Opioid substitution: improving cost-efficiency.

Editorials 83 The United Nations Office of Drugs and Crime in its 2012 World drug report estimates that 0.6% of the world's adult population – some 27 million people – are problem users of illicit drugs. 1 This represents about 10% of all people who used illicit drugs in 2011 and suggests that most people can use drugs recreationally without becoming dependent. What makes these 10% different is the subject of active research and remains poorly understood, but whatever the reason, drug dependency frequently has damaging effects to the user and society and is therefore stigmatized both socially and legally. Opioids (heroin, morphine and prescription opioids) may be the most harmful of the illicit drugs used. 2 Fortunately , treatment is available and has been for some decades. In the late 1940s methadone was tested as an abstinence treatment for opioid dependence and later as a maintenance treatment 3 under the hypothesis that at high, sustained doses methadone could block both the euphoric and adverse effects of opioids to a sufficient level that patients could stabilize their lives, find employment and reintegrate into society. 4 Worldwide, its use has increased considerably since the onset of the HIV epidemic 5 and it is now recognized as an important component of any strategy to control HIV infection among injecting drug users. Among 120 countries that report HIV transmission among people who inject drugs, 97 countries support a harm reduction approach and 78 have a metha-done programme or are piloting one. 6 The worldwide scale-up of metha-done maintenance treatment has been largely facilitated by the generosity of programmes such as the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as through bilateral foreign aid agreements. However, in the current economic climate, the stability of these sources of funding is precarious. The Global Fund has already announced reductions in its funding capacity and without financial support from their own governments, many low-and middle-income countries may not be able to continue to support methadone maintenance programmes. Few countries are in the same position as China where the shortfall in Global Fund support was, commendably, met by the central government. While methadone maintenance has been repeatedly shown to be an effective intervention for reducing drug-associated harms, no programme is without its problems. Chief among these is client retention. By definition, methadone maintenance is a long-term treatment typically requiring at least one year to achieve …