The issue of whether drug treatment services are providing methadone maintenance in line with the available evidence is an important one. However, the survey by Joseph & Moselhy (Psychiatric Bulletin, December 2005, 29, 459-461) requires further clarification in order to contribute to the debate. In Table 1 they classify services as either ‘ Community drug teams’ or ‘Addiction treatment units’. In the discussion they imply that the latter are in fact non-statutory agencies. The discussion also implies that the only community-based services are the community drug teams. It would seem likely that the majority of the services are community based, both statutory and non-statutory, since the ‘ move towards’ community-based treatment in fact goes back 20 years (Advisory Council on the Misuse of Drugs, 1982). The discussion mistakenly states that the Home Office (2000) document Reducing Drug Related Deaths advises against the prescribing of controlled drugs to drug users. The next sentence does refer to tablets and ampoules in this context but the reader could be left confused.

The notion of ‘opiophobia’ is interesting. Reasons which would explain practice by doctors that is out of step with the evidence include lack of awareness of the evidence, philosophical disagreement despite the evidence, and a lack of access to supervision of methadone consumption. In some cases there can be cause for reasonable clinical caution, for example in cases of polysubstance misuse. For patients, possible reasons for opiophobia include lack of awareness and fear of the criticism of family members or childcare agencies of doses perceived as ‘high’. Impending incarceration in prison, where effective detoxification from doses of methadone towards the upper end of the dose range may not be available, may also make patients resistant to effective treatment. This is certainly a topic that would benefit from further audit, intervention and re-audit.