Background Whilst methadone and buprenorphine are the mainstay treatments for opioid addition in the UK, rarely patients are maintained on prescribed intravenous diamorphine. Misuse of Drugs (Supply to Addicts) Regulations 1997 restrict prescription of diamorphine for addiction to medical practitioners with a license issued by the Home Secretary. Managing hospice inpatients with existing diamorphine maintenance prescriptions raises important practical and legal issues.
Aims and methods We aimed to highlight key issues identified when caring for two such patients at our institution. We searched for literature concerning hospice management of cancer patients with existing prescriptions for diamorphine for opioid addiction.
Results Patient 1 was admitted with a long-term prescription for drug addiction (80 mg daily intravenous diamorphine, 300mg oral morphine) dating back 20 years. His cancer pain required additional high-dose fentanyl and oxycodone due to morphine tolerance before discharge. Diamorphine prescribed for addiction should be collected daily from a designated pharmacy under normal circumstances. The Substance Misuse Team continued to prescribe the opioids for addiction, and agreed to arrange weekly collections by a relative with the patient’s written permission.
Patient 2 was admitted for terminal care, with a similarly longstanding prescription (60 mg daily intravenous diamorphine, 300 mg oral morphine). Legal and practical issues made organising injectable medication for symptom control in the community impossible in time to allow him to die at home.
Discussion There is a striking lack of literature on managing patients prescribed diamorphine for addiction in a hospice. Our experience highlighted the need for close communication with the relevant Substance Misuse Team. Patient self-administration of intravenous diamorphine can continue, provided hospice inpatient policy criteria for self-administration of controlled drugs are satisfied. Where the indication for diamorphine use changes from addiction management to symptom control in the terminal phase, hospice doctors may take over prescribing [patient 2].
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