Highlights: ► We review the pharmacological management of opioid dependence syndrome. ► Agonist maintenance therapy seems to be the first choice in the current setting. ► Buprenorphine has emerged as a first line agonist in view of safety profile. ► Areas of controversy include supervision, affordability and duration of treatment.Abstract: Opioid dependence is a chronic relapsing condition which requires comprehensive care; pharmacological agents form the mainstay of its long term treatment. The two most popular approaches are the harm reduction method using agonists and the complete abstinence method using antagonists. Currently, particularly from the harm minimization perspective and the low feasibility of an abstinence based approach, there is an increasing trend toward agonist treatment. The use of buprenorphine has gained popularity in view of its safety profile and the availability of the buprenorphine–naloxone combination has made it popular as a take-home treatment. This review outlines the pharmacological advances and controversies in this area.