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.
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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滥用毒品者的美沙酮耐受性测试

向药物滥用者询问维持美沙酮所需的剂量似乎有点夸大其词，但一种实践的经验表明，它可以在不损害安全性
的情况下改善治疗的吸收。1965年它从那以后获得体面，有证据显示它减少死亡率，1个 2 3犯罪活动，4的血源性病毒和传输5 ; 改善身心健康4 ; 并促进社会重返社会。1非法吸毒者的死亡率约为同龄人的20倍，6但是美沙酮维持治疗可将死亡风险降低75％以上。2 3然而，开始治疗时死亡率较高。7 8
在治疗的前两周有美沙酮毒性报告强调了没有“证实的耐受性”的患者过高的起始剂量的危险后，7许多国家发布了将维持治疗的起始剂量限制在20-40 mg的指南（见bmj。 com）。9然而，如此低的剂量并不能消除开始治疗时的死亡率8 10并且可能不足以缓解戒断症状，​​直到下一次服用，从而阻止吸毒者进入或继续接受治疗。我们认为，测试美沙酮耐受性（使用初始剂量近似于患者通常的阿片类药物摄入量）可提供更好的解决方案。我们描述了该方法的原理，其有效性的经验以及我们对美沙酮毒性的防护措施。
除非计划排毒，否则高耐受性患者需要高剂量的美沙酮。如果美沙酮的替代量少于其鸦片制剂习惯，吸毒者通常会补充非法海洛因，美沙酮或苯二氮卓类药物，直到达到足够的维持剂量为止。美沙酮诱导期间死亡的事后研究发现…