Acetomorphine - Usage - Medical Use

Medical Use

Under the chemical name diamorphine, diacetylmorphine is prescribed as a strong analgesic in the United Kingdom, where it is given via subcutaneous, intramuscular, intrathecal or intravenous route. Its use includes treatment for acute pain, such as in severe physical trauma, myocardial infarction, post-surgical pain, and chronic pain, including end-stage cancer and other terminal illnesses. In other countries it is more common to use morphine or other strong opioids in these situations. In 2004, the National Institute for Health and Clinical Excellence produced guidance on the management of caesarian section, which recommended the use of intrathecal or epidural diacetylmorphine for post-operative pain relief.

In 2005, there was a shortage of diacetylmorphine in the UK, because of a problem at the main UK manufacturers. Because of this, many hospitals changed to using morphine instead of diacetylmorphine. Although there is no longer a problem with the manufacturing of diacetylmorphine in the UK, some hospitals there have continued to use morphine. The majority, however, continue to use diacetylmorphine, and diacetylmorphine tablets are supplied for pain management.

Diacetylmorphine continues to be widely used in palliative care in the United Kingdom, where it is commonly given by the subcutaneous route, often via a syringe driver, if patients cannot easily swallow oral morphine solution. The advantage of diacetylmorphine over morphine is that diacetylmorphine is more fat soluble and therefore more potent (by injection only), so smaller doses of it are needed for the same analgesic effect. Both of these factors are advantageous if giving high doses of opioids via the subcutaneous route, which is often necessary in palliative care.

The medical use of diacetylmorphine (in common with other strong opioids such as morphine, fentanyl and oxycodone) is controlled in the United Kingdom by the Misuse of Drugs Act 1971. In the UK, it is a class A controlled drug and as such is subject to guidelines surrounding its storage, administration and destruction. Possession of Diamorphine without a prescription is an arrestable offence. When Diamorphine is prescribed in a hospital or similar environment, its administration must be supervised by 2 people who must then complete and sign a CD register detailing the patients name, amount, time, date and route of administration. In the case of a doctor administering diamorphine, then he/she may administer the drug alone, however the rule requiring two registered practitioners (ie. a nurse, midwife or another doctor) to sign the CD register still applies. The use of a "witness" when administering Diamorphine is to avoid the possibilty of the drug being diverted onto the black market.

For safety reasons, many UK National Health Service hospitals now only permit the administration of intravenous diamorphine in designated areas. In practice this usually means a critical care unit, an accident and emergency department, operating theatres by an anaesthetist or nurse anaesthetist or other such areas where close monitoring and support from senior staff is immediately available. However, administration by other routes is permited in other areas of the hospital. This includes subcutaneous, intramuscular, intravenously as part of a patient controlled analgesia setup, and as an already established epidural infusion pump. Subcutaneous infusion, along with subcutaneous and intramuscular 'bolus' administration is often used in the patient's own home, in order to treat severe pain in terminal illness.

Diacetylmorphine is also used as a maintenance drug to treat certain groups of addicts, normally long term chronic IV heroin users, and even in these situations it is only prescribed following exhaustive efforts at treatment via other means. It is thought that heroin users can walk into a clinic and walk out with a prescription but the process takes many weeks before a prescription for Diacetylmorphine is issued. Though this is somewhat controversial among proponents of a zero tolerance drug policy, it has proven superior to methadone in improving the social and health situation of addicts. See: Heroin prescription for addicts