Managing illicit drug use. A practical guide.

Illicit drug use is spreading, especially in the developing world, but has begun to stabilise in most developed countries. The phenomenon of illicit drug use is still poorly understood, with responses in most countries influenced largely by cultural factors. A range of psychosocial and pharmacotherapeutic treatments is available; of these, methadone maintenance treatment for heroin dependence has the most evidence of benefit. A large body of literature--including some well designed studies--indicates that methadone reduces heroin use, mortality, criminal activity and risk of human immunodeficiency virus (HIV) infection. Methadone is more likely to be effective if higher doses, longer durations of treatment and more realistic goals are set. However, research findings which would improve outcomes considerably are often not implemented. Methadone maintenance programmes, which attract and retain more illicit drug users than other treatment modalities, are now being made more available in many countries in recognition of their therapeutic effectiveness and utility in reducing the spread of HIV infection among people injecting heroin. HIV infection is now recognised in many countries to be the most serious complication of illicit drug use for both individual drug injectors and their communities. Levo-alpha-acetylmethadol (LAAM) has similar properties to methadone but a longer half-life. This suggests a number of clinical benefits which would also reduce the cost of treatment. However, LAAM has not been approved by regulatory authorities for routine use despite positive findings in some studies. Buprenorphine has shown some promise in the management of heroin dependence but is still undergoing evaluation. It is, however, unlikely to ever be used widely for the management of illicit drug users. Naltrexone may have some advantages for special populations. Pharmacotherapeutic treatment for cocaine and amphetamine users is still at a developmental stage.