Diamorphine is regularly used in palliative care, clinical medicine and addiction psychiatry. It also has its application in the controversial Liverpool Care Pathway. The routine clinical use of diamorphine in medicine is unique to the UK, but this is not well known outside the UK. This useful controlled drug has sadly been demonised following its misuse by those with criminal intentions.
Diamorphine achieved notoriety due to 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 2005, Anne Grigg-Booth was charged with injecting 12 patients.
An outcry in Gosport occurred due to a number of diamorphine related deaths. By 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". Dr Jane Barton the doctor involved continued to practise until recently.
David Glass' case related to a mother's objection to diamorphine use. The European Courts cited a breach of Article 8 European Convention of Human Rights. The public's perception was not helped by research in 2006. Clive Seale, Professor of Sociology at Brunel University found that 1930 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".
Recommendations made by the Shipman Inquiry do not appear to have been totally effective. Clinical evidence suggests that diamorphine is valuable in palliative care. An outright ban isn't an ideal solution but 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. Improved medical and public education, 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. It is becoming far more urgent now given the public uproar around the use of the Liverpool Care Pathway.
Related Links
4. Anne Grigg Booth - Nurse Dies Leaving Behind a Mystery
5.Gosport Memorial Hospital - We want Justice
11. Drug Laws