8.1.4 - Heroin and nicotine treatments

Methadone substitution

Methadone substitution targets opioid dependence by providing a medically managed opioid with a different pattern of action from illicit heroin use.

Methadone is a long-acting opioid agonist at mu-opioid receptors. In a supervised maintenance programme, its relatively slow and sustained action can reduce withdrawal and craving without the repeated rapid peaks associated with heroin use. Stabilising these effects can make illicit heroin use less necessary for relief and allow participation in work, relationships and further treatment. Methadone is an agonist, not an antagonist that simply blocks every opioid receptor. NIDA's medication account explains this receptor-based approach.

Maintenance aims to reduce harmful use and improve stability and retention, rather than requiring immediate abstinence from all opioids. Detoxification is a different aim: medically managed reduction or cessation. Physical dependence on methadone can remain, so ending it also needs clinical management. Calling maintenance “just another addiction” confuses physical dependence with compulsive harmful use and ignores the different circumstances of regulated treatment.

The Cochrane methadone review found better treatment retention and reduced heroin use compared with approaches without opioid replacement. Its included trials did not demonstrate statistically significant superiority for every outcome, including mortality. This is a limitation of that evidence set, not proof that mortality can never be affected.

Methadone can itself cause serious adverse effects, including respiratory depression, and requires appropriate prescribing and monitoring. Attendance requirements, availability and stigma may affect retention. It addresses withdrawal and craving more directly than it addresses drug-related friendship networks or coping habits, explaining why additional support can matter. This is an account of professionally delivered treatment, not a dose or withdrawal plan.

Contingency management

Contingency management changes the immediate consequences of a specified treatment-related behaviour.

Contingency management provides a valued incentive only when an agreed target is met, such as a test showing no non-prescribed opioid use or attendance at treatment. This is positive reinforcement: a reward is added following the target response so that the response becomes more likely. A reward for drug-negative samples strengthens the behaviours that achieve non-use; it does not reward taking heroin. “Contingent” means dependent on meeting the target, not an unconditional payment.

The target must be clear, the measure credible and the reward timely and valued by the participant. If every participant receives the same voucher regardless of behaviour, the voucher cannot test the intended contingency. A programme may increase incentives for sustained success, while agreed rules determine what happens after a target is missed. Withdrawal management and ordinary care should not be confused with an optional incentive.

NICE psychosocial guidance includes contingency management for people receiving methadone maintenance. The 2021 review by Bolívar and colleagues synthesised randomised trials in adults receiving medication for opioid use disorder. It found benefits for several targets, including illicit-opioid abstinence, attendance and medication adherence. This supports contingency management as an adjunct; it does not show that rewards replace medication or that every outcome improves equally.

Repeated testing and incentives cost resources, staff need training, and effects after rewards end need separate assessment. A learned response may weaken if the old drug rewards remain stronger than available alternatives. Ethics concern informed agreement, privacy of samples and fair access. Material incentives are not automatically coercion, but a person's economic vulnerability can affect the freedom of a choice. Pairing incentives with longer-term social and coping support can help build alternatives which remain after the programme ends.

Nicotine replacement

Nicotine replacement therapy reduces nicotine withdrawal while the person changes the behaviour of smoking.