Medication-Assisted Treatment for Substance Use Disorders
Table of Contents
- What Does a Family Medicine Doctor Do?
- When to See a Primary Care Physician (PCP)?
- Pediatric Medicine
- Pediatric vs. Adult Medicine
- What to Expect During a Visit?
- Benefits of a Having Your Pediatric Doctor Also be Your Family Medicine Physician
- Benefits of Having a Family Medicine Doctor as Your Primary Care Physician
- Dr. Ligotti Can Be Your Family Medicine Physician
The Substance Abuse Treatment Center defines medication-assisted treatment (MAT) as a certified, registered opioid treatment regimen supervised by a doctor. Medications are combined with other treatments, including medical care and therapy.1 The FDA-permitted MAT drugs, combined with the other services, treat addiction comprehensively, giving the patient a better chance of getting sober.
MAT can be used for both opioid (OUD) and alcohol (AUD) use disorders. Before starting MAT, a medical professional evaluates the patient to determine if MAT is appropriate. Factors include:
How MAT Drugs Help
MAT is mainly used to treat opioid addiction, for instance, heroin as well as prescription painkillers containing opioids. These drugs help by:
A MAT program is customized to the needs of each and every patient. Doctors must rule out the chance of severe reactions between the MAT drugs and other medications.
Medication-Assisted Treatment Effectiveness
In 2013, a projected 1.8 million people suffered from opioid use disorders associated with prescription painkillers. Approximately 5 million people suffered from opioid use disorders associated with heroin usage.
It has been proven that MAT supports healthy recovery from addiction and can significantly decrease the requirement for hospitalized detoxification stays. MAT is effective because it offers personalized drugs, behavioral therapy programs, and support services to meet the needs of the patient. Studies have also shown that medication-assisted treatment can reduce the risk of HIV, Hepatitis C and other infections.3 Medication assisted treatment is used to:
Unfortunately, MAT is not used as much as the proven results would recommend. The slow acceptance of evidence-based alcohol as well as opioid-dependent treatment options is based on the belief that replacing one drug with another seems like a bad idea. Without proper medical supervision, a high dose of MAT drugs can create addiction; but state and federal laws have provided doctors with guidelines to reduce this risk.
Additional reasons for slow acceptance may include:
MAT for Opioid Use Disorder
Opioid Use Disorder (OUD)
Anyone taking opioids may have a physical dependence, even if they are taken exactly as prescribed. This medical condition is known as opioid use disorder (OUD). OUD occurs when taking opioids becomes a problem and you cannot stop using the drug. OUD is a chronic recurrent disease. Individuals with OUD are generally resistant to opioids and have withdrawal symptoms when they are stopped.5
The mortality rate of OUD patients is six to twenty times the overall population. Morbidity, as well as mortality related with opioid usage, have increased: In 2013, the number of prescription opioid deaths was 16,000 (a great increase since 2001), and the number of heroin deaths was 8,000. In the United States, 100 individuals die every day due to overdosage, about half of which comes from prescription opioids and about one-fifth from heroin. In 2016, overdose of opioids killed more than 42,000 people, and the entire number of opioid overdose demises since 1999 has exceeded 350,000.6
Medication-Assisted Therapy for OUD
Medication-assisted therapy, including opioid agonist or antagonist therapy and assisted psychosocial therapy, is the first-line management for many patients suffering from opioid use disorders. Although clinical judgments have established the superiority of MAT, some patients prefer individual psychosocial treatment. Also known as abstinence or no medication, non-pharmacological treatments often include multiple psychosocial services.7
Drugs Used During Medication Assisted Treatment
Methadone is considered the most widely used drug therapy for opioid use disorder.
How Methadone Works
Methadone works by changing how the brain reacts to drugs and withdrawal pain. Oral doses of methadone inhibit feelings of euphoria and prevent withdrawal symptoms. Methadone has been used for the treatment of heroin addiction since the 1960s and remains an effective treatment choice.8 Numerous studies have shown that it is superior to the use of abstinence-based methods.
The initial dose is determined by the degree of physical dependence. Care should be taken to avoid an excessive dosage to reduce the chances of addiction. Comparatively low doses of methadone can alleviate acute opioid withdrawal but are not generally effective for reducing euphoria and physical cravings.9
Higher quantities of methadone increase the chance of adverse reactions, including heart conditions that may be fatal. Other adverse effects include:
How Naltrexone Works
Naltrexone is used to prevent relapse. Naltrexone works in the brain to prevent the addictive effects of opioid use. It will stop feeling of well-being and pain relief. Naltrexone treatment is used after detox and after a drug like methadone has run its course. Using Naltrexone while using opioids can lead to sudden withdrawal symptoms.
Naltrexone can be used orally or by injection. Oral naltrexone is used when doctors believe a patient can consistently take the right dose. Injectable naltrexone is more appropriate for patients with compliance problems and who need monitoring.
There is no recommended duration for the management of oral naltrexone and extended-release injectable naltrexone. The period relies on medical judgment as well as the individual’s condition. If the patient has no physical dependence on naltrexone, it can be stopped suddenly without the withdrawal symptoms.
The most common adverse effects of naltrexone are:
Since the discovery of Buprenorphine in 1966 and its early approval for medical use in 1975 to treating opioid use disorders, buprenorphine has been proven to be successful for medication assisted treatment. It is now a globally used treatment to manage opioid use disorders. However, since most patients don’t have access to clinical treatment, its use has remained lower than you would expect. Buprenorphine could help many more people if its use was increased in health systems.10
How Buprenorphine Works
Like other drugs in the agonist class of drugs, buprenorphine binds to opioid receptors but triggers less intense symptoms than full agonists. Along with its effects on the μ-opioid receptor, buprenorphine might also have a beneficial impact on a patients mental well-being.
Various studies, as well as meta-analyses, have determined that buprenorphine is safe in its most effective dosages, can keep patients in recovery, and can reduce the illegal usage of opioids. Newer injectable buprenorphine may increase its effectiveness by helping patients take the drug in the right doses.
MAT for Alcohol Use Disorder
Alcohol use disorder (AUD) is a fatal public menace. In the United States alone, the monetary burden of alcohol-associated social hazards is approximately $250 billion per year.11 According to the National Drug Use and Health Survey, approximately 6.2% of people above age 18 used alcohol in 2015.
The abuse of alcohol is the third most preventable source of death in the United States. Moreover, it is believed that 88,000 persons die every year from the abuse.12 Alcohol-related deaths are high worldwide and it is worthwhile to focus on refining screening, management, as well as access to health care.13
Settings for Medication Assisted Treatment for AUD
According to the US Preventive Services Working Group, AUD is dealt with in diverse settings, which include fundamental care, hospitals, and specialized outpatient care centers. In particular, primary care centers are considered an important environment for screening adult AUD. It is recommended that once the identification and assessment are completed, primary care providers should start medication based on practice guidelines or refer patients to addiction specialists.
The Importance of Therapy
The backbone of treatment is psychosocial intervention. Unfortunately, the degree of relapse after psychosocial management alone is higher than psychosocial treatment and drug therapy combined.14 This data suggests that the combination of drug therapy and psychosocial therapy can significantly reduce the recurrence rate. Many drugs are publicized for the reduction of alcohol consumption and long-term abstinence. Three drugs were permitted by the FDA for the treatment of AUD, namely disulfiram, naltrexone, and acamprosate.15
Disulfiram has been an effective supplement in the treatment of alcoholism for 60 years.
How Disulfiram Works
This drug does not promote abstinence by reducing cravings, but by causing distress if a patient uses alcohol, this distress helps prevent consumption. Disulfiram inhibits liver enzymes, which must be monitored.
Alcohol intake during treatment can lead to a disulfiram-ethanol response, such as:
Disulfiram is given in tablet form orally once a day. It is white in color, tasteless and odorless. Disulfiram comes in 250 mg or 500 mg tablets.17 When disulfiram is routinely administered under supervised conditions (e.g., under 12 weeks of supervision), there may be a more substantial reduction in severe drinking days as well as extended periods of abstinence.18 A recent appraisal showed that the monitoring of disulfiram treatment has a role in short-term smoking cessation as well as alcohol relapse prevention.19
Common adverse effects are:
Uncommon but severe side effects include liver toxicity and neurosis.
Acamprosate is usually considered to be artificial alcohol. Since 1989, acamprosate has been used in Europe to treat alcohol dependence. In 2004, it became the third drug accepted by the FDA for AUD treatment.20
How Acamprosate Works
Acamprosate influences chemicals in the mind that may be unbalanced for those who are addicted to alcohol. A number of meta-analyses found that acamprosate reduced alcohol use. For patients with alcohol dependence, acamprosate appears to be good therapy to support continued abstinence after alcohol detoxification. When acamprosate is added to psychosocial cure strategies, it decreases the threat of relapse after detoxification.21
The typical dose is 333 mg doses three times a day, but the suggested dose for patients with kidney damage is lower. It is not addictive, and overuse is safe.
Naltrexone began as a treatment for opioid and heroin addiction, but now it is also widely used for alcohol disorders.
How Naltrexone Works
Naltrexone blocks the μ-opioid receptor. Initially, the way the brain reacts to alcohol is very similar to the response of opioids. Naltrexone inhibits the excitement and pleasure of alcohol. Alcoholics no longer obtain a feeling of “reward” for consuming when on naltrexone, so they are much less likely to continue drinking.22
A regular beginning dose of naltrexone is 25 mg for several days and then increased per day to 50 mg for about a week. Furthermore, the drug must be taken after meals. If abdominal symptoms occur, the doctor may have to reduce the dose. A liver enzyme test must be obtained a month after the start of treatment. These tests are then done monthly during the course of treatment. Everyday oral naltrexone treatment should last at a minimum of 3 to 4 months. After treatment is done, if the desire to drink again starts, you can start using naltrexone again.23
Naltrexone is contraindicated in sufferers with liver enzyme stages 4 to 5 times greater than the top of the regular range. Furthermore, naltrexone must not be given to patients who rely on opioids or require opioids to relieve chronic pain as a result of naltrexone’s blockage of the brains opioid receptors.
Many adverse reactions that occur initially in the treatment of naltrexone include:
Least common but nonetheless severe adverse effects of naltrexone are:
Misconceptions about MAT
Although studies have shown that drug-assisted therapy can reduce the use of opioids, relapse, addiction rates, and death, the misconceptions and stigma of this proven and effective treatment are still present.24
MAT Replaces One Addiction with Another
One misconception of MAT is that using drugs for the treatment of addiction is only replacing one addiction with a different one. However, it is well documented that MAT rarely results in addiction to the treatment drug. Unfortunately, this uninformed perspective has undermined many brave attempts to break the cycle of opioid addiction. Many studies have concluded that the use of long-acting opioids such as methadone or buprenorphine for therapy can help maintain patient health, reduce criminal activity, and help prevent drug-related illnesses such as HIV/AIDS and hepatitis.
Some people think that complete abstinence is the only way to treat addiction. To some, people who use medication assistance are seen as “not so serious about quitting.” MAT patients do not meet the definition of abstinence in some 12-step programs because they are not completely abstinent from all medications, and they may be excluded from these groups.
MAT Doesn't 'Really' Treat Addiction
Opioid use disorders or addiction aren’t cured by utilizing MAT strategy. Many see this a failing of the treatment. However, addiction is a chronic illness. Just as diabetes is not cured by using insulin and hypertensive patients usually continue to take drugs for many years, people with opioid addiction are not cured by MAT, but the addiction is treated.
MAT Only Works in Severe Cases
MAT is for patients who are experiencing varying degrees of addiction. A variety of drugs are used to help patients overcome the urge to use opioids. This includes antagonists, partial agonists, and agonists. The MAT program can be tailored to meet the specific addiction level of each patient and can be adjusted as the patient’s treatment plan changes.
Research on Medication Assisted Treatment
Research helps to eliminate misunderstandings about science. As discussed throughout this article, data shows that MAT is a uniquely successful treatment for opioid addiction. Research has shown that addiction is a chronic condition that can be better managed with the assistance of medication. Understanding the data and science behind addiction – especially how opioid addiction alters individual brain chemistry – is essential for selecting opioid addiction treatments that are most likely to end the destructive cycle of opioid addiction.
Many children with OUD drop out of school, but buprenorphine or naloxone treatment reduces this rate significantly.25 In contrast, present evidence is inadequate to support the effectiveness of individual psychological treatments alone.
Medication Assisted Treatment Improves the Chances of Beating Addiction
It should be no surprise that MAT increases the success of addiction treatment, because MAT relies not on one form of treatment, but takes a holistic approach. The patient usually participates in group therapy, individual therapy, and family therapy. A MAT patient will also receive education and be taught skills to reduce the risk of relapse. The patient will also receive access to many supports, like 12-step programs or SMART recovery. Medication does not replace these important parts of addiction treatment, but it does make all of these parts more effective; giving the patient a better chance for long-term sobriety.
- Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction in opioid treatment programs.
- Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine. 2014 May 29; 370(22):2063-6.
- National Academies of Sciences, Engineering, and Medicine. Medication-Assisted Treatment for Opioid Use Disorder.
- Berrios M, Mancher M, Stroud C, Flynn D. Medication-Assisted Treatment for Opioid Use Disorder: Proceedings of a Workshop—in Brief.
- Degenhardt L, Whiteford HA, Ferrari AJ, Baxter AJ, Charlson FJ, Hall WD, Freedman G, Burstein R, Johns N, Engell RE, Flaxman A. Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010. The Lancet. 2013 Nov 9; 382(9904):1564-74.
- Hser YI, Evans E, Grella C, Ling W, Anglin D. Long-term course of opioid addiction. Harvard review of psychiatry. 2015 Mar 1; 23(2):76-89.
- Oliva EM, Maisel NC, Gordon AJ, Harris AH. Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Current psychiatry reports. 2011 Oct 1; 13(5):374.
- WANT JE. Methadone maintenance treatment and other opioid replacement therapies. The Netherlands: Harwood Academic Publishers. 2008.
- Comer S, Cunningham C, Fishman MJ, Gordon FA, Kampman FK, Langleben D, Nordstrom B, Oslin D, Woody G, Wright T, Wyatt S. National practice guideline for the use of medications in the treatment of addiction involving opioid use. Am. Soc. Addict. Med. 2015; 66.
- Shulman M, Wai JM, Nunes EV. Buprenorphine Treatment for Opioid Use Disorder: An Overview. CNS drugs. 2019 May 6:1-4.
- Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 national and state costs of excessive alcohol consumption. American journal of preventive medicine. 2015 Nov 1; 49(5):e73-9.
- National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism, US Department of Health & Human Services. Helping patients who drink too much: a clinician’s guide. (United States of America). 2005.
- Grant BF, Saha TD, Ruan WJ, Goldstein RB, Chou SP, Jung J, Zhang H, Smith SM, Pickering RP, Huang B, Hasin DS. Epidemiology of DSM-5 drug use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA psychiatry. 2016 Jan 1; 73(1):39-47.
- Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera SF, Aboyans V, Adetokunboh O, Afshin A, Agrawal A, Ahmadi A. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2017 Sep 16; 390(10100):1151-210.
- Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the US Preventive Services Task Force. Annals of internal medicine. 2012 Nov 6; 157(9):645-54.
- Martin B, Beresford TP. Disulfiram in context: structure and safety. Journal of clinical psychopharmacology. 2007 Aug 1; 27(4):415-7.
- Krampe H, Ehrenreich H. Supervised disulfiram as adjunct to psychotherapy in alcoholism treatment. Current Pharmaceutical Design. 2010 Jun 1; 16(19):2076-90.
- Miller PM, Book SW, Stewart SH. Medical treatment of alcohol dependence: a systematic review. The International Journal of Psychiatry in Medicine. 2011 Oct; 42(3):227-66.
- Jørgensen CH, Pedersen B, Tønnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcoholism: Clinical and Experimental Research. 2011 Oct; 35(10):1749-58.
- Hunter K, Ochoa R. Acamprosate (Campral) for treatment of alcoholism. American Family Physician. 2006 Aug 15; 74(4):645-6.
- Rösner S, Hackl‐Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M. Acamprosate for alcohol dependence. Cochrane Database of Systematic Reviews. 2010(9)
- Kim Y, Hack LM, Ahn ES, Kim J. Practical outpatient pharmacotherapy for alcohol use disorder. Drugs in context. 2018; 7.
- Anton RF. Naltrexone for the management of alcohol dependence. New England Journal of Medicine. 2008 Aug 14; 359(7):715-21.
- White WL. Long-term strategies to reduce the stigma attached to addiction, treatment, and recovery within the City of Philadelphia (with particular reference to medication-assisted treatment/recovery). Philadelphia: Department of Behavioral Health and Mental Retardation Services. 2009.
- Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard review of psychiatry. 2015 Mar 1; 23(2):63-75.