Introduction

This book is mainly concerned with the treatment of opiate misuse, for the simple reason that that is the form of drug misuse for which there are the most effective clinical treatments. As we have discussed, the treatment scene for opiate misusers, in contrast to other groups, is fundamentally altered by the widespread availability of the substitution option, in the form of methadone or possibly alternative opioids. Physical dependence is part of the rationale for that approach, and the occurrence of clear-cut withdrawal symptoms also indicates the use of drugs such as lofexidine or clonidine, followed where possible by naltrexone. For reasons of severity of dependence and treatment options, it is therefore understandable that services are drawn to having caseloads dominated by opiate users.

This does not mean that there is nothing that can be done for other drug misusers, although that is the message which is sometimes conveyed. In the UK around the late 1980s there was a definite impression of helplessness regarding managing users of nonopiate drugs, which followed the large expansion of methadone prescribing services. Low threshold prescribing had been advocated for opiate users at risk of HIV transmission, and the recently-formed community drug services were strongly encouraged to deliver such treatment, with counselling approaches becoming neglected. If amphetamine users or other groups then presented, the often openly-asked question was ‘if we can't prescribe, what can we do with them?’, and debates followed about the relative need for nonmedical and medical services.