The evolving role for lofexidine in the treatment of opiate detoxification over the last decade is reviewed. Lofexidine is no better than methadone or clonidine in attenuating withdrawal symptom severity, although it has a more favourable side-effect profile than clonidine. In conjunction with opiate antagonists, lofexidine may facilitate accelerated withdrawal, although activity and low liability for misuse, lofexidine may be more widely acceptable to clinicians than methadone, particularly those working in out-patient, non-specialist and prison treatment settings. Further studies in these treatment settings will be particularly apposite since, apart from the studies highlighted, the evidence base for the clinical value of lofexidine is mainly to be derived from in-patient trials.

Buprenorphine is a partial μ-opioid receptor agonist that is being increasingly used in clinical practice in the treatment of opioid dependence in the UK, USA, and, elsewhere. Its unique pharmacological properties mean it is a relatively safe drug, it can be given by alternate day dispensing, and it is associated with relatively mild symptoms on withdrawal. The interpretation of the research literature on buprenorphine is however, complex, and often appears to be in conflict with how buprenorphine is used in clinical practice. This article describes these apparent contradictions, their likely explanations, and how these may further inform our clinical practice. The article also describes the clinically relevant pharmacological properties of buprenorphine, compares it to methadone, relates the evidence to clinical experience, and provides practical advice on how to manage the most common clinical techniques. The best quality evidence suggests that very rapid buprenorphine induction is not associated with a higher drop-out rate than methadone, that buprenorphine is probably as good as methadone for maintenance treatment, and is superior to methadone and α-2 adrenergic agonists for detoxification. However, buprenorphine cannot yet be considered the ‘gold standard’ treatment for opiate dependence because of the higher drop-out rates that may occur on induction using current techniques, its high-cost relative to methadone, and because the place of buprenorphine in treatment is still continuing to evolve.

Heroin has been prescribed in England for the treatment of heroin addiction for almost 100 years. For many years, England was almost the only country where this occurred, and the British system was consequently the subject of international curiosity. In spite of this long history, very little research has been carried out locally, and until recently, there were no guidelines as to best practice. In 1965, it was decided that only doctors with a Home Office license could prescribe heroin. Since that time, the proportion of opiate addicts treated with heroin has greatly diminished, as has the number of doctors willing to prescribe. One doctor in particular remained an enthusiastic proponent of heroin prescription. His claims impressed some Swiss clinicians, who proceeded to establish a multicentre trial in Switzerland. This was followed by a similar trial in the Netherlands. These trials apparently indicated that a proportion of treatment-resistant opiate addicts could respond well to heroin, although the researchers' conclusions have been disputed. The National Treatment Agency in England is now developing guidelines for good practice based on this new information and is planning to set up some pilot sites. It is likely that practise in England will remain somewhat different from continental practice, particularly with respect to long-term supervised injecting. It is unclear how much funding will be released to support heroin prescription. Without adequate funding, it is likely to disappear.