Tag Archives: Medication Assisted Treatment

MAT MEdication Assisted Therapy opiate detox west palm

Medication Assisted Treatment MAT; A New Breed of Drug Addict

Medication Assisted Treatment Disease Models, and Addiction Treatment for Opiates

Medication assisted treatment MAT in West Palm Beach, FL needs to be addressed. At Whole Health outpatient addiction treatment clinic in West Palm Beach, FL., we see 100’s of patients suffering from drug and alcohol addiction. Many do not have a clear understanding on MAT due to bad information on social media. We see many social media posts giving incorrect information, mainly based on personal experience. MAT must be properly diagnosed by a qualified addiction physician.

As most of us are aware, the opioid and heroin problem in our country is at epidemic proportions, and I would go so far as to state unequivocally that we are dealing with a magnitude and severity of a situation in addiction medicine that is unprecedented in nature. Suddenly, relapse isn’t an “oops let me try again,” it is DEATH.

Too Many Deaths from Opiate Epidemic

A recent CNN article detailed some alarming statistics: “heroin-related deaths increased 439% from 1999 to 2014. As of 2014, heroin-related deaths had more than tripled in five years and quintupled in 10 years. In 2014, opioids were involved in 28,647 deaths, 61% of all US drug overdose deaths and 10,574 were related to heroin, in particular.

addiction treatment Fort Lauderdale, West Palm Beach, and Miami Florida

Data from 2014 reflects “two distinct but interrelated trends,” the CDC notes, a long-term increase in overdose deaths due to prescription opioids, and a surge in illicit opioid overdose deaths, mostly related to heroin.” At Whole Health outpatient addiction treatment clinic, 70% or greater of our patients are addicted to heroin. Very clearly, the near-universal mechanism by which we as a country have dealt with substance use disorders to date, namely traditional 12 step rehab, is inadequate in this new and exploding population of opiate use disorder patients.

Addiction is a brain disease opiate addiction treatment west palm

There are two prevailing “thought models” which attempt to explain the pathophysiology behind addiction.

Moral Model of Addiction

The first is termed “the moral model,” which asserts that addiction is entirely a choice and secondary to an individual’s moral decision-making (or lack thereof). This model presupposes that, if not for one’s dysfunctional values and choices, he or she would not have an addiction problem.

Disease Model of Addiction

The second model is known as the “disease model”, which categorizes addiction as a chronic disease. ASAM (the American Society of Addiction Medicine) defines addiction as ”a primary, chronic disease of brain reward, motivation, memory and related circuitry”. And as part of a recent landmark statement, the US Surgeon General, Vivek Murthy, distinctly stated that addiction is “a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer”.

Medication Assisted Treatment MAT Supported

Furthermore, President Obama’s 2017 fiscal year budget includes $1.1 billion to support cooperative agreements with States to expand access to medication-assisted treatment for opioid use disorders. All of this did not happen on a whim. These statements and decisions are directly based on clinical evidence that including MAT in the treatment of the chronic disease of addiction increases the likelihood of abstinence from the illicit substance and decreases the probability of overdose and death.

Medication Assisted Treatment (MAT) Education Needed

Accepting addiction as a chronic disease mandates that we, as addiction professionals, view and treat it in the same multi-disciplinary manner in which we treat other chronic diseases. Namely a COMBINATION of medical interventions and behavioral adjustments and modifications. In other words, we as physicians don’t look at an obese diabetic patient and simply say “lose a hundred pounds and your diabetes will go away” and omit insulin therapy.

Whole Health Primary Care Physician Delray Beach FL

Nor do we look at a smoker with emphysema and simply say “stop smoking and you will breathe better” and omit inhalers that improve lung function. Are the insulin and inhalers, respectively, “crutches” for these patients? I suppose one could look at it that way, but mainstream medicine, and our society as a whole, would submit that these medications are imperative to preserve life and improve the quality of one’s life.

So, if the addition of medication is perfectly acceptable, appropriate and the actual standard of care for all these other chronic disease states, why the stigma when discussing medication assisted treatment MAT, as it applies to the chronic disease of addiction? As an addiction medicine Doctor, I feel that it is imperative to at least consider utilizing any and all available tools at our disposal, and this includes MAT (Medication-Assisted Treatment.)

Medication Assisted Treatment MAT opiate detox west palm

Having said that, medication assisted treatment MAT should also not be used in a cookie-cutter fashion, and is not appropriate in all forms for all patients. The specifics regarding MAT medications are beyond the scope of this introductory article, but will be detailed in a future editorial. However, suffice to say that, when used responsibly and appropriately, MAT saves lives.

Our national academy and addiction authority, ASAM, our surgeon general, our Country’s President, and addiction medicine physicians in the trenches with these patients concur that that is, indeed, the case. The recovery community cannot continue to treat our current climate of heroin addiction in a rigid, dogmatic fashion, or thousands of more deaths will be left in the wake- guaranteed.

Abstinence, or Die (What’s Really Happening in the Recovery Community)

I would submit this question to the recovery community as a whole: given the REALITY that abstinence is only attainable by approximately 10% of our patients addicted to heroin, what should our answer be to the other 90%? Attain the recovery community’s traditional idea of abstinence, or go die?

harm reduction opiate addiction treatment west palm Medication Assisted Treatment MAT

In the course of treating no other disease would that be the sentiment. The logical answer is harm reduction. If a portion of our patients are utilizing some form of medication assisted treatment MAT, yet going to work, having meaningful relationships, and living a fulfilling life devoid of crime and an elevated risk of death and communicable disease, what is wrong with that? If I could actually attach a title to the current arena of mainstream heroin addiction treatment it might be “Abstinence- worth dying for.” The unyielding ideals in the context of the current patient population are at the very least antiquated and simplistic, and at the very most, downright dangerous.

Medication Assisted Treatment MAT Saves Lives

In summary, we have an absolute epidemic of opioid/heroin abuse in this country of a never-before-seen magnitude, and our current historic methods of dealing with alcoholism and other addictions are NOT WORKING. Traditional 12-step, “abstinence-based”, one-size fits all programs are simply NOT acceptable as a uniform approach to this new and evolving segment of addicts, and these patients are DYING IN RECORD NUMBERS.

one more time could be your last Medication assisted treatment MAT saves lives

One More Time, Could Be Your Last.

The primary difference between heroin and alcohol, or other drugs of abuse, is that with ANY relapse, just ONE use or momentary lapse in judgment, the heroin addict has a significant rate of sudden death. Perhaps being dogmatic about traditional, Big Book, 12 step programs are more acceptable when the risk of relapse does not include the very high likelihood of immediate death. But, because of the totally unknown mixture of drugs in each purchased “bag” or “cap,” including the most potent opioids known to man, namely fentanyl and carfentanil, a relapse is not necessarily an invitation to “try again,” but is a game of Russian roulette often ending in death.

Harm Reduction – Medication Assisted Treatment MAT

In my time treating patients with substance use disorders, I have often heard the statement “the definition of insanity is doing the same thing over and over again and expecting a different result,” I think the way we are currently treating our heroin-addicted patients accurately, albeit ironically, fits that definition.  It’s time that we as a recovery community stop preaching and demanding that our idea of “abstinence” in the course of addiction treatment is the ONLY acceptable goal. We must embrace harm reduction.

not one more suboxone treatment west palm one more time could be your last Medication assisted treatment MAT saves lives

We can continue jumping up and down screaming abstinence-based rhetoric while our patients continue to die, or we can think more pragmatically about the issue and consider the non-judgmental addition and acceptance of appropriate medically-based therapies to the paradigm of addiction treatment. Our patients’ lives truly depend on our willingness in the recovery community to adapt to this uncharted territory by implementing the same treatment paradigm that we use as a society in any other chronic disease.

For more information on Medication Assisted Treatment MAT, or outpatient addiction treatment options in West Palm Beach, Fort Lauderdale, and Miami please visit our website HERE or call 855.365.1626 (majority of medical insurance plans and Medicare, excluding HMOs. Flexible financial arrangements are available to patients unable to afford their entire deductible or who are without insurance and are paying cash.)

More Addiction and Behavioral Health Treatment Options


Addiction Treatment Ft Lauderdale Whole Health Facebook Group Addiction and Behavioral Health Options

CLICK HERE to join.

#100 - This Page may not be public. Here are some possible solutions to fix the error.

You may also be interested in some of our other articles on addiction treatment; “Unchecked Addiction Treatment Diseases“, “What Does (MAT) Medication Assisted Therapy Mean for Generation Z?“, and “Narcan Education by Opiate Detox West Palm Doctor“.

MAT Part 2 opiate detox west palm

MAT Part 2: Addiction Antagonist Therapy

MAT part 2 Medication Assisted Treatment a continuation of our last opiate addiction treatment article from Whole Health in West Palm Beach, FL., explained the definition and use of MAT or Medication Assisted Treatment, in addressing patients struggling with particular substance use disorders.

MAT Part 2 opiate detox west palm

The first article examined the use of opiate agonist MAT therapy (i.e. buprenorphine products/”Suboxone” and methadone),) while this installment will examine the utility of opiate antagonist MAT therapy. The principle disorder to be focused upon, primarily because of its ubiquitous nature and the fact that we are predicted to experience greater than 50000 fatalities this year (MORE THAN AUTO ACCIDENT DEATHS,) is opiate use disorder.

What is Medication Assisted Treatment MAT Part 2

First, a very brief and simplistic review of neurobiology as it pertains to addiction. Opiate addiction is all about the reinforcing experience the patient’s behavior has upon the brain’s dopamine levels (the “feel good” neurotransmitter.)

Opiate detox West Palm dopamine

All addictions, whether they be substance-based, or behaviorally oriented (such as gambling and sex addiction) are rooted in the basic fact that these activities cause a surge of dopamine in a specific part of the brain known as the nucleus accumbens. This dopamine surge is perceived as the “high.” This feeling is obviously pleasurable, and the patient wants to repeat and repeat the addictive activity, as the dopamine release becomes a positively reinforcing result of the behavior.

Opioids and Medication Assisted Treatment (MAT)

In the case of opioids, when these drugs attach to the brain’s “mu” receptors, the result is a huge surge of dopamine, which floods the nucleus accumbens, resulting in an intense and euphoric “high.” The patient uses again and again to keep experiencing that dopamine high, and if they stop using they get extremely ill with withdrawal symptoms.

Therefore, the actual use of the drug is reinforcing, while cessation of use causes them to feel horrible (i.e. Not using is NEGATIVELY reinforcing.) This “double whammy” almost guarantees that an opioid addict will continue to use and/or chronically relapse (if you recall from the first article, the “success rate” of stand-alone abstinence-based treatment such as various psychotherapy, 12 steps, etc. is only around 10% at best.)

MU Receptors Oral Naltrexone, Vivitrol and Naltrexone Implants

It is at the brain’s mu receptor sites where antagonist MAT therapies exert their effect.  Antagonist MAT therapies include oral naltrexone, intramuscular Vivitrol, and the off-label use of naltrexone implants that typically provide up to three months of medication with each implant. All of these formulations function in the same fashion- they bind to the brain’s mu receptors very strongly (much stronger than opioids,) preventing any opioids from reaching the patient’s brain and causing that euphoric dopamine surge.

Whole Health stops addiction with opiate detox west palm beach

In other words, with antagonists at work the patient will not derive any high from opioids should he or she decide to use them.  Therefore, this breaks the cycle of positive reinforcement and helps patients with opioid cravings because they know if they use they will simply not derive the expected and desired feeling. The various formulations primarily differ amongst one another in how compliant the patient is likely to be on the given therapy.

naltrexone implants opiate detox west palm Whole Health

Generally, the injection, or implant are much more efficacious than the daily oral naltrexone, because the patient can forget or “forget” to take the daily naltrexone, but the injection or implant is in their body for one or three months, respectively.  Incidentally, MAT antagonist therapy (MAT Part 2) helps immensely with alcohol cravings, and there is emerging evidence that they may be useful for other addictions as well, but that is another topic entirely. However, to stay focused on opioids, I think you can see how incredibly useful antagonist MAT can be in extinguishing the Pavlovian behavior of opiate addicts, and really assist them in putting together solid, long-lasting sober time, and often permanent sobriety!

Abstinence for up to Two Weeks (Understanding the Use of Suboxone)

What is the catch? The primary and most frequent and frustrating problem in initiating antagonist therapy is that, depending on what type of opioid the patient was using, we need anywhere between one and two weeks of total avoidance of ALL opioid and opioid-related products. This includes buprenorphine products (i.e. Suboxone) and methadone.  Therefore, for instance, we can’t take a heroin addict, stabilize him or her on Suboxone, and then transfer immediately to naltrexone/Vivitrol/naltrexone implant.

Similarly, we can’t take a patient right out of detox (opioids are actually used to detox opioid addicts) and transfer them to antagonist therapy.  The reason is that, as stated, the antagonist has a much stronger affinity for the brains mu receptors.  If there are any opioids occupying those receptors at the time that antagonists are introduced, they will “kick off” the opioids and result in severe withdrawal for the patient.

Reasons Why Many Do Not Get Antagonist Therapy (Naltrexone and Vivitrol)

So, the primary issue becomes how do we get the patient to be abstinent for the requisite one to two weeks so that we can utilize this effective antagonist therapy? Unfortunately, many addicts are unwilling or unable to be totally devoid of any and all opioids (including Suboxone or methadone) for more than a couple of days before feeling so horrible that they go right back to using. This is, indeed, the eternal challenge of initiating antagonist MAT therapy, and probably the most frequent reason why it is not implemented in more recovering addicts.

It's time for opiate detox Whole Health Delray Beach, FL

There are other reasons as well- not the least of which is a patient who refuses antagonist therapy because they are scared they won’t be able to get high (they are not “ready” to live a sober life.) Other potential downsides to antagonist MAT is that they can cause nausea, occasionally worsen, or cause depression, and can cause liver inflammation (many of our patients have alcoholic, or viral hepatitis, so this is a particularly relevant concern.) Of course all of these potential side-effects are closely monitored and actually different forms of antagonist therapy tend to have more or less of these side-effects, but they are concerns nonetheless.

Antagonist Therapy is Not Habit Forming (Naltrexone and Vivitrol)

In summary of our MAT Part 2 education, antagonist MAT can be incredibly helpful in the treatment of opioid use disorder (and other addictions,) assuming the proper timing of treatment initiation, and appropriate patient selection. Antagonists are not narcotics, are not habit-forming, and have no discontinuation syndromes.

1 year of opiate addiction treatment West Palm Beach, FL Whole Health

I typically shoot for a twelve month period of closely monitored treatment in my opioid addiction treatment protocol at Whole Health in West Palm Beach FL. With the continuation of cognitive based therapies such as structured PHP/IOP/OP programs, NA/AA, 12 step work, spiritually based programs, or whatever positive and helpful course of psychotherapy my patient gravitates towards. Success rates (which I define as prolonged abstinence- greater than one year) utilizing this methodology in my practice have been impressive and encouraging.

The real question is how to effectively bridge the gap between opioid use and antagonist MAT so that we don’t lose patients to recidivism secondary to severe discomfort.

Comfort Meds and FDA Unapproved Meds

There are some “comfort meds” we use with variable efficacy, such as clonidine, vistaril, baclofen, trazodone, etc., but these are rarely able to accomplish bridging of that gap.  There are other methods of bridging this gap, including plant-based detox regimens (i.e. Ibogaine) that detox the patient without the use of opiates, which are extraordinarily interesting and deserving of further research, but they are currently not legal for use in the US.  There is also a exciting new non-pharmacologic, “non-substance” device called the Bridge device for opiate detox which when installed on the patient’s ear, can significantly or totally ameliorate withdrawal symptoms, also without the use of opiates.

As usual, insurers presently consider this modality experimental and will not reimburse for its use (though I am optimistic that this will and should change.) If we could just bridge that gap we could really get a lot more patients on effective antagonist therapy, and this is where I truly believe that what the recovery community at large deems “true sobriety” can be much more frequently attained. Until then, I will continue to pray for progress and utilize the appropriate available medications to assist my patients in the avoidance of death, and the realization of the most rewarding and fulfilling lives they can possibly experience.

“We,” collectively in the recovery treatment community, owe it to our patients to place whatever personal biases we may possess aside, and make this our unified and uncompromising goal at all times!

More Addiction and Behavioral Health Treatment Options


Addiction Treatment Ft Lauderdale Whole Health Facebook Group Addiction and Behavioral Health Options

CLICK HERE to join.

#100 - This Page may not be public. Here are some possible solutions to fix the error.

You may also be interested in some of our other articles on addiction treatment; “Unchecked Addiction Treatment Diseases“, “What Does (MAT) Medication Assisted Therapy Mean for Generation Z?“, and “Narcan Education by Opiate Detox West Palm Doctor“.

Unchecked Addiction Treatment Diseases

Recognizing unchecked addiction treatment diseases must be included in every person’s treatment plan. We see many cases where our clients have been in treatment and did not know they had diseases directly related to their addiction. In a recent instance, Mary, a 23-year-old female with a long-standing history of intravenous drug and alcohol abuse. We found several issues that were left unchecked with this individual.

Individuals Reaction to Unknown Drug Abuse Related Diseases

When we informed her, the first response was, “What does that mean?” Then, “How did this happen?”.  She was just informed that she has hyperthyroidism (an overactive thyroid disease).  Every day here at Whole Health people are diagnosed with conditions they don’t fully understand. We thoroughly check all our patients in recognizing unchecked addiction treatment diseases.

recognizing unchecked addiction treatment diseases dr ligotti

Unchecked Addiction Treatment Diseases

When incorporating integrative medicine with addiction treatment medicine, we can discover many conditions upon physical examination and routine blood work that can exhibit an extensive array of signs and symptoms if left untreated.  We are educating the community in recognizing unchecked addiction treatment diseases.

Such disorders include thyroid dysfunction, vitamin deficiencies, sexually transmitted infections (STIs), anemia, and many more.  The symptoms from these underlying medical issues can, and often do, contribute to our patients relapsing on their drugs of choice as they struggle to feel “normal” in the face of always feeling terrible!

As one specific example of recognizing recognizing unchecked addiction treatment diseases, many studies have shown opiate use can cause changes in thyroid-binding globulin (TBG: a circulating protein produced in the liver).  High TBG levels can cause elevated TSH which is indicative of hypothyroidism (underactive thyroid), liver disease, and can be seen in pregnancy.  On the other hand, low TBG levels can lead to elevated Free T4 and Free T3 which is indicative of hyperthyroidism.

Advantage Dealing with a Specilized Physician

In Mary’s situation, routine labs were checked within 1 month of her last use that showed mildly elevated Free T4 and a low thyroid stimulating hormone (TSH).  At this point we recommend re-checking thyroid function in one month for follow up and re-assess.  Upon doing so, we have found that Mary’s Free T4 continued to be elevated and TSH was low.

An ultrasound of Mary’s thyroid was performed in our office which showed multiple thyroid nodule.  Mary was then sent for a thyroid uptake scan to further clarify her clinical state and to evaluate for the likelihood of thyroid cancer.  Luckily for Mary, her thyroid scan was not concerning.

After thorough evaluation and discussion with Mary, it was discovered that her biological mother also had hyperthyroidism, specifically Graves’ disease, which tends to run in families and is more common in women than men.  Mary had been experiencing symptoms for a while but was never aware that her symptoms could be from something other than withdrawal symptoms. In treating our patients, we are always recognizing unchecked addiction treatment diseases.

Mary realized her recent weight loss, racing heart, palpitations, nervousness, difficulty sleeping, frequent bowel movements, and no period for the past 6 months were all contributing to her new diagnosis of hyperthyroidism.  In retrospect, she realized that she had felt so poorly for so long, and wondered if she started and continued using drugs because she felt so terrible.  Now Mary can be treated appropriately and her symptoms should resolve accordingly, hopefully contributing to her ability to stay clean and sober.

Diet is Often Left Untreated in Addiction Treatment

Also, when people use drugs and/or alcohol, many times they do so in a binge fashion.  It is very common in this time period for a person to eat unhealthily, if they eat at all.  With this poor nutrition comes vitamin deficiencies such as B1 (Thiamine), B12, folic acid, iron and these can lead to anemias (a low amount of red blood cells in the body).

It is also common for an individual to be dehydrated due to lack of fluid intake or while experiencing withdrawal symptoms such as diarrhea, vomiting, sweating.  With this comes electrolyte changes; decreased or increased sodium levels and decreased potassium levels.  Consequently, these electrolyte changes can cause muscle weakness, muscle spasms and cramps, confusion, lethargy, and even seizures.

The aforementioned are just a few examples of how general medical problems intertwine with our patients’ addiction issues.  Make sure your Doctor, or rehab capable of recognizing unchecked addiction treatment diseases. At Whole Health, we focus on “Integrative medicine”, or the combination of physical medical diagnosis and treatment alongside effective psychiatric care.  This combination of body and mind medicine offers our patients, whether living in our community or staying at a local treatment center, a true holistic approach to healing and gives them every chance to succeed!

Dr. Ligotti has completed training sponsored by the American Academy of Addiction Psychiatry in the use of Suboxone for the rapid outpatient treatment of opiate addicted patients. He also has specialized training and DEA authorization as a physician offering office-based opiate detoxification using Suboxone (opiate detox West Palm). Dr. Ligotti is among a very small number of physicians licensed to offer this treatment in a private office-based setting. You may be interested in some of Dr. Ligotti’s other articles on medication assisted Treatment (MAT) like “What Does (MAT) Medication Assisted Therapy Mean for Generation Z?.

Deanna Weilbacher, PA-C

Addiction Treatment Ft Lauderdale Whole Health Facebook Group Addiction and Behavioral Health Options

CLICK HERE to join.

#100 - This Page may not be public. Here are some possible solutions to fix the error.

You may also be interested in some of our other articles on addiction treatment; “What Does (MAT) Medication Assisted Therapy Mean for Generation Z?“, and “Treating Addiction (Pregnant Women“.

Generation Z Medication Assisted Treatment in West Palm Beach Florida

What Does (MAT) Medication Assisted Treatment Mean for Generation Z?

MAT Medication Assisted Treatment, in the context of Addiction Medicine, is an acronym that stands for “Medication Assisted Treatment.” It starts with opiate detox and continues with drug and alcohol addiction treatment centers, Suboxone clinics and drug rehabilitation programs. How does this apply to opioid use disorders (addiction to heroin, Dilaudid, Roxicodone, etc.). In our first article introducing the concept of MAT Medication Assisted Treatment, we discussed two different “models” often used to explain an individual’s predilection for addiction- the “moral model” and the “disease model.”

MAT Medication Assisted Treatment using opioid agonist therapy

My contention, reinforced by the vast majority of experts in the field of addiction medicine, was that addiction is, in fact, a chronic brain disease. It should be managed as we would manage other chronic disease states such as diabetes and hypertension. This management of other chronic diseases includes the comprehensive approach of lifestyle modification and medication, when appropriate. We are already aware of the lifestyle component of addiction treatment- namely the various stages of rehabilitation, and then proceeding with 12 step work, attending meetings, etc. But, what about the medication aspect of treating this particular chronic disease? This aspect of treating addiction with medication is known as MAT.

Tools for Drug Addiction Rehabilitation

With respect to opioid use disorder, MAT Medication Assisted Treatment falls into two general categories: opioid agonists, and opioid antagonists. They are used at different times, and in different patient circumstances. Again, like anything in medicine, this a treatment that is individually tailored to each specific patient, and sometimes the patient is simply not a candidate for any MAT at all. In this article I would like to specifically discuss the opioid agonist group of MAT, methadone and buprenorphine products, and address the topic of opioid- antagonists in the next article.

Using opiate agonists and opiate antagonists for drug addiction treatment

The concept behind opioid agonist therapy is straight forward- replace the illicit substance that our patient is addicted to with a similar substance that is more controllable, but effects the brain in a similar fashion. The severe withdrawal symptoms and cravings an addict experiences upon discontinuation of an opioid are essentially due to the relatively sudden absence of the abused opioid on the addict’s brain receptors. Most often, statistically around 90% of the time, this withdrawal and/or craving is severe and uncomfortable enough that the addict relapses on his or her drug of choice. The sudden introduction of the opioid back into the addict’s body and brain brings an immediate halt to withdrawal symptoms and acute cravings.

Fighting Opiate Addiction

The problem is that the opioids most addicts use have an extremely short half-life and must be used several times a day to avoid withdrawal. Maintaining the happiness/euphoria to which they are accustomed (hedonic tone). Also, the chosen method of introduction into the body is typically one that offers the most immediate desired results- specifically intravenous drug use. This method of use is obviously fraught with risks, such as infectious disease transmission (HIV, hepatitis C, among others), and a drastically increased risk of overdose.

High relapse resulting from opiate epidemic

Overdose typically occurs because the addict has no idea what is actually in the “heroin” they are injecting into their veins, or how potent the substance is- it is, quite literally, a game of Russian roulette with a substantial risk of overdose and death with every single self-administration. The urine drug test results on my “heroin addicts” very commonly reflect the unknown presence of numerous substances. They include, cocaine, fentanyl, and most recently carfentanyl (an opioid often used as an elephant tranquilizer that is about 1000 times as potent as morphine).

It is easy to see that the slightest bit too much of any of these uber-potent drugs can, and often does, result in overdose and death. This concept, and the reality of drug dealers mixing their own drug cocktails with these novel drugs (and I assure you that these drug dealers do NOT possess Louis Pasteur’s drug mixing proficiency), is the reason why “heroin overdoses” and deaths have risen to such a stratospheric level.

So, that’s the background- 90% of the time the addict picks back up because the withdrawal symptoms and/or cravings are so unbearable that they simply can’t take it any longer. Opioid agonist MAT drugs attach to the opioid receptors in the patient’s brain, and just like they would if they used their opioid of choice, the withdrawal symptoms and cravings abate. When properly prescribed, opioid agonists used for MAT reduce or eliminate drug-seeking behaviors (i.e. stealing, robbing, prostituting, needle-sharing) and do not produce a “high” or impair functioning.

Complicated Addiction Treatment Options

I feel it is also imperative that I comment on an extremely disturbing circumstance that I routinely witness. The simultaneous prescribing of chronic opioid agonist MAT Medication Assisted Treatment (i.e. methadone or buprenorphine/”Suboxone”) and chronic benzodiazepines in an out-patient setting. This combination can cause serious and sometimes FATAL RESPIRATORY DEPRESSION (and this risk is exponentially higher in our opioid use disorder population- if they could take things according to a prescription on a bottle they wouldn’t be addicts!). Any physician prescribing these drugs in combination is truly doing a disservice to his or her patients, and their liability in event of an adverse outcome is absolutely indefensible and unforgivable!

MAT Medication Assisted Therapy and Methadone

Chemical formula of Methadone

Methadone is the oldest example of an opioid agonist used to treat opioid addiction. As described, methadone attaches to the same opiate receptors in the brain that heroin and other opioids do, and attenuates withdrawal symptoms and reduces cravings. The downsides of methadone are that it is only available at specific government-sponsored clinics, the patient has to go to the clinic daily (at least initially) in order to receive their dose for the day, the safety profile of methadone is somewhat problematic (interactions with other drugs, a propensity to cause respiratory depression, a very real risk of overdose if too much is consumed, and cardiotoxicity and “QT prolongation”), and the patient does remain dependent on an opioid. Although methadone has certainly been used successfully for decades in the treatment of opioid use disorder, these limitations make it less desirable, in my opinion, than the newer medication on the market, namely buprenorphine.

MAT Medication Assisted Treatment and Buprenorphine (Suboxone)

Suboxone use for opiate detox in west palm beach by Dr Ligotti

Buprenorphine is sold as a generic and also in the branded combinations Suboxone, Zubsolv, and Bunavail, which contain both buprenorphine and naloxone. With the exception of Probuphine (a new buprenorphine sub-dermal implant), buprenorphine products are dissolved in the mouth (Suboxone and Zubsolv), or applied to the inside of the cheek (Bunavail). Buprenorphine is a partial opioid agonist that has a “ceiling effect”, making overdoses and fatal respiratory depression much less likely than methadone or abused full-agonist opioids like oxycodone, heroin, etc.

Buprenorphine comes alone as a medication, and this form has a higher street value. It has a greater propensity for diversion or misuse (intravenous administration). In my practice, straight buprenorphine is preferred only in our pregnant patients (naloxone is contraindicated in pregnancy.) Naloxone is an opiate “blocker” which is not active or absorbed to any significant extent when administered orally, and there is also a deterrent to diversion and misuse, as the opiate blocker reduces or eliminates any “high” which could be obtained from intravenous use of the product. This is why combination buprenorphine/naloxone products are generally preferable to prescribe.

The DATA 2000 program is a special training course which familiarizes physicians with buprenorphine products and enables certain physicians to prescribe the products for out-patient management of opiate use disorder. This enables patients to live a fairly normal life- going to work, maintaining relationships, etc. Downsides of buprenorphine treatment include the fact that the patient remains dependent on an opioid and cost.

Health Insurance Company’s Delay MAT Medication Assisted Treatment

Unfortunately, many insurances still play the “prior authorization” game with these medications. What this means is that, if I write a prescription at my Suboxone clinic of Suboxone for one of my patients and they take it to the pharmacy, many times the insurance company will ask me to fill out papers and jump through hoops before they will cover the medication. This can take 3-4 days, and in the meantime my patient is either very ill, or already relapsed because of severe withdrawal symptoms. This is very problematic, but I am optimistic that insurers will be forced to increase their coverage for MAT.

opiate dependence treatment offered by Suboxone Clinics West Palm Beach

You may notice that I listed ongoing opiate dependence as a drawback applicable to both medications. It is important here to differentiate between DEPENDENCE and ADDICTION. Dependence is a physiologic phenomenon experienced by any animal given regular opioids, and is characterized by withdrawal symptoms upon sudden discontinuation.

ADDICTION is distinct from dependence in that addiction is defined as compulsive, out-of-control drug use, despite negative consequences. Thus, a patient being treated with buprenorphine is quite naturally DEPENDENT, but generally devoid of harmful addict behaviors and living a normal existence- i.e. he or she is not “addicted”. This ends up being the rationale for the incorporation of MAT into the treatment paradigm of opiate use disorder- the very real concept of harm reduction. We are essentially trading a condition of dependence and addiction for one of solely dependence, and we must at times believe that this is a “win”!

MAT Medication Assisted Treatment Management

We must accept that the outcome REALITY of the majority of our patients is either relapse or death- PERIOD, NOT the all-too-elusive “abstinence”. Given the REALITY that 90% of our opiate use disorder patients will relapse, and the REALITY that the substances our patients are putting in their bodies nowadays are often fatal with a SINGLE USE OF MINUTE AMOUNTS, we as addiction professionals MUST come to grips with the REALITY of considering MAT Medication Assisted Treatment in the management of our opiate use disorder patients. In the final analysis, the REALISTIC question we must ask ourselves for the vast majority of our patients is: “is my patient better off alive and using MAT, or dead because of blind allegiance to our industry’s traditional, draconian ideals”?

Get More Content Like this at Facebook Group Addiction and Behavioral Health Options by Clicking HERE