MEDICATION-ASSISTED TREATMENT (MAT)
Medication-Assisted Treatment is the latest tool in the arsenal of professionals seeking to help individuals in their struggle with alcohol and drug abuse. All fields of healthcare are constantly evolving as new scientific advances and evidence from clinical studies challenge previous assumptions about the best means to treat a variety of illnesses – and the field of addiction treatment is no different. These treatments, often referred to as MAT in the field, have been shown to be a very effective adjunct to the already well-established techniques and approaches that substance abuse professionals have been using for years in both inpatient and outpatient settings. However, they should never be viewed as a “magic bullet” that will “cure” addiction and abuse disorders without the aid of (often numerous) other resources and support.
Table of Contents
- What Is Medication-Assisted Treatment?
- A Timeline of Medication-Assisted Treatment of Substance Abuse
- Off-Label vs. FDA-Approved
- The Limits of Medication-Assisted Treatment
- Medication-Assisted Treatment for Opioid Addiction
- What Opioid MAT Doesn’t Treat
- Specific Medications that Treat Opioid Addiction
- Medication-Assisted Treatment for Alcohol Use Disorder
- Specific Medications that Treat Alcohol Use Disorder
- The Resistance to “Miracle Cures”
- Other Concerns with Medication-Assisted Treatment
- MAT Can Help Give You a Fresh Start
What Is Medication-Assisted Treatment?
Medication-Assisted Treatment is a form of medication-based treatment that your substance abuse physician and counseling team may recommend based on various factors related to your substance abuse, including medical, psychiatric, and psychosocial factors. MAT uses medications prescribed by a physician, along with counseling and mental health care, to help those who are suffering from addiction to maintain sobriety after detoxification.
Cravings and the emotional dysregulation caused by cravings can last for months to years after stopping the use of substances of abuse. Because of this unfortunate fact, some who have become dependent on drugs or alcohol experience one or more relapses at some point in their recovery, especially during early recovery. During this critical stage, it may be recommended that you be placed on medications to reduce cravings, help stabilize emotional dysregulation, restore normal bodily functions (like proper sleeping and eating habits) and help you gain sobriety as you are learning the tools you will need to maintain long-term abstinence and recovery from substance abuse.
Off-Label vs. FDA-Approved
Physicians can and commonly do prescribe medications “off-label” which means that they are prescribed for uses that have not yet been approved by the Federal Drug Administration, but the prescribing is based on immense clinical data that demonstrates effectiveness for this off-label use. For the purposes of this discussion, only medications for MAT that have been approved by the Federal Drug Administration (FDA) will be covered. The most common Medication-Assisted Treatments are those used to treat cravings caused by alcoholism, opioid addiction, and nicotine addiction. The medications that have been approved by the FDA have undergone intense clinical scrutiny to ensure their safety and effectiveness. Since addiction follows similar pathways related to particular neurotransmitters in the brain (namely, dopamine among others), there is overlap between the medications used to treat opioid and alcohol dependence.
The Limits of Medication-Assisted Treatment
MAT is not a cure-all and is unlikely to be effective without other simultaneous treatment modalities and interventions. If you or a loved one is interested in Medication-Assisted Treatment it is critical to know that taking a medication for cravings and mood-stability is only an adjunct to a well-balanced recovery plan that should include all of the following elements:
- A stable recovery environment
- Mental health treatment
- Medical treatment
- Counseling services
- Case management services
- Self-help groups like AA, NA, Smart Recovery, or religious-based groups
- Productivity in employment, volunteering, or education
- Proper use of leisure time
Medication-Assisted Treatment for Opioid Addiction
Since opioid abuse has one of the highest relapse rates of all the substances of abuse – and arguably carries the most immediate risk of negative consequences like overdose, infectious diseases, illegal activity, suicide and others – MAT for the treatment of opioid substance use disorders has been a major focus since the 1970s when methadone first became used for the treatment of opioid addiction. In addition, LAAM (Levo-alpha-acetylmethadol) – another long-acting synthetic opioid – was FDA approved in 1993 for the treatment of opioid abuse but is no longer in widespread use. Later, the use of Revia (naltrexone), Vivitrol, and buprenorphine began to replace the use of some of these earlier drugs in Medication-Assisted Treatment.
What Opioid MAT Doesn’t Treat
During the process of treating patients with methadone, it became quickly apparent that MAT only treats the disorder that it was meant to treat. Methadone does not treat cocaine addiction, it doesn’t necessarily treat homelessness, nor does it treat criminal behavior. However, it was found to decrease cravings, prevent relapses onto other opiates, and enable many patients to restore their health, happiness, and productivity. Unfortunately, opioid addicts often develop many other negative behaviors that complicate treatment, requiring a holistic approach to treatment of which Medication-Assisted Treatment is just one component.
Specific Medications that Treat Opioid Addiction
Methadone is a synthetic opioid that has been used to treat pain since 1947 but was only approved to treat opioid addiction since the early 1970s. Since methadone is an opioid, it binds to – and activates – the same receptors that heroin, OxyContin, Vicodin, and fentanyl activate. Because of this, when one is switched from abusing their drug of choice to being maintained on methadone, their cravings decrease, relapses become less common, and the opioid-addicted person becomes more productive and experiences less consequences.
Because methadone is long-acting, it is well-suited for once-a-day dosing. The caveat to methadone maintenance treatment is that it cannot be taken home, except under very specific circumstances. So, it is generally administered daily as part of an OTP (opiate treatment program) and the patient must be present daily at the clinic to get his/her dose.
Tolerance develops to methadone over time and may require dosage increases on a periodic basis. Unfortunately, because methadone is so long-acting and has a very high affinity (binding capacity) to opioid receptors, the withdrawal from methadone can be particularly long and distressing. Another drawback of methadone is that it has a narrow therapeutic window (the difference between an effective dose and a lethal dose). Because of this, overdoses with methadone are not uncommon.
With the development of safer and easier to use treatments, such as Suboxone or other formulations of buprenorphine, the use of methadone in Medication-Assisted Treatment has been steadily decreasing. However, methadone deserves its place in the treatment of opioid dependence and works for some who have failed on other treatments. In fact, methadone has and continues to help countless individuals restore their lives from the insanity of opioid dependence.
Like methadone, buprenorphine was first approved for the treatment of moderate to severe pain. It was approved for this use in 1981, but it wasn’t approved for the treatment of opioid addiction until 2002. The Drug Abuse Treatment Act of 2000 allowed for the treatment of opioid addiction in an office, rather than in an OTP clinic, but Suboxone (the first approved buprenorphine-based treatment for opioid dependence) wasn’t approved for use until 2002. Since then, various forms of buprenorphine-based MAT have been approved and are in widespread use.
Buprenorphine has some differences from other opiates, which make it ideal for the treatment of opioid addiction. The first is that buprenorphine has a ceiling effect. This means that taking more of the drug won’t allow the user to become progressively more intoxicated. Because of this, it is relatively protective again the cardiorespiratory depression that leads to overdose with other opioids. Secondly, it is an agonist (activating) and antagonist (blocking) at different types of opioid receptors. This dual quality enables it to help relieve cravings and block pain without causing significant cardiorespiratory depression and other unwanted side-effects. Finally, because buprenorphine, like methadone, has a high affinity (binding ability) for opioid receptors, if another opioid is taken along with buprenorphine, the buprenorphine will block the action of the second opioid and prevent intoxication. One caveat of this is that if the buprenorphine is metabolized before the second opioid, one could experience a life-threatening overdose situation.
Certain buprenorphine-based medications contain naloxone. Naloxone is an opioid receptor blocker. Because naloxone has poor absorption through the GI tract (mouth, stomach, intestines), it does not become active unless the user attempts to inject this combination medication. In this scenario, the patient will immediately enter an uncomfortable opioid withdrawal syndrome, rather than becoming “high”. Because of this built-in safety mechanism, this combination drug is the most commonly prescribed form of buprenorphine-based MAT. Monotherapy using medications that only contain buprenorphine are reserved for pregnant patients or patients who have an allergy or hypersensitivity to naloxone.
Currently approved formulations of buprenorphine-based MAT are:
- Oral buprenorphine/naloxone – sublingual film or tablets, or buccal film – trade names Suboxone, Zubsolv, Bunavail
- Oral buprenorphine monotherapy – sublingual film or tablets – trade name Subutex
- Buprenorphine injectable extended-release – subcutaneous monthly injection – trade name Sublocade
- Buprenorphine implants – subdermal implants every 6 months – trade name Probuphine
Naltrexone works differently than the opiate-based treatments described above. Although technically an opioid, naltrexone blocks opioid receptors, rather than activates them. Because of this action, it is believed that a dopamine response that triggers endogenous endorphins will be blocked and, through this mechanism, cravings may be diminished. Furthermore, if the opioid-addicted person relapses on an opioid after taking naltrexone, the opioid should have no effect. As mentioned above with buprenorphine, the caveat is that, if the naltrexone is metabolized before the second opioid, the person could become intoxicated or even experience an overdose situation. But, because naltrexone has a high-affinity for opioid receptors and has a long half-life, it is relatively protective against opioid use on top of naltrexone.
Naltrexone preparations include:
- Oral naltrexone – swallowed tablets – trade name Revia – daily a.m. dosing is typical
- Naltrexone extended-release injectable suspension – trade name Vivitrol. The advantage of Vivitrol is that it is not subjected to the compliance issues of oral naltrexone, since it is injected in your doctor’s office once a month. Therefore, those on Vivitrol may be less apt to stop taking their medication during high-stress times and experience a relapse. The downside to Vivitrol is its cost. However, many insurance carriers will cover the cost of Vivitrol for those who have shown they have a medical need for this medication. Vivitrol was approved by the FDA in 2010 to treat opioid addiction.
Medication-Assisted Treatment for Alcohol Use Disorder
There are currently 3 medications that are approved for the treatment of alcoholism – or 4 if you count the two very different forms of naltrexone as separate drugs. They work either by decreasing cravings, blocking the “high” created by alcohol upon its initial ingestion, or by causing unpleasant effects when one drinks alcohol while also taking the medication. Until the advent of anti-craving medications for alcoholism, the only treatments available for the long-term maintenance of sobriety were mental health treatment, counseling, and self-help groups. These newer Medication-Assisted Treatments have added new weapons to the arsenal of addiction professionals in their fight against alcohol addiction and abuse.
Specific Medications that Treat Alcohol Use Disorder
Disulfiram – Trade name Antabuse
Disulfiram works in two different ways. The first is that it causes unpleasant effects when one drinks alcohol while taking the drug. Disulfiram blocks the effects of an enzyme that breaks down acetaldehyde (a byproduct of alcohol metabolism in the liver). Once blocked, the build-up of acetaldehyde will cause nausea, vomiting, flushing, headache, palpitations, and dizziness. This reaction is so uncomfortable that it is typically enough to prevent the alcoholic from taking another drink.
The problem with Disulfiram is that the recovering alcoholic must take it every day for it to be effective. If the alcoholic chooses to relapse, they may stop taking the medication for a period of time and then begin their relapse. However, since the effects of disulfiram may last in one’s system for up to two weeks, the crisis that prompted this type of “planned relapse” may be resolved by the time the alcoholic is able to take their first drink without unpleasant side effects. In addition to the unpleasant effects that Disulfiram causes (making alcoholics less likely to relapse), it also seems to help reduce cravings for alcohol, although the chemical mechanism for this effect is currently unknown.
Acamprosate – trade name Campral
Acamprosate was approved by the FDA for the treatment of alcohol dependence in 2004, although it had been used in Europe much earlier than that. It finally became available for use in the United States in 2005. This medication works as a neuromodulator, which seeks to restore the changes in neurobiology that have occurred due to chronic alcohol intake. These changes, among others, create cravings for alcohol. Glutamate receptors in the brain cause excitation; whereas, GABA receptors are inhibitory. Alcohol binds to the GABA receptors, creating inhibition. Once the alcohol is removed, the glutamate receptors create a state of excitation, uninhibited by the GABA receptor. Acamprosate works to restore the imbalance in neurochemistry and to reduce cravings by interaction with a third receptor, the NMDA receptor. Although Acamprosate is associated with very few side-effects, it must be taken 3 times a day, making it very reliant upon the patient’s commitment to this regular routine of Medication-Assisted Treatment.
Naltrexone – trade name Revia
Although this medication was approved to treat opioid addiction back in 1984, it wasn’t approved to treat alcohol dependence until later. Since naltrexone blocks opioid receptors, it is thought that it can block the euphoria that one gets when they first consume alcohol, which is modulated by dopamine and the subsequent release of endogenous endorphins (opioids). By blocking this effect, cravings are diminished, and, should one drink alcohol while taking naltrexone, the effects like euphoria are less pronounced, making drinking less reinforcing as a pleasurable activity. Although Naltrexone must be taken at least 3 days a week to be effective as a Medication-Assisted Treatment, most patients take it daily to develop a regular habit of use.
A different form of naltrexone, called Vivitrol (trade name), is available by the intramuscular injection of a suspension of naltrexone that is repeated monthly. It works in the same way as oral naltrexone, but it removes part of the problem of patient compliance in that it only needs to be injected once a month. Vivitrol was approved for the treatment of alcoholism in 2006. Vivitrol is more costly than oral naltrexone but may be more effective because the injections are given in your doctor’s office, making compliance assured and recorded. Though Vivitrol is more costly than oral naltrexone, this cost may be outweighed by the extraordinary costs of relapse – financial and otherwise – particularly for individuals with a history of not complying with a regular MAT regimen of oral naltrexone usage.
The Resistance to “Miracle Cures”
With all of the obvious and evidence-based benefits of Medication-Assisted Treatment of alcohol and drug abuse, it seems like everyone would be “on-board” with the use of MAT as part of an overall approach to these widespread problems. However, that has not been the case for a number of reasons. First off, many addiction treatment professionals and even addicts themselves are naturally wary of any approach to substance abuse treatment with even a hint of a “miracle cure” aspect to them. This is due to the long history of failed “cures” for addiction and “non-addictive” alternatives to many drugs over the years. In fact, many of the drugs developed to wean people from addictive substances have turned out to be even more dangerous than their predecessors – the initial marketing of “safer” heroin over “dangerously addictive” morphine being just one in a long list of these unmitigated disasters.
Other Concerns with Medication-Assisted Treatment
In addition to this well-founded suspicion based upon long-documented history, addicts and the professionals who treat them are naturally wary of having to rely upon any drug (even temporarily), due to their past history with abuse. However, taken in the proper manner with the right kind of supervision, these new forms of Medication-Assisted Treatment have proven to be quite safe and effective, particularly when contrasted with the dangers of continued abuse and addiction.
Another concern, especially among addiction treatment specialists, is that the existence of relatively inexpensive MAT-based approaches will cause governments and insurance companies to push for “Medication-Only” treatments as a low-cost way to address the problem of addiction. This, however, is not a reason to resist using Medication-Assisted Treatment as one element of a more comprehensive treatment plan. Any move by government agencies or insurance carriers to pursue a “Medication-Only” approach to treatment would actually fly in the face of the data that suggests that MAT works best in conjunction with other time-tested addiction treatment techniques such as education, individual counseling and group therapy, among others.
MAT Can Help Give You a Fresh Start
If you or a loved one have struggled with alcohol or drug abuse or addiction, you know that it can be a difficult road toward recovery, filled with false starts and potential pitfalls. So, why wouldn’t you take advantage of any opportunity to increase your chances of long-term success? Medication-Assisted Treatment can be a critical component in helping you or your loved one achieve long-term success in your fight against addiction. Don’t hamstring your odds of success by limiting the tools you employ in treatment; in the fight of a lifetime, you need to use everything at your disposal.
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"THE GOLD STANDARD IN CARE"
Behavioral Wellness & Recovery is a Joint Commission accredited program. The Joint Commission recognizes excellence in health care organizations and programs.
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