Opioid dependence (opioid use disorder): treatment and support in the UK

Opioids include heroin, a drug made from morphine extracted from the opium poppy, and prescription painkillers such as codeine and morphine. They act on receptors in the brain and body to relieve pain and produce calm and euphoria. Regular use leads to tolerance, so that more is needed, and to physical dependence, so that stopping brings withdrawal.

In the UK the condition is usually called opioid dependence or opioid addiction; opioid use disorder is the term used in the diagnostic manuals. FRANK explains that effects on the brain cause cravings and a strong drive to keep using, which is why willpower alone is rarely enough.

Dependence can follow illegal use or the long-term use of prescribed opioids. The risk is present with prescribed opioids too, and anyone who finds they are taking more than prescribed, or using them for the effect rather than the pain, should tell their prescriber.

FRANK says heroin sedates, slows the heart rate and breathing, and in overdose a person becomes very sleepy, breathing slows and they can fall into a coma and die. The risk is higher if heroin is used with other sedatives such as alcohol, benzodiazepines or methadone, and if it is injected. Tolerance drops fast after a break, so returning to a previous dose after time in prison, hospital or treatment is especially dangerous.

Street heroin may also be cut with more potent opioids, and FRANK warns that synthetic opioids called nitazenes have killed hundreds of people in the UK in a year and that you can never really know what is in a street or counterfeit drug. Injecting brings risks of vein damage, abscesses, clots and, with shared equipment, HIV and hepatitis B and C.

If someone becomes very sleepy and their breathing slows, treat it as an emergency and call 999 immediately. FRANK advises telling the ambulance crew everything you know.

The NHS says a GP is a good place to start. They can discuss your problems and help get you into treatment, usually by referring you to your local drug service. If you are not comfortable talking to a GP, you can approach your local drug treatment service yourself, and the FRANK service can help you find support near you or talk you through options by phone.

At the first appointment, staff ask about your drug use, work, family and housing, and may ask for a urine or saliva sample. They talk you through the treatment options and agree a treatment plan, and you are given a keyworker who supports you throughout. The NHS adds that your plan may include several treatments and strategies.

For opioid dependence, the central treatment is a prescribed substitute taken under supervision, alongside psychological and social support. The NHS says that if you are dependent on heroin or another opioid you may be offered methadone or buprenorphine, which means you can get on with treatment without having to worry about withdrawing or buying street drugs.

NICE technology appraisal TA114 recommends methadone and buprenorphine (oral formulations) as options for maintenance therapy, with the choice made case by case. It says that if both are equally suitable, methadone should be prescribed as the first choice, and that both should be administered daily under supervision for at least the first 3 months as part of supportive care. The DHSC’s later guidance for England says services must offer both medicines, that people should usually be offered a choice, that rapid prescribing should be available, and that decisions about supervised consumption should be made on an individual assessment.

FRANK says that drug treatments are intended to supplement the counselling and social support normally needed to become drug-free and recover from addiction. Some people stay on substitute medicine for long periods because it keeps them well; others later reduce or stop with medical supervision. The DHSC says the optimal dose is one that supports people to reduce or stop non-prescribed opioid use and remain in treatment.

The DHSC says engagement with opioid substitution treatment is associated with reduced mortality and that people who are not in treatment are at increased risk. Mutual aid groups such as Narcotics Anonymous and SMART Recovery, family support organisations such as Adfam, and help with housing and work, which the NHS says staff ask about at the first appointment, all contribute.

The NHS says charities and the NHS provide most drug treatment, with private drug and alcohol treatment organisations also available at the person’s own cost. Opioid substitution treatment itself is prescribed through local drug services and community pharmacies.

If you decide to use a private provider, it is worth asking whether they will coordinate with your GP and local drug service, so that prescribing is not duplicated and your treatment continues smoothly if you move between settings.