Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Therefore, with a growing ageing opiate dependent population who would benefit from detoxification from OST, this article provides an overview of the current state of opiate dependence in clinical practice, explores the reasons why availability and acceptability of detoxification pathways are declining, and discusses emerging pharmacological therapies that could provide benefit in relapse prevention.

HIV-associated neurocognitive dysfunction persists in the highly active antiretroviral therapy (HAART) era and may be exacerbated by comorbidities, including substance use and hepatitis C virus (HCV) infection. However, the neurocognitive impact of HIV, HCV, and substance use in the HAART era is still not well understood. In the current study, 115 HIV-infected and 72 HIV-seronegative individuals with significant rates of lifetime substance dependence and HCV infection received comprehensive neuropsychological assessment. We examined the effects of HIV serostatus, HCV infection, and substance use history on neurocognitive functioning. We also examined relationships between HIV disease measures (current and nadir CD4, HIV RNA, duration of infection) and cognitive functioning. Approximately half of HIV-infected participants exhibited neurocognitive impairment. Detectable HIV RNA but not HIV serostatus was significantly associated with cognitive functioning. HCV was among the factors most consistently associated with poorer neurocognitive performance across domains, while substance use was less strongly associated with cognitive performance. The results suggest that neurocognitive impairment continues to occur in HIV-infected individuals in association with poor virologic control and comorbid conditions, particularly HCV coinfection. (JINS, 2012, 18, 68–78)

Backgroung – Little is known about specific treatment needs of mentally ill clients abusing substances and infected by HIV. The major gap concerns residential programmes. Aims – To explore differences in outcomes between seropositive and seronegative dually diagnosed opiate dependent clients who participated in a residential therapy programme. Methods – Data were gathered on 154 clients treated in a therapeutic community in Milan between October 1999 and September 2004. Odds ratios with 95% confidence intervals were used to study the association between HIV serostatus and outcome. Results – At 12-month follow-up, seropositive clients were more likely to relapse. Conclusions – The impact of HIV seropositivity on behavioural outcomes should be taken into consideration when planning residential programmes for the HIV (+) dually diagnosed population. Further research could test the need of incorporating dedicated treatments into existing programmes.

Declaration of interest: None.

This study examined the expenditure of compensation received from legal claims by service users attending an outpatient methadone programme in Dublin. Most claims (n = 62) were as a result of road traffic accidents (74%) or personal injury (15%). There were 28 reports of claims resulting in payment of compensation totalling €912,871. Of the compensation not placed in trust (€477,871), almost 40% was spent on drugs and 8% on alcohol. Of those who reported no drug misuse at the time of the compensation being paid, seven out of 11 (64%) reported subsequently spending a significant amount on substance misuse.

The risks of receiving large amounts of money in this population are substantial and include initiation and exacerbation of substance misuse, and risk of overdose. Alternative ways of managing the payment of compensation should be considered for this vulnerable population.

Objectives: The objectives of the study were to identify the characteristics of the patients who were commenced in a newly developed opiate substitute prescribing (OSP) programme, to determine their rate of retention and to ascertain the patients' opinions of the service. We also wished to determine rates of blood borne viruses in this population.

Methods: Data were collected from three sources: the Shaftesbury Square Hospital Substitute Prescribing Database, patient charts and an anonymous user views questionnaire. We also conducted viral screening. Inclusion criteria were opiate dependence according to ICD-101 for at least one year, in individuals who were 18 years of age or older. The sample comprised the first 80 patients who attended the service, who were followed up over two years.

Results: A total of 44% of our original cohort remained engaged with the service two years after commencement. Of the remainder, 18% engaged with OSP elsewhere and 13% completed a successful detoxification from all opiate drug use. Factors which were associated with continuation in the programme were prescription of methadone (as compared with buprenorphine), female sex and higher doses of OSP. Patients reported high levels of satisfaction with the service. Of those who were tested for blood borne viruses, more than half were positive for hepatitis C infection.

Conclusions: The response to the development of the opiate substitution programme demonstrated that there was a need in the community which had not been met in the past. Service users who attended the programme reported high levels of satisfaction.

Objectives: The aim of this study was to assess the prevalence of alcohol dependence and anxiety and depressive disorder symptomatology among heroin users in drug treatment.

Method: Fifty-five clients on methadone maintenance treatment programmes in Dublin were interviewed.

Results: Prevalence rates were found to be 56% [n = 31] for alcohol dependence, 56% [n = 31] for anxiety disorder symptomatology, and 42% [n = 23] for depressive disorder symptomatology. This finding of comorbid alcohol dependence and psychopathology among methadone maintenance treatment clients suggests that both clients' health and methadone maintenance treatment participation and completion rates may be compromised.

Conclusions: Alcohol dependence and psychopathology among methadone maintenance treatment clients should be considered when providing effectively targeted services to the drug using population.

Objectives: The aim of the study was to evaluate buprenorphine as a detoxification agent for heroin dependence in an outpatient setting. Specifically we sought to establish the rate of completion of detoxification and retention in treatment, the duration of successful detoxification and dose requirements.

Methods: The study was an open prospective evaluation of routinely collected clinical data on the first 60 consecutive heroin dependent patients who underwent buprenorphine detoxification. A flexible dosing regime was adopted with the dose of buprenorphine being adjusted daily against the previous day's withdrawal symptoms.

Results: The majority of patients (40 (67%)) completed detoxification. The median duration of treatment for completers was 17 days (range 9-30 days) with 90% of detoxification episodes completed within 21 days. Patients were commenced on initial median dose of 4mg buprenorphine (range 2mg-6mg) and the median stabilisation dose for the sample was 10mg daily (range 6mg-14mg). The median final dosage of buprenorphine required by patients retained in treatment was 1.2mg (range 0.4mg-2mg). We found older patient age to be a significant predictor of treatment completion.

Conclusions: Buprenorphine was an acceptable and a feasible outpatient detoxification treatment option for heroin dependent patients. Based on the study findings we propose a standard 21-day fixed-dose detoxification schedule.