Diamorphine deficiency may be more than just a problem for drug users

The UK has faced many shortages of essential medicines, especially since the start of the pandemic. The latest deficiency is diamorphine, a pain reliever that can be prescribed to drug users who have not responded well to other treatments.

While only about 200 people in England are prescribed diamorphine as a treatment for drug addiction, these shortages can have serious consequences for those who rely on it to help them live normal lives, keep jobs and be part of society.

Diamorphine is also used as a pain reliever in surgery and even for severe cancer pain. As a result, these current shortages could affect thousands of people in the UK.

The shortage also points to a bigger problem affecting people in both the UK and around the world when it comes to accessing essential medicines.

Insight into shortages

While diamorphine (laboratory-made heroin) is used as a pain reliever, Britain was the first country in the world to prescribe it to street heroin users as a treatment for opioid addiction. In most countries, the medicinal use of diamorphine is banned because of the risks and potential for abuse. It is illegal to use or sell in the US.

While most street heroin users will be given oral methadone or buprenorphine as a substitute, diamorphine is offered when these substitutes are ineffective. UK-based programs that help drug users access products such as diamorphine have resulted in a decline in drug-related crimes and deaths. But for the small number of diamorphine users in the UK, when this treatment is not available it can lead to a relapse, putting them at risk for harm if they turn to street heroin.

This is not the first time there has been a diamorphine shortage in the UK. By 2021, a shortage of supplies meant that some NHS trusts had to buy more expensive pre-filled vials of the medicine for patients. This is one of the reasons why morphine is now recommended for pain relief, as it is cheaper and more available. However, morphine is not approved for use in drug addiction.

Diamorphine shortages worsened in March 2022. The main reason for this is that England is dependent on two main suppliers – Wockhardt and Accord Healthcare, manufacturers of generic medicines that both have facilities in India – which are experiencing inventory problems. In fact, as early as 2004, this product has had occasional availability issues that have not been resolved. Some of these problems were caused by manufacturing problems.

In January 2022, 5mg and 10mg vials were reported to be unavailable, with fears that demand for other dosages (such as 30mg vials) would lead to further shortages. This is now the case, with diamorphine injections in various strengths out of stock in the UK.

Five 5 mg vials of diamorphine wrapped in plastic.
Many doses of diamorphine now suffer from deficiencies.
NSnap/Alamy Stock Photo

Northern Ireland has also reported a supply shortage. But Scotland has not reported any shortages – probably because they get their supplies from a source in Switzerland, which is also used by a clinic in England. Wales has also experienced no supply disruptions as diamorphine use is extremely limited and other drugs are prescribed for heroin addicts recovering.

Look forward to something

The supply shortages mainly affect people who use disposable vials of diamorphine at home, including former heroin users and patients in palliative care.

Alternative medicines are available for most patients, such as morphine in cancer care. GPs and health professionals are advised to encourage patients to use other medicines whose stock is more stable. But for recovering heroin users who haven’t found success with methadone or buprenorphine, diamorphine may be their only option. Therefore, decisions about changing treatments must be made with patients, rather than for them.

Hospitals, hospices and palliative care teams have already stopped using diamorphine, and newly referred street heroin users are instead being prescribed different treatment to help them. This means that deficiencies will probably only be a big problem for people who are already prescribed diamorphine.

It is not clear how the current shortages can be reduced or if other companies want to produce this product for the UK market. But to reduce its impact and avoid a situation like this in the future, the following actions should be considered:

  1. Switch to alternatives. A recent study states that other products may be successful in helping patients with opioid addiction. But again, if a patient is already taking diamorphine, he should be consulted carefully about decisions to change his treatment.

  2. Responsible Prescribing† This means not prescribing opioids, such as diamorphine, unnecessarily (as for chronic pain), as there is a risk of becoming addicted.

  3. Reduce over-reliance on a few sources. The UK is largely dependent on India and China for the supply of many drugs – not just diamorphine. Developing production capacity in the UK or purchasing from other countries should make medicines more accessible.

While diamorphine shortages affect only a small proportion of the UK population, it highlights the wider drug shortage the UK has been experiencing for years – which has only been exacerbated by Brexit and the pandemic. The war in Ukraine can only further contribute to the shortage of medicines. This is why the UK Government needs to find alternative ways to deliver essential medicines to the population and invest further in UK manufacturing capacity to ensure this doesn’t happen – or at least happens less often.