2 - More than methadone? The case for other substitute drugs

Summary

Introduction

For all the evidence in support of methadone, clinicians cannot fail to observe that not all dependent opiate misusers progress well on the treatment, even when it is made available over generous time scales. There may be any number of reasons for this to do with individual circumstances and clinical situations, but the nature and properties of the drug are also important. One problematic group are those users who appear to find it impossible to adjust to the noneuphoriant nature of methadone, desirable though that adjustment is generally considered to be. They will continue to use other drugs, often in direct combination with methadone, to gain some euphoria and so, as well as all the important considerations of motivation which such behaviour raises, the adequacy of the substitute drug must be called into question. If a maintenance methadone user persistently combines their drug with benzodiazepines, cocaine, cyclizine, or alcohol, ostensibly to make the effects more like those of heroin, it can be argued that fewer problems would result if heroin were actually prescribed, rendering the other drug-taking behaviours and risks unnecessary.

Most interest in this way has indeed focused on diamorphine, but other opiates have also been used with a similar rationale, and the first part of this chapter examines the relevant arguments and the limited available evidence.