Authors' reply

I agree with Critchlow & Nadeem that abstinence-based treatment may only be appropriate for a minority of opiate-dependent patients and that risk awareness is an essential first step for both patient and treatment provider. There is an increased risk of accidental overdose in the weeks following discharge from abstinence-oriented residential treatment.

In common with centres in Britain and Australia, addiction treatment services in Dublin are oriented towards harm reduction. However, there is no conflict between a goal of harm reduction yet continuing to provide patients with the option of an abstinence-based treatment such as that examined in our study. In all medical specialties, doctors are charged with the responsibility of weighing up the advantages and disadvantages of various treatment options. There are many circumstances in which patients will have to choose between a more conservative treatment option and a more aggressive approach with a higher risk but a greater reward.

In the case of opiate dependence, both clinicians and patients in Dublin are fortunate to have the option of both methadone maintenance and abstinence-based treatments. Although there are real risks of accidental overdose associated with the latter, we believe that in a therapeutic relationship that is collaborative and respectful, the patient should be given the choice. Denying them the choice of an abstinence-based treatment would represent a retreat to a paternalistic approach to medicine which was so commonplace a generation ago and which is criticised by patient groups today. At the other end of the spectrum, there are many countries where patients are denied, or have very restricted access to, methadone maintenance treatment (Kakko et al, 2003; World Health Organization, 2004). This has occurred when treatment options have been determined by politicians instead of clinicians and decisions have unfortunately being driven by ideology rather than evidence.