public, other professionals and patients, so we’ve moved to “diamorphine-assisted treatment”.’ Funding was initially secured to treat 20 people, with the programme going live in October 2019. People turn up twice a day, seven days a week, requiring a huge level of commitment, he said, and the service was currently funded for ten people. ‘Their drug use is stable, and their treatment concordance is excellent.’ However, the clinic was still in discussions around what level of funding it would receive to continue the work. ‘This is where we’re coming across some interesting attitudes in senior public health figures. I think there are some really ingrained negative perceptions about the programme, and the argument that all treatment interventions need to be targeted at a large population.’ The programme was under constant independent evaluation, he said, ‘and we have no problem with that because it just adds to the body of evidence.’ Research by Teesside University found that some people were stabilising more quickly than expected and soon asking to be moved from two to one dose a day, with some successfully finishing treatment. ‘They’re completely drug-free and looking at being an ambassador for the wider treatment system.’ 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?’A Delicate balance 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.