Diamorphine for pain and distress in young patients: case examples and discussion of mechanisms

Diamorphine is a strong opioid licensed in the UK for many uses, including moderate and severe pain. In the early 2000s, its use in palliative medicine was widespread before a supply disruption led to preferential use of alternative, cheaper opioids. Though these supply issues were resolved, the use of diamorphine in palliative medicine has remained reduced, particularly with another UK supply disruption in 2021. Following anecdotal reports of good results from diamorphine use in younger patients, this piece discusses two cases of young patients with metastatic cancers suffering significant pain and psychological distress. Both patients were approaching end of life and required high doses of opioids, benzodiazepines and co-analgesics, all given to limited benefit. Both patients were rotated to diamorphine giving objective and subjective improvement in symptoms. These cases are presented in the context of newer information and description of the biochemical actions of diamorphine and its metabolites, which exert their own clinical effect before themselves generating active metabolites. Various trials on, and discussion about, diamorphine's unique metabolism and subsequent central nervous system effects help argue for its use in situations where extreme pain and psychological distress overlap.