I agree with Dunn et al (Psychiatric Bulletin, September 2006, 30, 337–339) that statutory drug services cannot meet all the needs of homeless people, who have chaotic lifestyles and multiple physical health, mental health and social needs. In view of this the outreach clinic model offers an innovative way of engaging this group of clients.

We know that methadone maintenance has a strong evidence base in harm reduction (Reference LutyLuty, 2003). The outcomes described by Dunn et al probably could be attributed to this, as evidenced by the decreased use of heroin, the amount of money spent and the number of injections per day.

However, I was not convinced that sanctions should not be imposed for continued opiate use, given the risk of overdosing. I appreciate that a harm reduction model is more concerned with reducing harm than achieving abstinence. The range of heroin use among the clients was quite wide (amount spent per day £10–£200). It is not clear whether the drop in heroin use and number of injections was a direct result of clients who stopped using opiates altogether. I would be interested to know whether any harm reduction actually took place in people who continued to use opiates on top of methadone.

Although I agree that there should be some leniency in the imposition of sanctions with this difficult group of clients, I feel that sanctions should be used at some point, if the methadone prescription is not achieving anything.