Practice Practice controversy

Methadone tolerance testing in drug misusers

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39016.471840.68 (Published 16 November 2006) Cite this as: BMJ 2006;333:1056
  1. Adam Bakker, general practitioner1,
  2. Cindy Fazey, visiting professor of international drug policy2
  1. 1Lisson Grove Health Centre, London NW8 8EG
  2. 2Department of Sociology, Social Policy and Social Work Studies, University of Liverpool, Liverpool L69 7ZA
  1. Correspondence to: A Bakker bakker{at}nhs.net
  • Accepted 25 September 2006

Asking drug misusers the dose they need for methadone maintenance might seem like an invitation to exaggerate, but experience in one practice suggests that it could improve uptake of treatment without compromising safety

The use of methadone maintenance to treat opioid addiction was controversial when it was introduced in 1965. It has since gained respectability, with evidence showing that it reduces mortality,1 2 3 criminal activity,4 and transmission of bloodborne viruses5; improves physical and psychological wellbeing4; and facilitates social reintegration.1 The mortality of illicit drug users is around 20 times that of their peers,6 but methadone maintenance treatment reduces the risk of death by over 75%.2 3 However, mortality is higher at the start of treatment.7 8

After reports of methadone toxicity in the first two weeks of treatment highlighted the dangers of excessive starting doses in patients without “demonstrated tolerance,”7 many countries issued guidelines that limited starting doses for maintenance treatment to 20-40 mg (see bmj.com).9 Yet such low doses do not eliminate mortality associated with starting treatment8 10 and may not be sufficient to alleviate withdrawal symptoms until the next dose, thus discouraging addicts from entering or staying on treatment. We believe that testing methadone tolerance, which uses an initial dose that approximates the patient's usual opioid intake, provides a better solution. We describe the rationale behind this method, our experience of its effectiveness, and our safeguards against methadone toxicity.

Risk of undertreatment

Unless planning to detoxify, patients with high tolerance need high doses of methadone. If the substituted amount of methadone is less than their opiate habit, addicts will usually top up with illicit heroin, methadone, or benzodiazepines until they have reached adequate maintenance doses. Postmortem studies of deaths during methadone induction have detected the presence of …

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