Practice Therapeutics

Maintenance drugs to treat opioid dependence

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2823 (Published 15 May 2012) Cite this as: BMJ 2012;344:e2823
  1. Michael Farrell, director1,
  2. Alex Wodak, director2,
  3. Linda Gowing, affiliate senior lecturer 3
  1. 1National Drug and Alcohol Research Centre, University of New South Wales, Sydney NSW 2031, Australia
  2. 2Alcohol and Drug Service, St Vincent’s Hospital, Darlinghurst NSW 2010, Australia
  3. 3Discipline of Pharmacology, University of Adelaide, SA 5005, Australia
  1. Correspondence to: M Farrell michael.farrell{at}unsw.edu.au

A 39 year old woman started injecting heroin when she was 18 but soon found she could not control her drug intake or her life in general. At age 30, she sought help and did well with methadone treatment, taking no illicit drugs for three years. However, she then relapsed to heroin use and spent a year in prison, where she continued to inject heroin. After being released, she went to a residential rehabilitation centre. Subsequently in the community her general practitioner started her on buprenorphine. Her life became more stable. She did well with buprenorphine treatment for a few years but restarted injecting heroin after stopping buprenorphine. She restarted buprenorphine and now takes no non-prescribed medication. She works as a waitress and lives with her non-drug using partner.

What is opioid dependence?

This article is intended for practitioners who occasionally manage patients with opioid dependence. Methadone, a mu opioid agonist, and buprenorphine, a partial agonist, are the main drug treatments for dependence on opioids (which include heroin, morphine, and oxycodone, as well as the other pharmaceutical opioids1 2) for detoxification, maintenance, and ultimately abstinence. Treatment with maintenance goals is referred to as opioid substitution treatment or opioid agonist pharmacotherapy.3 Such treatment is reserved for patients with clearly established opioid dependence and prolonged daily opioid use (by either smoking or injecting). In some countries the combination of buprenorphine and naloxone is preferred (and is now becoming available as a film taken sublingually). Prescription heroin, known in the United Kingdom as heroin assisted treatment or injectable opiate treatment, is used in some countries but is not discussed in this article.4 5 6 Naltrexone blocks the effects of heroin on the mu receptor,2 but oral naltrexone treatment has had low adherence and high discontinuity rates.7 8 Use of naltrexone in the …

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