The model of methadone tolerance testing Bakker and Fazey describe is not the solution to this problem.1 They make the assumption that low mean maintenance doses of methadone are a consequence of low starting doses, which are separate issues. The model of induction into methadone treatment recommended in the national clinical guidelines for the management of drug dependence allows for the attainment of adequate optimised maintenance doses.2 Reluctance on the part of some prescribers (and patients) to increase doses to the recommended range between 60 mg and 120 mg a day is the clinical issue needing further attention.
Bakker and Fazey cite no drug related deaths during tolerance testing as evidence of the accuracy of their patients' estimated dose of methadone required to relieve withdrawal. However, this speaks more for the particular characteristics of the primary care practice involved, its drug dependent clientele, its prescribers, and the therapeutic and professional relationships of the key stakeholders in this model of induction than for the safety of the methadone tolerance testing protocol. It therefore cannot be extrapolated to other drug treatment settings. Neither large, high volume drug treatment services nor small, less experienced settings can afford to invest such confidence in unknown, newly presenting drug users' own predictions of the “right” methadone dose for them.
Even with cautious clinical practice during the first week of treatment, deaths occur, of the order of seven deaths per 10 000 inductions, about double that for heroin users not in treatment.3 Overall, however, methadone treatment reduces by two thirds drug users' risk of death while in treatment.4
Clinicians need to be aware that death during induction while rare, is preventable through cautious and responsible practice that takes account of the known biovigilance data.5 The practice as outlined by Bakker and Fazey is well beyond such data and if practised on a widespread basis will inevitably result in unnecessary deaths.
We think the publication of this paper, unaccompanied by an independent expert commentary, is an example of poor editorial judgment.
Competing interests: None declared.
References
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