Supplementary Material for: Diversion of diacetylmorphine in heroin-assisted treatment – a focus group study among patients and treatment providers

Introduction: Heroin-assisted treatment (HAT) involves the supervised administration of pharmaceutical heroin (diacetylmorphine, DAM), either injectable or oral, for individuals with severe opioid use disorder who have not achieved stabilization with conventional opioid agonist treatment. Despite its growing adoption, there is limited literature on the phenomenon of diversion in HAT. Diversion refers to the redirecting of legal prescription medications from their intended medical use to illegal or unauthorised use. This study aims to investigate the reasons for, experiences with, and consequences of DAM diversion, as reported by both patients and treatment providers. Methods: In this qualitative study, two separate focus groups were conducted with patients and treatment providers (nurses, psychiatrists, social workers, and psychologists) respectively. Discussions were audio-recorded, transcribed, and analysed. Mayring’s qualitative content analysis was used to evaluate findings. Results: Five themes with fourteen categories emerged. Providers and patients both described procedures and motives of diversion, discussed the positive and negative consequences, and suggested solutions for reduced future diversion of DAM. An important motif for diversion stemmed from patients’ urge for more autonomy over route, timing, and fractioning of administration, while also being used to finance concurrent cocaine use. Treatment providers and patients both noted that diversion may lead to increased overdose risk for individuals in and out of treatment. Nurses noted a substantial negative impact of diversion on the therapeutic relationship. Suggestions for reducing diversion included allowing for more take-home dosing, allowing for more flexibility in routes of administration, adapting HAT clinic opening hours, and providing effective treatment for cocaine use disorder. Conclusions: The main drivers of diversion in HAT included a desire for more autonomy, unaddressed concurrent substance use, and significant barriers to the existing treatment options. Addressing patients’ preferred opioid effect profile, accommodating their social needs, and managing concurrent cocaine use disorder may reduce diversion in the future.