Outcomes of methadone maintenance treatment are determined by caseload characteristics, treatment processes and complex environmental factors. The paper aims to describe some clinical and organizational features of new community-based methadone services in Dublin, where many dysfunctional, alienated or destitute multisubstance addicts were in urgent need of harm reduction and rehabilitation.

Data were drawn from a participant observation journal recorded over the period 1998-2002 by the author, a clinical public health doctor. Analytic themes were derived from the journal record by a process of induction and were refined in discussion with colleagues. The evolution of the new service is described, and problems of treatment delivery, addiction counselling, and multilevel intervention are discussed.

The paper also reports on the results of a pilot project on family involvement in dose supervision and risk reduction. Some fundamental issues of service organization, community participation and evaluation are addressed briefly from a public-health perspective. It is proposed that reflexive practice is a valid and necessary form of enquiry in human service work, allowing access to knowledge which is embodied, tacit and resistant to explicit formulation.