Treatment

There is a legal requirement for all doctors to notify the Home Office Drugs Branch, Queen Anne's Gate, London SW1H 9AT, of opiate addicts with whom they come in contact.

Overdose should be managed as a medical emergency; treatment may include the opiate antagonist naloxone to reverse respiratory depression. Other management depends on whether patients wish to become abstinent or not. If they do wish to get off, they will be helped either by gradually reducing the dose or by detoxification. For those who elect to withdraw, clonidine or lofexidine may be given. The antagonist naltrexone can be used for help in relapse prevention, but its effectiveness is unclear.

Most users prefer, at least initially, to stay on opiates, so harm reduction programmes are the mainstay. Methadone maintenance is key; the patient is prescribed a legal supply of opiate in oral (liquid) form. This is designed to satisfy cravings and reduce the need to purchase illegal supplies, with associated crime in order to finance this. Oral administration can be observed if there is concern that the patient may be selling his supply (this is usual in other countries, although less frequent in the UK). Oral administration is also the safest route of ingestion.

If the patient can be stabilized on methadone, and develop a good relationship with the clinic, his lifestyle and health may improve, and he may eventually consider gradual reduction in dose and abstinence. There is evidence (Mattick et al., 2006) that methadone as part of a maintenance programme 'can reduce the use of heroin in dependent people, and keep them in treatment programs'.

Buprenorphine sublingual is an alternative to methadone. Maintenance prescriptions of diamorphine or dipipanone also have their proponents, but they are in a minority. Maintenance prescriptions can only be issued by doctors with a special licence, working from a treatment centre, and it is advisable for the prescriptions to be dispensed from a designated pharmacy. (Any doctor may prescribe diamorphine for relief of severe pain.)

For those who continue to inject, many chemists provide sterile needles free of charge under the 'harm-reduction' policies designed to restrict spread of HIV and other infections.

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