Medication Assisted Treatment

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What is Medication Assisted Treatment (MAT)?

Medication assisted treatment (MAT) combines behavioral therapy and counseling with FDA-approved medication to provide a whole person approach to substance abuse treatment. MAT is primarily used in the treatment of opioid use disorders resulting from misuse of prescription drugs containing opiates or illicit opiates like heroin, and it has also been used for the treatment of other substance use disorders related to alcohol use. Contrary to popular belief, MAT is not the substitution of one drug for another. Medications that are used in MAT programs ameliorate the withdrawal symptoms and psychological cravings associated with the cessation of illicit drug use and licit drug misuse, and they can only be dispensed through a SAMHSA-certified Opioid Treatment Program (OTP).

FDA-Approved Medications for Opioid Dependence

Buprenorphine
The generic form of Subutex, buprenorphine is prescribed for opioid dependence and pain management, especially for those recovering from surgery. Side effects include dizziness, weakness, fatigue, nausea, constipation, perspiration and numbness or tingling sensations. In substance abuse treatment for narcotic addiction, buprenorphine is often used in conjunction with naloxone, also known as Suboxone. Available in the form of a sublingual tablet (Zubsolv), sublingual film (Suboxone) or buccal film (Bunavail) buprenorphine is sometimes prescribed alone or in conjunction with naloxone.

Methadone
Classified as a synthetic opioid, methadone is prescribed to treat moderate to severe pain. Available in tablet, powder and liquid form, methadone is also used to treat opioid dependence and narcotic addiction. Methadone has a high potential for abuse and addiction. If used with alcohol, it can have very serious or fatal consequences. Methadone’s side effects may include insomnia, restlessness, dry mouth, nausea, anxiety, diarrhea, constipation and loss of appetite.

Naltrexone
ReVia and Vivitrol are common brand names for naltrexone, a medication used to treat alcohol, opioid and narcotic dependence. Available in tablet form, naltrexone is an antagonist drug that prevents the drug-dependent person from experiencing the desired effect of alcohol or misused drug, which helps reduce the allure of the drink or drug that keeps people coming back for more. However, although naltrexone helps to reduce cravings, it does not prevent impairment. Side effects of naltrexone may include nervousness, headache, nausea and vomiting, fatigue, anxiety and drowsiness.

FDA-Approved Medications for Alcohol Dependence

Disulfiram
Prescribed for severe alcohol use disorder, Disulfiram is sold under the brand names Antabuse and Antabus to deter individuals from drinking. When someone takes a tablet of disulfiram, it produces adverse side effects when a small amount of alcohol is consumed. These adverse effects may include chest pain, mental confusion, blurred vision, respiratory difficulties, choking and vomiting.

Acamprosate
Under the brand name Campral, Acamprosate is prescribed for those who have stopped drinking heavily and helps the brain to function again without alcohol. It does not prevent alcohol withdrawal symptoms, nor does it work if the person is still drinking and using other drugs. It comes in a delayed-release tablet form which is taken three times a day and is effective in relapse prevention. Side effects of Campral may include skin rashes, constipation, heartburn, weight loss, dry mouth, dizziness and headaches.

Learn more about FDA-approved medications for alcohol use disorder.

FDA-Approved Medications for Tobacco Dependence

Chantix (varenicline tartrate)
Chantix is prescribed in tablet form to treat nicotine addiction. It reduces cravings and diminishes the rewarding effects of cigarettes and other tobacco products such as e-cigarettes (e.g., vape pens, ehookahs, hookah pens, etc.), water pipes (e.g., hookah), chewing tobacco and other tobacco products. Side effects include nausea, vomiting, constipation, restlessness, decreased heart rate, sleep disturbance, anxiety, and changes in appetite and weight. Patients may experience new mental health problems, or if they have a history of mental illness, they may experience worsening of mental health symptoms. Changes in mental health may occurring during or after treatment with Chantix.

Zyban (buproprion hydrochloride)
Also used as a smoking cessation aid, this non-nicotine product is prescribed as sustained-release tablets which contain the same active ingredient as some antidepressants such as Wellbutrin. Patients who have a history of depression should notify their health practitioner about their mental health history and medications they may be using to treat depression. Zyban has been demonstrated to help patients effectively achieve abstinence from smoking for as long as six (6) months. However, serious psychiatric events have also been reported in patients who have used Zyban for smoking cessation. Side effects may include dry mouth, insomnia, risks of seizure, hypertension, onset of bipolar disorder and other neuropsychiatric reactions.

Learn more about FDA-approved medications for tobacco use disorder.

How Many Patients Actually Receive Medication Assisted Treatment?

Medication Assisted Treatment (MAT) is widely accepted as an evidence-based practice for treatment of substance use disorders, but this does not mean that it is readily available in many substance abuse treatment programs. According to the National Institute on Drug Abuse, about less than half of privately funded drug treatment programs offer MAT, and only a third of patients with opioid use disorder (OUD) actually receive MAT. The percentage of patients with OUD receiving MAT fell from 35% in 2002 to 28% in 2012. Almost all states in America do not have enough treatment capacity to provide medication assisted treatment to all patients with OUD. The National Council on Alcoholism and Drug Dependence (NCADD) reports that 60.1% of rural counties in the United States lack a physician who can prescribe buprenorphine.

MAT is under-utilized for various reasons, including lack of access to MAT programs, lack of provider training, stigma, high costs, and negative attitudes toward agonist maintenance. Provider attitudes toward MAT also affect whether or not patients with OUD will receive medication assisted treatment. Some health insurance carriers and treatment programs have placed limitations on the duration of MAT programs and eligibility of patients receiving MAT. For example, physicians may prescribe a dosage that’s too low, or they may cut the treatment plan short per the insurance carrier’s limitation, which could increase chances of relapse and therefore shake the confidence of patients and physicians in the effectiveness of medication assisted treatment.

To remedy the shortage of MAT services, President Obama signed the 2016 Comprehensive Addiction and Recovery Act (CARA) into law which would expand access to medication assisted treatment in addiction treatment centers. This law allows nurse practitioners and physician assistants to apply for waivers so they can prescribe buprenorphine for opioid dependence.

Examining Medication Assisted Treatment as Evidence-Based Therapy (EBT)

An ad hoc committee of the National Academies of Sciences, Engineering and Medicine (the National Academies) was formed in October 2018 to examine the evidence base on Medication Assisted Treatment for opioid use disorders among other tasks (National Academies of Science, 2018). The committee surveyed the current evidence and practice on each type of medication used for the treatment of opioid use disorder, such as what is known about the dosing ranges and the optimal length of time for MAT. Methadone remains excessively regulated due to its highly addictive properties, but it has been shown to reduce opioid-related mortality and transmission of HIV. Michelle Lofwall of the University of Kentucky supports the use of buprenorphine, one of the active ingredients found in Suboxone and Subutex, which has been shown to decrease mortality from opioid overdoses. Strict regulations limit the availability of buprenorphine due to risks of prescription misuse, even though evidence suggests that buprenorphine diversion is driven by limited access to treatment, according to Lofwall. Sullivan and colleagues (2018) found that treatment retention with the injectable form of naltrexone was better than oral naltrexone. It’s easier to discontinue treatment with naltrexone because it does not cause dependence with the risk of overdose if patients drop out of treatment, according to Adam Bisaga of Columbia University Medical Center. Naltrexone is comparable to buprenorphine as it has similar effects on treatment retention, cravings and opioid use, and Bisaga endorses the injectable form of naltrexone, which should be included among the range of choices for medication assisted treatment for patients. Researchers assessed the effects of medication assisted treatment and found that those who stayed in treatment for over a year had a lower mortality rate than those who were in the program for less than a year.

According to SAMHSA, medication assisted treatment has demonstrated the following benefits:

• Increase treatment retention
• Lower mortality rates
• Decrease illicit opiate use and drug-related criminal activities
• Help patients to gain and maintain employment
• Lower risks of HIV or HCV transmission
• Improve birth outcomes among pregnant women with substance use disorders

Comorbidities for Opioid Use Disorder (OUD)

Studies show that individuals with OUD have co-occurring psychiatric and substance use disorders. The findings, published in Psychiatric Research and Clinical Practice, show the range of comorbid substance use disorders and mental health disorders as follows:

• 13% to 49% for alcohol use disorder
• 20% to 40% for stimulant use disorder
• 28% to 41% for cannabis use disorder
• 80% to 95% for tobacco use disorder
• 28% to 35% for major depression
• 11% for bipolar disorder
• 17% to 30% for anxiety disorders
• 10% for post-traumatic stress disorder

Substance use disorders associated with tobacco, alcohol and cannabis often precede the development of OUD, whereas anxiety, chronic pain and depression are likely to either develop before or after the onset of OUD (Sofuoglu, DeVito & Carroll, 2018).

Medication Assisted Treatment and Substance Abuse Counseling

Opioid Treatment Programs (OTPs) are accredited by the Substance Abuse and Mental Health Services Administration (SAMHSA), and patients who are in OTPs are required by federal law to receive substance abuse counseling, medical, vocational, educational and other treatment services in addition to Medication Assisted Treatment (MAT).

Substance abuse counseling incorporates behavioral health treatments that target substance use disorders and mental health disorders by changing patients’ cognitive, emotional and behavioral patterns. Patients are able to manage their symptoms effectively with the use of prescribed psychotropic medications that turn their negative perceptions into a healthier outlook on situations. Cognitive behavioral therapy, dialectical behavioral therapy, and holistic therapy that utilizes non-traditional interventions are examples of evidence-based practices that are included in behavioral health therapy and counseling. Patients who don’t respond well to traditional talk therapy would respond better to holistic treatment such as equine therapy, paddleboard therapy and surf therapy.

Early interventions work best, and there is no cookie-cutter method to substance abuse counseling and medication assisted treatment. Each treatment plan should be custom-tailored to meet the individual needs of each patient.

References

1 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy. Medication Assisted Treatment for Opioid Use Disorder: Proceedings of a Workshop—in Brief. Washington (DC): National Academies Press (US); 2018 Nov 30. Available from: https://www.ncbi.nlm.nih.gov/ doi: 10.17226/25322

2 Sofuoglu M, DeVito E & Carroll K. (2018). Pharmacological and behavioral treatment of opioid use disorder. Psychiatric Research and Clinical Practice. Retrieved from https://doi.org

3 Sullivan M, Mannelli P, Yu M, Nangia N, Graham C, Webster I, Andrew Tompkins D, Kosten T, Akerman S, Silverman B. Outpatient transition to extended-release naltrexone in patients with opioid-use disorder. American Journal on Addictions. 2018;27(4):323

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