For those that become opiate dependent, it is very often a long-lasting phase of life. The evidence is clear that maintenance doses of methadone that are within an effective therapeutic range (usually 60mg - 120mg) are the best intervention for many.

Quick detoxes are seldom a lasting solution, with very high relapse rates the outcome for the vast majority.

Detox should only be attempted where there is an option of long term maintenance as a 'fall back' option.

Many opiate users are deeply ambivalent about their drug use, and a large part of them wants to be opiate free. Unfortunately many drug workers feel that they aren't succeeding unless they are getting people drug free.

Persuaded by the evidence of experience both know that rapid detox won't work, so all too often a slow detox is agreed upon. The outcome of this regime in the NTORS studies was in fact a sort of sub-therapeutic maintenance dosing, with doses fluctuating, and responding to pressure from workers, and crises in the life of the drug users.

The reason that the methadone briefing included the WHO category of 'long-term detoxification' was that it was (and still is) a common regime and I hadn't been practicing long enough to understand what Dr Duncan Raistrick from Leeds Addiction Unit was saying when he said to me, having read a draft of the briefing, "people should either be on a detox or on maintenance".

It was some time before I came to realise that these long term detoxes were almost always a compromise treatment option that is often sought by the client and worker because it appears to aim towards a desirable goal, and avoids having to seriously address the issue that it isn't likely to be effective.

My view has changed to believing that the evidence supports maintenance as the treatment of choice, with the option of supported 7-21 day detoxes as a treatment option that can be followed by a return to maintenance treatment should it not work.

I realise that this will be as big a challenge for many practitioners as it was for me, but we have to work to end the huge amount of sub-therapeutic methadone dose prescribing in the UK, and the large numbers of opiate users who are exposed to viral transmission and overdose risk through trying to make treatment regimes that are proven to be ineffective work for them.

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