Management of dependent use of illicit opioids

Use of illicit opioids, most commonly heroin, has a wide ranging impact on individuals and society. It may lead to dependence, which is best conceptualised using a “chronic disease” model: effective treatments are available, but illness is often characterised by relapses, remissions, and risk of premature death. Across Europe, four trends are noteworthy: a decline in the use of intravenous heroin, a rise in the use of high potency synthetic opioids (for example, fentanyl), a rise in opioid related deaths, and an increase in the number of long term opioid users aged over 40. The widely reported “epidemic” of opioid associated deaths in the US and Canada is also of global concern and has been attributed to under-regulated medical prescribing of high potency synthetic opioids and a growth in internet supply chains. Concurrent use of other substances, for example, alcohol, cocaine, benzodiazepines, neuropathic agents, and novel drugs such as “spice,” increases the risk of adverse outcomes of opioid use in all settings. In this review we describe an evidence based collaborative approach to caring for people who are dependent on illicit opioids (heroin or synthetic opioids that have been obtained illegally, against custom, and used harmfully) and who seek help for their dependence