22 - Injectable diamorphine

Injectable diamorphine

514 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 4 Alternative oral opioid preparations Oral methadone and buprenorphine continue to be the mainstay of treatment.8 Other oral options such as slow-­release oral morphine (SROM) preparations and ­dihydrocodeine are not licensed in the UK for the treatment of opiate dependence. These alternatives can be considered in exceptional cases where clients are unable to tolerate methadone or buprenorphine. Note the short half-­life, supervision requirements and diversion potential.8 SROM preparations have been shown elsewhere in Europe to be useful as maintenance therapy in those who fail to tolerate methadone, again only for prescribing by specialised clinicians.8 A review of studies on SROM suggested that there was ­insufficient evidence to assess the effectiveness of this treatment.75 Injectable diamorphine There is compelling evidence supporting the use of injectable diamorphine maintenance for the treatment of patients who fail to benefit from first-­line OST.76 Contemporary injectable prescribing differs from the earlier practice of prescribing unsupervised injectable opioids in that the patient must: ■ ■Attend in person for their prescribed injectable opioid maintenance treatment – daily or more frequently, according to the treatment plan. ■ ■Inject their dose under the direct supervision of a competent member of staff. ■ ■Be given no take-­away injectable medication. In the UK the prescribing doctor must have a licence from the Home Office to prescribe diamorphine for opioid dependence. Oral OST is prescribed for those days when supervised injectable treatment is not available. This treatment differs from ‘injecting rooms’ – safe places with sterile equipment for people who use intravenous drugs but who are usually not in treatment – in that it is part of a holistic package of care with adjunctive psychosocial interventions. Although its cost-­effectiveness has been demonstrated,77 its implementation has been limited by various factors including high set-­up costs. At present, people should only be considered for injectable opioid prescribing in combination with psychosocial interventions, as part of a wider package of care. It is an option in cases where the individual has not responded adequately to oral opioid substitution treatment, where it can be supported by the necessary provisions for supervised consumption.8,78 Patients are seen for supervised injecting in a specialist facility twice a day. Doctors caring for patients who are admitted to the acute hospital on diamorphine prescription will need to consult their local policies – ordinarily a documented conversation with the prescribing community addiction psychiatrist is sufficient to continue the prescription. Where withdrawal symptoms occur on stopping OST or other opioids, Table 4.18 gives some advice on the treatment of specific symptoms.