Opioid substitution with oral methadone is the most widely implemented treatment for heroin dependence. In Britain, a complex array of specialist and generic health care services have evolved to deliver this treatment modality. Several minority aspects of British substitution practices receive enduring international interest, including the use of heroin itself as a substitute and the prescribing of methadone in an injectable form. This paper focuses on six linked dimensions that characterize substitution services: (1) treatment providers and settings, (2) prescribing regimes and treatment goals, (3) substitute drugs, (4) dose administration, (5) dose levels, and (6) substitute formulations. Against a background of increasing central and local accountability for the quality and efficiency of specialist providers and critical attention toward their effectiveness, the strengths and weaknesses of the British approach are considered and key issues and future directions are discussed.
Get full access to this article
View all access options for this article.
References
1.
AnglinM.D.SpeckartG.R.BoothM.W.RyanT.M.1989Consequences and costs of shutting off methadone. Addictive Behaviors14:307–326.
2.
BallJ.RossA.1991The Effectiveness of Methadone Maintenance Treatment. New York:Springer.
3.
BammerG.1995Report and Recommendations of Stage 2 Feasibility Research into the Controlled Availability of Opioids. Canberra:National Centre for Epidemiology and Population Health.
4.
BlenkinsoppA.1997Community pharmacy services and standards: The 1996 Royal Pharmaceutical Society Survey. The Pharmaceutical Journal258:633–635.
5.
BrownB.S.WattersJ.K.InglehartA.S.AtkinsC.1982Methadone maintenance dosage levels and program retention. American Journal of Drug and Alcohol Abuse9:129–139.
6.
CapelhornJ.R.M.BellJ.KleinbaumD.G.GebskiV.J.1993Methadone dose and heroin use during methadone maintenance treatment. Addiction88:119–124.
7.
Centre for Substance Abuse Treatment1993State Methadone Treatment Guidelines. Rockville, MD: U.S. Department of Health and Human Services Treatment Improvement Protocol Series 1.
8.
ChaissonR.E.BacchettiP.OsmondD.BrodieB.SandeM.A.MossA.R.1989Cocaine use and HIV infection on intravenous drug users in San Francisco. Journal of the American Medical Association261:561–565.
9.
CohenJ.SchamrothA.1989General practice management of drug misusers. The Practitioner223:1471–1474.
10.
Commonwealth of Australia1993National Policy on Methadone. Canberra:Australian Government Publishing Service.
11.
ConnellP.H.1991Treatment of drug dependent patients 1968–1969. British Journal of Addiction86:913–916.
12.
ConnellP.H.StrangJ.1994The creation of the clinics: Clinical demand and the formation of policy. In The British System, eds. StrangJ.GossopM., 167–177. London:Oxford University Press.
13.
CooperJ.R.1989Methadone treatment and acquired immunodeficiency syndrome. Journal of the American Medical Association262:1664–1648.
14.
Council of the Royal Pharmaceutical Society of Great Britain1991Pharmaceutical services for drug misusers (policy statement). Pharmaceutical Journal247:223.
15.
D'AunnoT.VaughnT.E.1992Variations in methadone treatment practices: Results from a national study. Journal of the American Medical Association267:253–258.
16.
D'AunnoT.VaughnT.E.19921989General practice management of drug misusers. The Practitioner223:1471–1474.
17.
Commonwealth of Australia1993National Policy on Methadone. Canberra:Australian Government Publishing Service.
18.
ConnellP.H.1991Treatment of drug dependent patients 1968–1969British Journal of Addiction86:913–916.
19.
ConnellP.H.StrangJ.1994The creation of the clinics: Clinical demand and the formation of policy. In The British System, eds. StrangJ.GossopM., 167–177. London:Oxford University Press.
20.
CooperJ.R.1989Methadone treatment and acquired immunodeficiency syndrome. Journal of the American Medical Association262:1664–1648.
21.
Council of the Royal Pharmaceutical Society of Great Britain1991Pharmaceutical services for drug misusers (policy statement). Pharmaceutical Journal247:223.
22.
D'AunnoT.VaughnT.E.1992Variations in methadone treatment practices: Results from a national study. Journal of the American Medical Association267:253–258.
23.
Department of Health, Scottish Office Home and Health Department, Welsh Office1991Drug Misuse and Dependence: Guidelines on Clinical Management. London:Her Majesty's Stationery Office.
24.
Des JarlaisD.C.1992The first and second decades of AIDS among injecting drug users. British Journal of Addiction87:347–353.
25.
DrummondD.C.TurkingtonD.RahmanN.Z.MullinP.J.JacksonP.1989Chlordiazepoxide vs. methadone in opiate withdrawal: A preliminary double blind trial. Drug and Alcohol Dependence, 23:63–71.
26.
DoleV.P.NyswanderM.E.1965A medical treatment for diacetylmorphine (heroin) addiction. Journal of the American Medical Association193:646–650.
27.
ElanderJ.PorterS.HodsonS.1994What role for general practitioners in the care of opiate users?Addiction Research1:309–322.
28.
FarrellM.NeedlemanJ.GossopM.GriffithsP.BuningE.FinchE.StrangJ.1996A Review of the Legislation, Regulation and Delivery of Methadone in 12 Member States of the European Union. Luxembourg:Office for Official Publications of the European Communities.
29.
FarrellM.WardJ.MattickR.HallW.StimsonG.V.Des JarlaisD.GossopM.StrangJ.1994Methadone maintenance treatment in opiate dependence: A review. British Medical Journal309:997–1001.
30.
General Accounting Office.
31.
GreenwoodJ.1992Persuading general practitioners to prescribe - good husbandry or a recipe for chaos?British Journal of Addiction, 87:567–575.
32.
GrovesP.HeustonJ.DurandM.A.AlberyI.GossopM.StrangJ.1996The identification and management of substance misuse problems by general practitioners. Journal of Mental Health5:183–193.
33.
HartnollR.MitchesonM.C.BattersbyA.BrownG.EllisM.FlemingP.HedleyN.1980Evaluation of heroin maintenance in a controlled trial. Archives of General Psychiatry37:877–884.
34.
HaywardJ.1994Purchasing clinically effective health care. British Medical Journal309:823–824.
35.
HM Prison Service1995Health Care Standards for Prisons in England and Wales. London: Clinical Services for Substance Misusers Health Care Standard 8.
36.
HM Prison Service1996Drug Misuse in Prisons: Policy and Strategy. London:HM Prison Service.
37.
Home Office Statistical Bulletin1996 Statistics of Drug Addicts Notified to the Home Office, UK. London:Government Statistical Service issue15/96.
38.
HubbardR.L.MarsdenM.E.RachalJ.V.HarwoodH.J.CavanaughE.R.GinzbergH.M.1989Drug abuse treatment: A national study of effectiveness. Chapel Hill:University of North Carolina Press.
39.
Institute of Medicine1995Federal Regulation of Methadone Treatment. Washington, DC:National Academy Press.
40.
JaffeJ.H.MartinW.R.1990Opioid analgesics and antagonists. In Goodman and Gilman's the Pharmacological Basis of Therapeutics, 8th ed., eds. GilmanA. G.RallT. W., New York:Pergamon Press.
41.
JohnsonR.E.EissenbergT.StitzerM.L.StrainE.C.LiebsonL.A.BigelowG.E.1995A placebo controlled clinical trial of buprenorphine as a treatment for opioid dependence. Drug and Alcohol Dependence, 40:17–25.
42.
JosephH.AppelP.1985Alcohol and methadone treatment: Consequences for the patient and program. American Journal of Drug and Alcohol Abuse11:37–53.
43.
JudsonH.F.1973Heroin Addiction in Britain. Newhaven, CT:Yale University Press.
44.
LingW.RawsonR.A.ComptonM.A.1994Substitution pharmacotherapies for opioid addiction: From methadone to LAAM and buprenorphine. Journal of Psychoactive Drugs26:119–128.
45.
MacGregorS.EttoreB.CoomberR.CrosierA.LodgeH.1991Drug Services in England and the impact of the Central Funding Initiative. London: Institute for the Study of Drug Dependence Research Monograph No. 1.
46.
MacGregorS.EttoreB.CoomberR.CrosierA.LodgeH.1995Federal Regulation of Methadone Treatment. Washington, DC:National Academy Press.
47.
JaffeJ.H.MartinW.R.1990Opioid analgesics and antagonists. In Goodman and Gilman's the Pharmacological Basis of Therapeutics, 8th ed., eds. GilmanA.G.RallT.W., New York:Pergamon Press.
48.
JohnsonR.E.EissenbergT.StitzerM.L.StrainE.C.LiebsonL.A.BigelowG.E.1995A placebo controlled clinical trial of buprenorphine as a treatment for opioid dependence. Drug and Alcohol Dependence, 40:17–25.
49.
JosephH.AppelP.1985Alcohol and methadone treatment: Consequences for the patient and program. American Journal of Drug and Alcohol Abuse11:37–53.
50.
JudsonH.F.1973Heroin Addiction in Britain. Newhaven, CT:Yale University Press.
51.
LingW.RawsonR.A.ComptonM.A.1994Substitution pharmacotherapies for opioid addiction: From methadone to LAAM and buprenorphine. Journal of Psychoactive Drugs26:119–128.
52.
MacGregorS.EttoreB.CoomberR.CrosierA.LodgeH.1991Drug Services in England and the impact of the Central Funding Initiative. London: Institute for the Study of Drug Dependence Research Monograph No. 1.
53.
MacGregorS.SmithL.E.FloryP.1994The Drugs Treatment System in England. Middlesex University School of Sociology and Social Policy.
54.
MarksJ.1994Dependence on prescribed and socially tolerated substances. In Seminars in Alcohol and Drug Misuse, ed. Gaskell, 53–74.
MasonP.MarsdenJ.1994The state of the market: Revisited. Druglink9:8–16.
57.
McLellanA.T.ArndtI.O.MetzgerD.S.WoodyG.E.O'BrienC.P.1993The effect of psychosocial services in substance abuse treatment. Journal of the American Medical Association269:1953–1959.
58.
Medical Working Group on Drug Dependence1984Guidelines for Good Clinical Practice in the Treatment of Drug Misuse. London:Department of Health and Social Security.
59.
MetrebianN.ShanahanW.StimsonG.V.1996Heroin prescribing in in the United Kingdom: An overview. European Addiction Researc, 2:194–200.
60.
Ministerial Drugs Task Force1994Drugs in Scotland: Meeting the challenge. Edinburgh:The Scottish Office.
61.
MitchesonM.1994Drug clinics in the 1970s. In The British System, eds. StrangJ.GossopM., 178–191. London:Oxford University Press.
62.
Northern Ireland Committee on Drug Misuse Sheridan, J., J. Strang, C. Taylor, C. and A. Glanz n.d. HIV prevention services for drug misusers: A national study of community pharmacists' attitudes and their involvement in service specific training. Addiction, in press.
63.
SimpsonD.D.1981Treatment for drug abuse: Follow-up outcomes and length of time spent. Archives of General Psychiatry38:875–888.
64.
SpearH.B.1969The growth of heroin addiction in the United Kingdom. British Journal of Addictio, 64:245–255.
65.
SpuntB.HuntD.LiptonD.S.GoldsmithD.S.1986Methadone diversion: A new look. Journal of Drug Issues, 18:569–583.
66.
StimsonG.V.1995Aids and injecting drug Use in the United Kingdom, 1987–1993: The policy response and the prevention of the epidemic. Social Science and Medicine41:699–716.
67.
StimsonG.V.AlldrittL.DolanK.DonoghoeM.1988Syringe exchange schemes for drug users in England and Scotland. British Medical Journal296:1717–1719.
68.
StimsonG.V.OppenheimerE.1982Heroin Addiction: Treatment and Control in Britain. London:Tavistock.
69.
StrainE.C.StitzerM.L.LiebsonI.A.BigelowG.E.1993Methadone dose and treatment outcome. Drug and Alcohol Dependence33:105–117.
70.
StrangJ.1984Abstinence or abundance: What goal. British Medical Journal289:604.
71.
StrangJ.1989Turning the generalist onto drugs: A model service. In Drugs and British Society: Responses to a Social Problem in the 80s. ed. McGregorS., London:Routledge.
72.
StrangJ.1990aIntermediate goals and the processes of change. In AIDS and Drug Misuse: The Challenge for Policy and Practice in the 1990s, eds. StrangJ.StimsonG. V., 211–221. London:Routledge.
73.
StrangJ.1990bThe roles of prescribing. In AIDS and Drug Misuse: The Challenge for Policy and Practice in the 1990s. eds. StrangJ.StimsonG.V., 142–152. London:Routledge.
74.
StrangJ.1992Harm reduction for drug users: Exploring the dimensions of harm, their measurement, and strategies for reductions. AIDS and Public Policy Journal7:145–152.
75.
StrangJ.ClementS.1994The introduction of the Community Drug Teams across the UK. In The British System, ed. StrangJ.GossopM., 207–221. London:Oxford University Press.
76.
StrangJ.ClementS.1984Abstinence or abundance: What goal. British Medical Journal289:604.
77.
StrangJ.1989Turning the generalist onto drugs: A model service. In Drugs and British Society: Responses to a Social Problem in the 80s. ed. McGregorS., London:Routledge.
78.
StrangJ.1990aIntermediate goals and the processes of change. In AIDS and Drug Misuse: The Challenge for Policy and Practice in the 1990s, eds. StrangJ.StimsonG. V., 211–221. London:Routledge.
79.
StrangJ.1990bThe roles of prescribing. In AIDS and Drug Misuse: The Challenge for Policy and Practice in the 1990s, eds. StrangJ.StimsonG.V., 142–152. London:Routledge.
80.
StrangJ.1992Harm reduction for drug users: Exploring the dimensions of harm, their measurement, and strategies for reductions. AIDS and Public Policy Journal7:145–152.
81.
StrangJ.ClementS.1994The introduction of the Community Drug Teams across the UK. In The British System, ed. StrangJ.GossopM., 207–221. London:Oxford University Press.
82.
StrangJ.ConnellP.1994The creation of the clinics: Clinical demand and the formation of policy. In Heroin Addiction and Drug Policy: The British System, eds. StrangJ.GossopM., Oxford:Oxford University Press.
83.
StrangJ.RubenS.FarrellM.GossopM.1994Prescribing heroin and other injectable drugs. In Heroin Addiction and Drug Policy: The British System, eds. StrangJ.GossopM., 192–206. London:Oxford University Press.
84.
StrangJ.SheridanJ. n.d. Heroin-prescribing in the “British System” of the mid 1990s: Data from the 1995 National Survey of Community Pharmacies in England and Wales. Drug and Alcohol Review, in press.
85.
StrangJ.SheridanJ.BarberN.1996Prescribing injectable and oral methadone to opiate addicts: Results from the 1995 national postal survey of community pharmacists in England and Wales. British Medical Journal313:270–274.
86.
StrangJ.SmithM.SpurrellS.S.1992The community drug team. British Journal of Addiction87:169–178.
87.
TogetherTackling Drugs1995A strategy for England 1995–98. London:Her Majesty's Stationery Office.
88.
TantamD.DonmallM.WebsterA.StrangJ.1993Can general practitioners and general psychiatrists be expected to look after drug misusers? Results from the evaluation of a non-specialist treatment policy in the northwest of England. British Journal of General Practice43:470–474.
