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An Overview: Medication Assisted Therapy

The compulsive use of drugs or drinks alcohol despite the pervasively harmful effects of those substances is a hallmark of addiction. People who struggle with addiction will go to great lengths to obtain and use their drug of choice—behavior that can lead to significant distress and impairment in an individual’s life.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 15.7 million people needed treatment for an alcohol use disorder and nearly 2.6 million people needed treatment for an opioid use disorder in 2015.3  The cycle of addiction is a challenge to break, especially on your own, though; and, unfortunately, less than 11% of people who needed substance abuse treatment that year received specialized recovery services.3 Fortunately, for people abusing alcohol or opioids, medication-assisted treatment options are available to help break the pattern of addiction and better maintain sobriety.

What is Medication Assisted Therapy?

Medication assisted therapy or treatment (MAT) is a way for people who are addicted to and physically dependent on substances to safely and effectively quit abusing those substances and sustain recovery. In those with opioid use disorders, specific MAT interventions may also help to minimize the risk of opioid overdose.4 MAT is currently used in the treatment of alcohol use disorder and opioid addictions, with ongoing research studying options for other substances like cocaine.4,5

MAT, which aims at providing a whole-person approach to addiction treatment, is comprised of three valuable components:4

  • A medication prescribed by an addiction specialist.
  • Behavioral therapy provided by a mental health or addiction expert.
  • Support, encouragement, and stability offered by family and friends.

Although many people succeed in quitting drugs with just behavioral therapy, medications can help to augment addiction treatment and promote long-term recovery. Medications should not be used without counseling, because medications do not address the underlying issues that led to substance abuse in the first place. In fact, federal law prohibits anyone from receiving MAT medications without concurrent counseling or therapy.4

By adhering to the prescribed dose and dosing schedule, MAT medications may be safely taken for months or years to aid the individual by:4

  • Regulating brain chemistry and bodily functions.
  • Blocking the euphoric highs produced by drugs.
  • Reducing cravings for the drugs.
  • Regaining balance and control over behaviors.

Between alcohol and opioids, MAT is more frequently employed in the treatment of opioid addiction.4 Heroin abuse may be most closely associated with MAT, but the same opioid dependence medications that help people manage heroin addiction are also effective in treating addictions to many prescriptions painkillers, such as:6

  • Codeine.
  • Vicodin.
  • Norco.
  • Percocet.
  • OxyContin.
  • Dilaudid.
  • Morphine.
  • Fentanyl.

Over recent years, the number of prescriptions for these types of medications have climbed to very high levels with about 207 million prescriptions written in 2013 alone, according to the National Institute on Drug Abuse.7 As increasingly more of these prescription drugs are circulated, the number of people abusing them has also risen. With a higher amount of people suffering from substance abuse disorders, the need for successful MAT options increases.

How Does It Work and What Medications Are Used?

Several MAT medications work by addressing the physiological changes caused by chronic substance use. When someone consistently abuses an opioid or alcohol, the substance modifies brain functioning and disrupts the normal equilibrium.8 Over time, the brain and the body come to depend on the presence of the substance to maintain balance. When an individual suddenly quits abusing drugs or alcohol, the levels of certain neurotransmitters, the chemical messengers in the brain, become unbalanced, resulting in withdrawal symptoms.8

Select medications used in MAT help to minimize the distress associated with quitting and encourage abstinence by normalizing brain chemistry.4 Others discourage continued use by minimizing cravings, decreasing the reward associated with the abused substance, or eliciting an unpleasant reaction should the substance be used again. Each medication used functions in a unique way with its own set of advantages.

MAT options for opioid addiction and dependence include:2,4,6

  • Methadone: A relatively long-acting, full opioid agonist that works similarly to heroin and other opioids by binding to and activating opioid receptors, which reduces the discomfort of withdrawal and reduces cravings. Methadone is available as a pill, an oral concentrate liquid, and an orally disintegrating wafer, but it is only dispensed from sites specially certified by SAMHSA called opioid treatment programs (OTPs).
  • Buprenorphine: A partial opioid agonist that provides a less pronounced opioid effect in the brain than full agonists, which minimizes the potentially rewarding euphoria if taken as directed. In the drug Suboxone, buprenorphine is combined with naloxone, a medication that blocks the effects of opioids, to help prevent abuse. Buprenorphine can be prescribed by approved physicians.
  • Naltrexone: An opioid antagonist that blocks the effects of heroin and prescription painkillers by preventing these drugs from attaching to opioid receptors in the brain. If a person using naltrexone attempts to abuse an opioid, they will not experience any high or desired effects. Naltrexone is available as a pill or a long-acting intramuscular injection called Vivitrol that can block opioids for a month with a single dose. Naltrexone treatment is widely available and can begin once opioid detoxification is complete. Since it is not an opioid agonist medication, there is no risk of physiological dependence—it can be stopped at any time with no uncomfortable withdrawal symptoms.

MAT options for alcohol addiction and dependence include:2,4

  • Disulfiram (Antabuse): A medication that produces unpleasant effects, such as nausea, when combined with alcohol. The major problem with disulfiram is compliance. Someone interested in using alcohol can skip the medication to drink without any ill effects.
  • Acamprosate (Campral): A medication that can be started several days after an individual’s last drink. The medication helps by reducing the long-term withdrawal symptoms of poor sleep, anxiety, and depression by interacting with the neurotransmitters gamma-aminobutyric acid (GABA) and glutamate.
  • Naltrexone: A medication that blocks the wanted effects of alcohol as well as opioids. By blocking some of the reward associated with alcohol intoxication, naltrexone discourages use and can promote extended abstinence. The extended-release version addresses some issues with compliance seen with the oral formulation as well as some other MAT medications.

As mentioned, medications are only one part of MAT. Counseling and behavioral therapies are essential features of MAT. Individual, group, and family sessions will be conducted using a variety of interventions and theoretical orientations including:2

  • Cognitive-behavioral therapy (CBT): Effective for a variety of mental health disorders and addictions, CBT focuses on the connection between thoughts, feelings, and behaviors while learning effective coping skills. Once triggers and cravings are identified, the individual can use relapse prevention strategies to maintain sobriety.
  • Motivational interviewing (MI): This therapy style works to build the individual’s desire for abstinence and a drug-free life. With the internal motivation to stay clean, the person’s thoughts and behaviors will focus on change, not continued use.
  • Contingency management (CM): CM provides tangible rewards for recovery-based activities and accomplishments. If a person attends treatment or provides a clean drug screen, therapists will reinforce these positive behaviors with money, prizes, or valuable tokens. These rewards work to offset the positive feelings experienced with drug use.
  • Community reinforcement approach (CRA): CRA is a highly structured and intensive type of therapy that offers a combination of services over a 24-week period. The sessions will build coping skills, assertive communication, vocational abilities, and healthy social outlets to increase the person’s positive behaviors.

Since finding the support of trusted friends and family members is another aspect of MAT, many therapy options will include significant others in treatment. Other people in recovery can attend support group meetings as a way to extended and enhance their social network.2

Cost of Medication Assisted Therapy

The cost of MAT will vary greatly depending on factors, such as:

  • The type of treatment.
  • The treatment duration.
  • The provided services.
  • The location of treatment.

Perhaps, the most significant contributor to cost is the type of medication used.9,10

  • Methadone treatment has an average monthly cost of $400 – about $13 daily.
  • Buprenorphine treatment has an average monthly cost of between $200 and $450 – between $8 and $15 daily.
  • Naltrexone treatment has an average monthly cost of between $750 and $1,200 – between $25 and $40 daily.

Many insurance providers cover some or all of MAT costs. Others will not pay for medication or may place restrictions on the length of time medication are covered with limitations ranging from 12 to 36 months.10

There is assistance for people struggling to pay for MAT. State and federal insurance programs like Medicaid often pay for at least one medication for MAT. Additionally, drug manufacturers may have programs to lower the cost. For example, the makers of Vivitrol have a co-pay savings program to reduce the expense.11

Effectiveness of Medication Assisted Therapy

MAT is a very effective form of substance abuse treatment with many advantages. The combination of medication, behavioral therapy, and family support can:4

  • Reduce the need for inpatient detoxification services necessary to control dangerous withdrawal symptoms.
  • Offer a comprehensive treatment approach that addresses multiple needs of the individual.
  • Lower the mortality rate of chronic opioid abusers.
  • Increase the duration of treatment.
  • Decrease drug use and other illegal behaviors.
  • Improve the person’s odds of getting and maintaining employment.
  • Create better results for pregnant women with addictions and substance use disorders.
  • Lower the risk of contracting and spreading infectious diseases, such as:
    • HIV.
    • AIDS.
    • Hepatitis C.

MAT Controversies and Misunderstandings

Though very helpful to many with opioid and alcohol use disorders, MAT remains a controversial treatment largely due to misconceptions and misinformation on the issue.2,4 Many falsely believe that prescribing a substance like methadone or buprenorphine is not treatment. Contrary to popular belief, MAT is not substituting or exchanging one addiction for another.2 Buprenorphine and methadone are administered orally/sublingually at specific doses, with relatively slow-onset of action and steady, stabilizing effects. They are offered in a controlled way with monitoring from addiction professionals to ensure safety and end the cycle of addiction.

Despite the strong evidence for success, MAT may be underutilized. In 2010, only about 28% of people seeking treatment for heroin addiction were going to receive MAT during their treatment, a 7% decrease from 2002.4

Some groups and organizations that support an “abstinence-only” policy may oppose MAT.6 These groups adhere to strict guidelines that limit what substances their members can consume. 12-step programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), may not accept participants that use MAT to manage their addictions, but it is valuable to discuss the policy with your local groups.6

Patient Rights

People using MAT may encounter other problems with bias or discrimination in areas of life like employment, housing, and education.12 Like in other situations, solid information is a great tool to combat ignorance about MAT. As potential MAT patient, it is important to know your rights and responsibilities related to MAT.

MAT does not impair or reduce:12

  • Intelligence.
  • Mental capacity.
  • Physical functioning.
  • Employability.

Those who are in an MAT program show levels of attention, focus, and judgment equivalent to those without this treatment. They can perform various occupations at high levels and function well within their communities.12

Because of this, efforts have been made to lower the chance of discrimination by protecting people using MAT under the:12

  • Americans with Disabilities Act (ADA).
  • Rehabilitation Act of 1973.
  • Fair Housing Act (FHA).
  • Workforce Investment Act (WIA).

Additionally, there is a federal confidentiality code that requires medical information related to drug and alcohol abuse treatment to be handled with a higher level of confidentiality and privacy, which means someone disclosing this information without consent can face harsh penalties.4

Potential Risks

Like any treatment, there are risks to medication-assisted treatments for opioid and alcohol abuse.5 MAT medications:5,13,14,15

  • Can be dangerous: As opioid receptor agonists, both methadone and buprenorphine can result in an overdose if misused, especially when taken by children, with symptoms like:
    • Breathing problems.
    • Extreme sleepiness.
    • Blurred vision.
    • Difficulty walking, speaking, and thinking clearly.
  • Can impact pregnancy: Currently, methadone is the only MAT drug for opioid dependence that is recommended for pregnant women and breastfeeding mothers. Be sure to communicate your status to your prescriber.
  • Have side effects: Different MAT drugs have distinct side effect profiles, with symptoms ranging from minor stomach discomfort and insomnia to more serious issues, such as liver problems or significant mental health problems, such as:
    • Anxiety.
    • Confusion.
    • Hallucinations.
  • Can be abused: Since methadone and buprenorphine are opioids, they have some inherent abuse potential. Even when taken as directed, these medications create their own physical dependence as well, which means that stopping abruptly will be uncomfortable. A taper will need to be planned by the prescriber.
  • Cannot be mixed with other medications: Many illicit, prescription, and over-the-counter drugs will react with medications used in MAT to cause unwanted or harmful effects. Combining a substance that slows breathing with certain MAT medications may prove fatal.

MAT might not be the right decision for all people in their recovery from alcohol and opioids, but for many, medication-assisted therapy offers a range of medication and therapy options to establish and maintain long-term abstinence.

Sources

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide.
  3. Substance Abuse and Mental Health Services Administration. (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health.
  4. Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
  5. Kampman, K. M. (2005). New Medications for the Treatment of Cocaine Dependence. Psychiatry (Edgmont)2(12), 44–48.
  6. Substance Abuse and Mental Health Services Administration. (2011). Medication-Assisted Treatment for Opioid Addiction.
  7. National Institute on Drug Abuse. (2014). America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.
  8. Medscape. (2016). Withdrawal Syndromes.
  9. French, M. T., Popovici, I., & Tapsell, L. (2008). The Economic Costs of Substance Abuse Treatment: Updated Estimates and Cost Bands for Program Assessment and ReimbursementJournal of Substance Abuse Treatment35(4), 462–469.
  10. U.S. Government Accountability Office. (2016). Opioid Addiction.
  11. Vivitrol. (n.d.). Co-Pay Savings Program.
  12. Substance Abuse and Mental Health Services Administration. (2009). MAT: Know your Rights.
  13. Substance Abuse and Mental Health Services Administration. (2012). The Facts about Naltrexone.
  14. Substance Abuse and Mental Health Services Administration. (2015). Methadone.
  15. Substance Abuse and Mental Health Services Administration. (2014). The Facts About Buprenorphine.
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