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Drs White and Adams raise several points which we wish to address. First, in any discussion of the comparison of the clinical efficacy of buprenorphine and methadone it is important to delineate treatment for opioid detoxification withdrawal and substitution/maintenance. The Cochrane review (Mattick et al, 2004) referred to by White and Adams compares these two drugs for opioid maintenance/substitution. The conclusion reached is that buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence but that it is no more effective than methadone at adequate doses. This result hardly ‘clearly came down on the side of methadone’as declared by White and Adams.

The significance of the methadone dose in relation to efficacy was emphasised in our paper. There is evidence (Ward et al, 1999) to demonstrate that methadone stabilising doses of less than 50 mg are associated with higher patient dropouts and doses greater than 60 mg are associated with longer stays in treatment and greater reductions in heroin use.

An updated Cochrane review (Gowling et al, 2005) investigated the effectiveness of buprenorphine in managing opioid withdrawal/detoxification and concluded that buprenorphine was more effective than clonidine but that there was no significant difference compared with methadone in terms of completion of treatment. However, it was suggested that the withdrawal symptoms might resolve more quickly with buprenorphine.

Second, our intention was to inform clinicians of the viability of buprenorphine as a treatment option for opioid dependence. The import of procedures and protocols for prescribing was emphasised. In this regard, we were interested in the Cornwall experience and particularly the difficulties encountered by community pharmacists with supervising buprenorphine administration. White and Adams poignantly bring to light the risks of diversion into the community when drug administration is not carefully monitored. Surely this highlights the need for local protocols and as such is in keeping with clinical governance principles. This approach should address the roles of pharmacies, diversion into the community, supervision, care plans and prescribing because it may be the best choice for the patient.

Finally, White and Adams comment on the ‘optimism’ which ‘ may have misled readers’. At no stage did we state that buprenorphine was superior in its efficacy to methadone, neither did we state that buprenorphine should be the mainstay treatment for opioid dependence. Furthermore, reference to the French situation is of limited relevance to the UK. In France, methadone is not as readily available as a treatment option and buprenorphine is the mainstay treatment. It is also wise to remember that although systematic reviews underscore good clinical practice, they do not always translate accurately into clinical practice and the context within which one prescribes is an important factor.

If any element of optimism was present, it most likely reflected the authors’ enthusiasm about the potential for extending the treatment options for those who struggle with opioid dependence.