The new diamorphine programmes may not be the holy grail that some think, says Nick Goldstein.
As I’m sure many of you have noticed, diamorphine programmes have been in the news – both Durham (DDN, March 2017 page 4), and Glasgow (DDN, December/January, page 4) have announced they will start diamorphine programmes in the near future. But before we go any further it’s only right that I declare a very personal interest – I spent the best part of 20 years in a diamorphine programme and without it I’m convinced I’d be dead or in a cell, and they’re both too dark and claustrophobic for my taste. Certainly the fate of many of my peer group suggests diamorphine saved me. So, to use the modern parlance, diamorphine provision is a game I have ‘skin’ in.
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. Diamorphine was first synthesised by C.R. Alder-Wright in 1874 by acetylating morphine, but only went into mass production after it was rediscovered by Bayer pharmaceuticals 20 years later. Bayer gave diamorphine a trade name that we’re all familiar with – heroin. However diamorphine has found another role over the years, as a maintenance tool for treating heroin addiction.
There is nothing new in prescribing diamorphine for addiction. Diamorphine 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 and became the treatment ‘norm’ in the early 1970s. From then until now diamorphine programmes have withered on the vine for lack of political interest – by the time I left the programme around 2005 there were less than 500 diamorphine prescriptions in the UK, and although it’s virtually impossible to guess current prescription numbers I’d bet they’ve fallen further.
So, these new diamorphine programmes are a boon, yes? Well, maybe and maybe not. As ever the devil will be in the detail, and there’s enough detail regarding the future direction of diamorphine programmes already in the public domain to worry 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.