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Stevenson, a senior British forensic doctor, observes that methadone treatment does not work, contrary to 40 years of high quality research showing that it does.1
The reason can be found in the lack of adherence to evidence based clinical guidelines in much of the United Kingdom.2 With some notable exceptions, UK addicts are routinely given dose schedules that are contrary to guidelines (such as mean doses of less than 40 mg daily in place of double that found in well run clinics). These advise strict dose supervision for new and unstable patients with an effective dose range from 60 mg to 120 mg daily after careful induction starting with no more than 40 mg daily.3
Hong Kong, Australia, and New Zealand may be the only places where methadone has been available for over 30 years under reasonably open access and with a largely evidence based approach. Uniquely, all three have very little HIV in their large injecting populations. Few would believe this is coincidental (although hepatitis C has been a different and as yet unanswered story).
The question of whether addicts should receive incentives in treatment should be decided by practical research, not moralist opinions.4 5 Methadone treatment is already one of the most cost effective things we do in medicine and probably compares with washing hands. It would seem logical to raise the abysmal standards of practice in the UK and then examine incentives to improve results still further if needed.
Competing interests: AB charges a fee for administration of drugs in the treatment of addiction.