Off the menu

There is no ‘one size fits all’ approach to treatment. We know this intuitively, as we all navigate the world as individuals with not just different biology, but also different experiences, preferences, strengths and weaknesses. It follows, therefore, that in order to meet the needs of a varied and diverse population, those working in treatment services would want access to the widest possible range of both psychosocial and pharmacological interventions. 

Unfortunately, due to myriad factors – including closer scrutiny of prescribers, rising caseloads and more than 15 years of real-terms budget cuts – it seems that many practitioners are only making use of a narrow range of tools, leaving others gathering dust in the toolbox. Arguably the clearest example of this is the current state of diamorphine prescribing in the UK.

Gavin’s problems began in the early 2010s when he was started on a new epilepsy medication, phenytoin, while being prescribed methadone. Within 12 hours of taking the new drug he knew something was wrong, and by the end of the day was experiencing familiar symptoms – nausea, cramps, sweats. The only thing that seemed to help was heroin – immediately after using the symptoms disappeared, and he was able to function for a few hours at least.

Gavin soon learned from a pharmacist that phenytoin and methadone are contraindicated. Armed with this new information and a copy of the methadone handbook, he booked an appointment with his drug service. When he explained the problem, and his fear that stopping the phenytoin could result in a life-threatening seizure, the response from the prescriber was to increase his methadone. When this failed to improve the situation, the methadone was increased again.

By the time it was agreed to take him off methadone, he was drinking 220ml a day, plus the heroin that was keeping him out of withdrawal. His service finally agreed to try him on an alternative agonist, but by then Gavin’s opiate tolerance was so high that switching to morphine proved impractical – he was having to swallow an inordinate number of pills just to get through the day.

It was at this point that his service agreed to try him with diamorphine, which he has been prescribed ever since. His quality of life drastically improved from that day on. When taking his medication, Gavin experiences no withdrawals, no lethargy or brain fog, and not even any discernable high. His head is clear, he’s stable, and he’s able to enjoy his life on his own terms. 

That is as long as he can still access the medication. As those who’ve prescribed or been prescribed diamorphine will know, the supply chain for ampoules is particularly volatile. At the end of December 2025, Community Pharmacy England issued an alert stating that 5mg and 10mg diamorphine ampoules were out of stock, and that 100mg ampoules would soon be too. At the time of writing no date has been given for when production will resume.

While alternative opiates can be used for many of diamorphine’s current medical uses, for people like Gavin these alternatives simply aren’t effective. During the last shortage in 2022, switching to morphine meant injecting so much liquid that he developed an abscess. It took many weeks of adjustments to stabilise him on a combination of morphine and oxycodone, and even then he experienced lower mood, brain fog and lethargy that simply wasn’t present with diamorphine. 

Gavin has retained his prescription for over a decade, but only just. Home Office restrictions make prescribing diamorphine for opiate dependence particularly difficult. Psychiatrists must apply for a specific license only granted to those already experienced with diamorphine patients. Gavin’s current prescriber has warned that although he has a license, there are simply not enough prescribers left with the necessary experience to train up others. Should he retire, it will not be possible for any of his colleagues to take over – and in the long term the future of Gavin’s treatment remains unclear.

With so few diamorphine patients remaining in the UK, it’s easy for their needs to be overlooked, disregarded or ignored. Those of us who know just how transformative this medication can be need to continue to loudly campaign and advocate for its use. If we don’t, we run the risk of it disappearing as a treatment option altogether, leaving many of those most vulnerable in our communities without the lifeline they need – a significant step backwards for drug users in this country. 

Fraser Parry is drugs advocacy and support advisor at Release