Intended for healthcare professionals

Practice Clinical Updates

Management of dependent use of illicit opioids

BMJ 2020; 368 doi: (Published 09 March 2020) Cite this as: BMJ 2020;368:m710
  1. Caroline Mitchell, senior clinical lecturer and general practitioner1,
  2. Neil Dolan, service user/BSc psychology student2,
  3. Kenneth M Dürsteler, chief clinical psychologist3 4
  1. 1Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
  2. 2University of Sheffield, Sheffield, UK
  3. 3Center for Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
  4. 4University Hospital of Psychiatry Zurich, Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, Zurich, Switzerland
  1. Correspondence to C Mitchell c.mitchell{at}

What you need to know

  • Illicit opioid users have complex needs and require agencies to work collaboratively to help them access healthcare, education, employment, and housing

  • Users may have multiple health problems associated with premature disability and mortality

  • Adopt a consistent, proactive, and non-judgmental approach in all therapeutic contacts with opioid users to counter stigma and pessimism about effective treatment

  • Train patients and carers in the first response to opioid overdose, including the use of naloxone treatment kits

  • Length of time in treatment with opioid agonists is the strongest predictor of positive bio-psychosocial outcomes and reduces premature mortality

Use of illicit opioids, most commonly heroin, has a wide ranging impact on individuals and society.1 It may lead to dependence, which is best conceptualised using a “chronic disease” model: effective treatments are available, but illness is often characterised by relapses, remissions, and risk of premature death.23

Across Europe, four trends are noteworthy: a decline in the use of intravenous heroin, a rise in the use of high potency synthetic opioids (for example, fentanyl), a rise in opioid related deaths, and an increase in the number of long term opioid users aged over 40.4 The widely reported “epidemic” of opioid associated deaths in the US and Canada is also of global concern and has been attributed to under-regulated medical prescribing of high potency synthetic opioids and a growth in internet supply chains.567 Concurrent use of other substances, for example, alcohol, cocaine, benzodiazepines, neuropathic agents, and novel drugs such as “spice,” increases the risk of adverse outcomes of opioid use in all settings.8910

In this review we describe an evidence based collaborative approach to caring for people who are dependent on illicit opioids (heroin or synthetic opioids that have been obtained illegally, against custom, and used harmfully) and …

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