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Ms M, a 24-year-old single woman, presented requesting treatment for her heroin problem. She had, two weeks before, been involved in a violent, drunken altercation with her boyfriend (and pimp) and had subsequently left him. As a consequence of this (and several other incidents), her six-year-old daughter had been taken into the care of Protective Services. She wanted her daughter back and had resolved to "get her act together" (i.e., to stop prostituting herself, to get off drugs and thus to show that she could be a responsible parent). She had not used any opiates for 48 hours, but had used between 5-10 diazepam tablets daily to alleviate symptoms of withdrawal.

In addition to opiates (two or three "tastes", or about l g daily, intravenously), Ms M was also using tobacco (about 50 cigarettes daily), cannabis (two or three joints or pipes, or about 1 g, on most days), alcohol (20-80 g on most days) and benzodiazepines (one or two tablets on most days). Ms M had begun using drugs at age 14 years, shortly after leaving home to escape unwelcome sexual advances from her mother's defacto. Her drug and alcohol use had escalated after she had started working the streets. She had made several unsuccessful attempts to stop using opiates and other drugs, but had never before sought medical help. Because she had been aware of the potential risks to her baby, she had abstained from alcohol during her pregnancy and had also weaned herself off opiates for about three weeks before the baby's birth.

Examination confirmed that Ms M was in the early stages of opioid withdrawal. She was acutely agitated and reported abdominal cramps with nausea and diarrhoea. She was sweaty, her pupils were dilated and she had marked piloerection. Needle tracks were present in several areas. She was pale, her tongue was furred and her blood pressure slightly elevated. Investigations revealed a raised mean corpuscular volume (99 fL) and raised gamma-glutamyltransferase level (105 U/L). Hepatitis C and HIV screens were negative.

Ms M began a methadone program and, after an initial period of daily attendance for dose titration, was stabilised on methadone syrup 60 mg daily. During this period she was provided with information about the consequences of her alcohol and other drug use. She was required to attend for counselling and support on a weekly basis. Her benzodiazepine and other drug use was closely monitored with random urine drug screens.

Ms M was initially reluctant to modify her alcohol and cannabis intake, but later agreed to a trial of controlled drinking and after 12 months was able to limit her intake to 3-6 standard drinks per week. She continued to use cannabis and tobacco but slightly reduced her consumption of both drugs. Although she used heroin on a couple of occasions in the first three months of the program and withdrew from the program for about four weeks, she later engaged more fully, and after 12 months felt confident enough to begin a gradual reduction of the dose of methadone.

Ms M was able to stop working as a prostitute and obtained casual work as a barmaid/waitress. Although problems with her former defacto (the father of her daughter) persisted, she was able to establish a reasonably stable relationship with another man (a former drug user). Eight months after entering the program she regained custody of her daughter.

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