Diamorphine hit the headlines recently when an overseas doctor flew into Cambridgeshire to do a shift and promptly prescribed too much, killing his very first patient.
The drug is regularly used in palliative care, clinical medicine and addiction psychiatry. The routine clinical use of diamorphine in medicine is unique to the UK but maybe not for much longer. This useful drug is becoming demonised following its misuse in high profile cases.
Diamorphine achieved notoriety due to its use by serial killer Dr Harold Shipman but continues to haunt the UK criminal courts in the trials of various nurses. Barbara Salisbury was found guilty of attempted murder in 2004. A year later, Anne Grigg-Booth was charged with injecting 12 patients but died before the trial.
More recently, there were investigations in Gosport where a high number of diamorphine related deaths were recorded. Dr Jane Barton, the doctor involved, continued to practise unrestrictedly until recently. In 2009, the Independent wrote “In April, an eight-strong jury decided diamorphine and other powerful drugs had “contributed more than minimally to five of the deaths.”
Then there was David Glass’ case, in which his mother objected to diamorphine use during his palliative care. The European Courts cited a breach of Article 8 ECHR.
The public’s perception was not helped by research in 2006. Clive Seale, Professor of Sociology at Brunel University found that 1,930 deaths were as a result of non voluntary euthanasia.
Gossop et al [2005] wrote: “At a time when diamorphine may be coming under increased scrutiny, more detailed information is required of its uses and applications”. Baker et al [2004] stated: “These findings are cause for concern about the risk of diversion of controlled drugs, and illustrate how patient safety systems can decay when they are not maintained”. In 2005, the National Patient Safety Agency received 16 diamorphine incident reports, two of which resulted in deaths.
The continued misuse of diamorphine suggests that the recommendations made by the Shipman Inquiry do not appear to have been totally effective. Clinical evidence suggests that diamorphine is valuable in palliative care so an outright ban isn’t an ideal solution. More robust guidelines may be a way forward.
Current NHS guidance concentrates on monitoring, counting and recording drug doses. Less attention is paid to reviewing whether or not diamorphine administration is actually appropriate. A solution may lie in greater involvement of pharmacists to ensure dual verification of the appropriate use of the controlled drug.
In the clinical setting, perhaps diamorphine should be used as last resort after all valid alternatives have been exhausted.
There’s no doubt that improved medical and public education and clearer local guidance on appropriate indication is desperately needed.
Current guidance appears too generalised and open to arbitrary subjective interpretation. This is influenced by the personal prejudices of staff. A more objective review to prescribing controlled medication would be beneficial.
Maintenance of public confidence in health professionals is essential. All regulatory bodies should be more proactive in developing comprehensive detailed guidance via a consultation on proper indications, policing and appraisal of controlled drugs.
Read more:
Investigation of systems to prevent diversion of opiate drugs in general practice
The Unique Role of Diamorphine in British Medical Practice: A Survey of General Practitioners and Hospital Doctors
National Patient Safety Agency safer practise notice
