Medication-Assisted Treatment

 What are the benefits of Medication-Assisted Treatment?

You may have had treatment in an addiction treatment facility to help with your illicit substance use. Perhaps, two previous treatments. Maybe, even more. Your treatment may have been a traditional 12-step program. It may have been a Medication-Assisted Treatment program. Perhaps, you had treatment that was a combination of both.

Regardless of how many treatments you may have had in the past, you do not want to be one of those who give up on recovery. Never give up!

In the past, treatment of addiction was almost predominantly 12-step based, with the emphasis being on abstinence from medications. A more scientific evidence-based approach to addiction treatment has however shown the importance of medications in the recovery process.

This modality of improving addiction treatment and maintaining sobriety is known as Medication-Assisted Treatment (MAT).

What is Medication-Assisted Treatment (MAT)?

Medication-Assisted TreatmentMedication-Assisted Treatment (MAT) is an evidence-based treatment approach that involves the use of medications with counseling and behavioral therapies to treat substance use disorders. This is as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The goal of Medication-Assisted Treatment is to provide a “whole-patient” approach to treatment.

MAT is often called the gold standard of addiction treatment. Research has shown that combining medications and therapy is more effective than either one alone in treating and sustaining recovery in people struggling with addiction.

Scientific evidence overwhelmingly shows that Medication-Assisted Treatment is the best form of treatment for addiction to drugs and alcohol.

The abstinence-only model, including the use of the 12-Steps program, had long been purported to be the best way to treat addiction, and essentially considers addiction as a moral failure. This is however not the case, though we do not doubt that this approach has helped several people in their recovery process.

B.K. is a 46-year-old man who once used to be a skeptic of Medication-Assisted Treatment. He had been in 6 different residential treatment programs and relapsed again 10 days after his last treatment.

In his words, “I didn’t believe MAT was for me until I watched a friend overdose and die in my arms. I knew it was time to do things differently.”

Who needs Medication-Assisted Treatment?

It needs to be made clear that MAT is not required for everyone who uses illicit substances. A diagnosis of a substance use disorder has to be made before MAT is considered a treatment option.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-5), there has to be a problematic pattern of alcohol or drug use leading to clinically significant impairment or distress. The DSM-5 requires at least two of such impairments or distress occurring within a 12-month period.

These impairments or distress include:

  1. The substance is often taken in larger amounts or over a longer period than was intended.
  2. A persistent desire or unsuccessful efforts to cut down or control use
  3. A great deal of time is spent in activities necessary to obtain, use or recover from the effects of the substance.
  4. Craving, or a strong desire or urge to use the substance.
  5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school or home.
  6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
  7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
  8. Recurrent substance use in situations in which it is physically hazardous.
  9. Continued use of the substance despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Developing tolerance to the substance. This may manifest as a need for markedly increased amounts to achieve intoxication or the desired effect. It may also present as a markedly diminished effect with continued use of the same amount of the substance.
  11. Withdrawal from the substance.

Vivitrol

Addiction to an illicit substance leads to the risky or dangerous use of the said substance, which causes a hindrance from being a healthy, functional person.

What kind of addiction is Medication-Assisted Treatment used for?

MAT is most commonly used for the treatment of opioid addiction. Medications are used to help with withdrawals and cravings from opioids such as heroin, fentanyl, hydrocodone, oxycontin, and other pain relievers that contain opiates. If you are addicted to alcohol or nicotine, you may also benefit from MAT.

There are several small studies that have shown the benefits of some medications in treating dependence on various other illicit substances. The evidence is however not robust and the 3 main groups of addictive substances which benefit from MAT treatment remain opioids, alcohol, and nicotine.

When treating substance use disorders, it is also important to consider underlying mental illnesses such as depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia. These disorders and several others may contribute to self-medication with drugs and alcohol.

Treating underlying mental illnesses in people who abuse illicit substances (co-occurring disorders) goes a long way in helping with the recovery process from drug and alcohol use. This may be done using medications variously categorized as antidepressants, anti-anxiety medications, mood stabilizers, and antipsychotics.

In some cases, such mental disorders may need treatment with Transcranial Magnetic Stimulation(TMS) and Electroconvulsive Therapy (ECT). A new nasal spray called Spravato (esketamine) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression.

 

How does Medication-Assisted Treatment work?

Medications used in MAT work by normalizing brain chemistry, relieve cravings, block the euphoria obtained from drugs and alcohol, and normalize body functions, without the negative effects of the abused drug.

There are several medications used in MAT. Examples are buprenorphine, methadone, naltrexone tablets, naltrexone injection (Vivitrol), nicotine replacement therapies, acamprosate, disulfiram, and Chantix. These medications are approved by the FDA.

One of the advantages of MAT programs is that they are individualized with the aim of meeting each patient’s needs.

Addiction to drugs and alcohol has a powerful grip on people who use, and this makes it difficult to stop using. Such people have the urge to keep using as the physical withdrawals which come about from not using can be horrible.

This attempt to avoid the withdrawals and “feel normal” is usually what causes people to continue to use, not necessarily to get a euphoric high. This is where some medications used in MAT come in. They help to combat this cycle and curb or make the withdrawals more tolerable.

 

How beneficial is Medication-Assisted Treatment?

MAT programs provide medication-assisted treatment for people addicted to alcohol and drugs. In addition to this, such programs also provide a range of services to reduce, eliminate, or prevent the use of alcohol and illicit drugs, the spread of infectious diseases and potential criminal activity.

The focus of Medication-Assisted Treatment is to improve the quality of life of people receiving treatment.Click To Tweet

Let us take an example of a heroin user with a long history of dependence, who eventually loses his job and source of income due to his heroin habit. To fund his use of heroin, he has resorted to stealing from friends, family and his workplace. He has also been sharing needles while injecting heroin, putting himself and others at risk for infection with blood-borne diseases like HIV and hepatitis.

In this scenario, a professional prescription of buprenorphine would decrease the likelihood of stealing and risking legal troubles. There would also most likely be less of a chance he would inject himself and risk infections. In addition, he would more likely be able to function better with his family, work, and other obligations.

The replacement of heroin with buprenorphine is a modality of treatment known as harm reduction. MAT encourages safer habits and decreases risky behaviors in people with substance use disorders.

People who receive MAT are also granted access to medical, counseling, educational, vocational, and other assessment and treatment services. This is in addition to prescribed medications. Treatment can be provided by MAT professionals in a range of settings including outpatient clinics, hospitals, correctional facilities, and substance abuse treatment facilities.

 

MAT can be quite effective! There is research evidence for this.

According to SAMHSA, in 2013, an estimated 1.8 million people had an opioid use disorder related to prescription pain relievers, and about 517,000 had an opioid use disorder related to heroin use.

MAT has proven clinical effectiveness and has been shown to decrease the need for inpatient detoxification. It provides a comprehensive, individually tailored program of medication and counseling services.

The goal of MAT is a full recovery, including the ability to live a self-directed life. This treatment approach has been shown to:

  • Decrease the use of alcohol and drugs
  • Increase the likelihood of completing treatment
  • Save lives
  • Decrease criminal activity
  • Increase the chances of gaining and maintaining employment
  • Improve the birth outcomes in pregnant women who use drugs and alcohol
  • Decrease the risk of infection with HIV or hepatitis
  • Decrease the potential for relapse

 

Differences between MAT and the more traditional 12-step programs

Medication-assisted treatment is also referred to as evidence-based addiction treatment. This is for good reason. The BMJ, one of the world’s most cited journals, gave this definition of evidence-based in 1996: “evidence-based means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

Medication-Assisted Treatment12-step programs usually combine spiritual and moralistic ideals into a support group for people struggling with alcohol and drugs. In the past, 12-step programs prohibited medication-assisted treatment. In recent times, however, more and more of such facilities have accepted MAT into their programs.

An article published in The Fix had this to say: “12-step programs are an incomplete approach and do not meet the requirements for evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.”

This is not to say people have not been successful with 12-step programs! Several people have been helped but there is evidence to show that even more people can be helped when a MAT approach is utilized.

 

Why is MAT underused despite its proven effectiveness?

It is rather unfortunate that the adoption of this evidence-based treatment option has been quite slow. There are several possible explanations as to why this might be the case.

A lack of awareness is one reason. Also, high on the list of reasons is the misconception about substituting one drug for another. Discrimination against people who utilize MAT is yet another reason, as some see addiction as a moral failure which can always be stopped at will. This is obviously not the case! Addiction is a chronic brain disease that should be managed as such.

A lack of training for physicians and other mental health providers also contributes to the underutilization of MAT. Negative opinions toward MAT in our communities and among health care professionals certainly do not help the cause of MAT either. We all need to cultivate a more positive attitude to this evidence-based treatment modality.

Though MAT is not a guarantee for recovery from addictive substances, it has been shown to work for several people.

 

Culture shift even with the top drug treatment providers

In view of the numerous researches being done to show the effectiveness of medication-assisted treatment, there is now more of an acceptance of the medication-assisted treatment approach. This welcoming of MAT has been observed in several facilities which previously regarded themselves as entirely abstinence-based or 12-step programs.

This change has been observed in several large treatment facilities which initially subscribed almost exclusively to the abstinence-only model – a model based on an interpretation of the 12 steps, as seen in groups like Alcoholics Anonymous and Narcotics Anonymous. This has however changed quite a bit with several programs now having more a combination approach to treatment, moving away from the one-size-fits-all model.

The scourge of the opioid epidemic and associated deaths from overdoses has contributed to a review of drug and alcohol treatment in the United States. It was obvious that the available treatment option was not working as well as it should. This has helped with a growing acceptance of Medication-Assisted Treatment. Rather than cling to the moral stigmatization of drug and alcohol use, there has been more of a shift towards the evidence-based scientific approach.

 

Medication-Assisted Treatment for Opioids

There are different medications used for opioid addiction. The choice of medication depends on the person being treated and the circumstances around the addiction.

Three medications are approved by the FDA for the treatment of opioid addiction:

  1. Methadone
  2. Buprenorphine
  3. Naltrexone

Methadone for opioid addiction is only administered in federally regulated clinics. Buprenorphine, on the other hand, is a medication prescribed by professionals that can be taken at home. Naltrexone is available as daily tablets and as an extended-release injection (brand name Vivitrol) given once a month.

 

Medication-Assisted Treatment is also used in Alcohol Treatment

The most common medications used to treat alcohol use disorder are:

  1. Naltrexone tablets
  2. Vivitrol (extended-release naltrexone)
  3. Disulfiram (Antabuse)
  4. Acamprosate

These medications do not cure alcohol use disorder but have been found to be helpful with recovery especially when combined with other treatment modalities.

As with other substance use disorders, medications should be prescribed as a part of a comprehensive treatment approach that includes counseling, other psychosocial therapies, and social support. Such social support may include participation in Alcoholics Anonymous (AA) and other mutual-help programs, as well as a closer involvement of family and friends.

 

                      Smoking cessation can be made easier with MAT

Tobacco products may be used by smoking, dipping, chewing or snuffing. Medications used to treat nicotine dependence include:

  1. Nicotine replacement therapy
  2. Bupropion (Zyban)
  3. Varenicline (Chantix)

Nicotine replacement is one of the most common treatments for tobacco addiction. Such therapies are readily available and can be purchased over the counter. Nicotine replacement therapies include the patch, lozenges, inhalers, spray, and gum.

Nicotine replacement therapy supplies reduced levels of nicotine such that the user can slowly wean off to reduce the withdrawal symptoms.

The 2 prescription medications approved by the FDA to help with tobacco addiction are bupropion, sold as Zyban, and varenicline, sold as Chantix. Both medications work by blocking cravings as a result of interactions with brain cells, thereby altering certain chemicals.

 

A misconception of Medication-Assisted Treatment

A common misconception with MAT is that it substitutes one drug for another. An example would be treating someone addicted to hydrocodone with a much safer option such as buprenorphine.

This approach, also known as harm reduction, works for several people dependent on drugs and alcohol. There are thousands of stories of saved lives,

family reunions, regaining employment, decrease in criminal activity, and decrease in infections, amongst several other positive outcomes.

Medications used in MAT relieve the withdrawal symptoms and psychological cravings in people with substance use disorders. Programs that utilize medications for treatment provide a safe and controlled environment to help with the recovery process.

The misconception and stigma of MAT are well highlighted in an article published in Vox, titled “There’s a highly successful treatment for opioid addiction. But stigma is holding it back.”

 

What is the best way to proceed?

Though MAT is currently viewed as the best approach to treatment, it does not work for everyone. Individualizing treatment is key. You may also not be keen on taking medications to help with your recovery. In such cases, abstinence and perhaps the 12-step program would be beneficial for you.

It is also possible you may have had side effects to MAT medications, or they may not have helped you abstain as much as they helped others. We all know that medications that work for one person will not necessarily work for everyone else. Again, individualizing treatment is key!

The length of time someone needs to take medications in a MAT program is a common question. There is no maximum recommended duration of maintenance treatment. While treatment may be for a few months for some, it may be indefinite for some others.

Counseling remains an integral and very important component of MAT. Depending on the individual and the circumstances, other types of treatment may be combined with MAT for better results. This may include 12 steps and other support groups.

Sarah Gad gives her personal account of MAT in her article titled “My Drug Overdose Saved My Life. Now I’m Saving Others.”                                         

Conclusion 

Medication-Assisted Treatment (MAT) is an evidence-based treatment approach that involves the use of medications with counseling and behavioral therapies to treat substance use disorders. Scientific evidence overwhelmingly shows that MAT is the best form of treatment for addiction to drugs and alcohol.

Medications used in MAT work by normalizing brain chemistry, relieve cravings, block the euphoria obtained from drugs and alcohol, and normalize body functions, without the negative effects of the abused drug.

There are several medications used in MAT. Some examples are buprenorphine, methadone, naltrexone tablets, naltrexone injection (Vivitrol), acamprosate, disulfiram, and Chantix.

Scientific evidence has shown the effectiveness of MAT, as compared to traditional 12-step programs. This has caused a culture shift from an abstinence-based approach to a Medication-Assisted Treatment approach, with some programs having a combination of both.

The goal of MAT is full recovery, including the ability to live a self-directed life. This treatment approach has been shown to save lives,  increase the likelihood of completing treatment, decrease the use of alcohol and drugs, decrease criminal activity, increase the chances of gaining and maintaining employment, improve the birth outcomes in pregnant women who use drugs and alcohol, decrease risk of infection with HIV or hepatitis and decrease the potential for relapse.

Treatment is individualized and MAT can be combined with the traditional 12-step program depending on the needs of that individual.

You may have had different experiences that could benefit others in their recovery. You may be for or against MAT. Regardless of your thoughts on this very important subject, sharing your experiences will likely help someone struggling with their addiction. Please leave us your comments. You may sign up for our newsletter to receive future articles on addiction and recovery.