The Complete Guide to Medication Assisted Treatment (MAT) in the US
Medication-assisted treatment (MAT) is an effective, multi-faceted form of substance abuse disorder treatment. By combining medication with counseling and behavioral treatment, care professionals often see increased rates of sobriety alongside an increased willingness to stay in treatment. MAT is used to treat a range of substance abuse disorders – primarily opioid use disorder, alcohol use disorder and an addiction to smoking. Unfortunately, MAT is underused for a number of reasons that we will look into later in this article. Education is the most important tool in increasing the adoption of this important treatment method – so firstly, what isthe process undertaken by MAT?
How It Works
When an individual reports a drug or alcohol dependency problem or is directed to seek help for substance abuse, there are three options that are generally suggested:
- Inpatient or outpatient counseling
- A self-help group (e.g. Alcoholics Anonymous, Narcotics Anonymous)
- A methadone clinic/program (for those suffering from opioid addiction)
These options have helped millions around the world recover from dependency issues. However, for some individuals, they are not sufficient on their own. Inpatient counseling is extremely effective, but there are patients who find themselves overwhelmed by cravings. The relative lack of accountability when attending a self-help group can make maintaining sobriety difficult for some – and for those in methadone programs that do not have a counseling aspect, unresolved underlying issues can negatively affect recovery.
MAT combines the best of both worlds - pairing FDA-approved medications shown to help individuals reduce or stop drug and alcohol use with specialized counseling programs, self-help programs or brief physician counseling.
Testing for Suitability
The patient will begin the process by visiting either a trained primary care physician or a treatment center with a MAT-trained physician on staff. The physician will first ascertain whether the patient suffers from alcohol or drug dependence by asking a list of questions related to dependence criteria as outlined by the DSM. If the patient gives three or more affirmative answers, he or she is considered a viable candidate for MAT (although physicians may, at their discretion, recommend MAT treatment even when this threshold is not reached).
The physician will then have an in-depth discussion on the patient’s desire to reduce or stop their alcohol or drug use. This is not to judge whether it is ‘worth it’ to prescribe medication, but rather to increase the likelihood of program success as well as safeguard the patient’s health, as continued drug use while on the medications could be disastrous.
Following this, the physician will conduct a physical exam to ascertain whether their current level of health will allow them to partake in a medication-assisted treatment program. There are a number of issues that could preclude a patient from suitability for a MAT program, including:
- General poor/unstable health
- Continued drug/alcohol use
- Use of certain prescription medications (e.g. anxiety medication)
- Need for inpatient detox prior to starting any treatment program
- Severe liver disease
- Any condition that will cause complications or interactions with the MAT medication
If a patient is deemed a suitable candidate, medication can then be administered. This will take place either on the first or second visit, depending on the circumstances. Medication for alcohol dependence is always administered by a health professional, while that for opioid dependence can be self-administered after the first instance. After this first administration, the patient will be closely monitored for any adverse side effects. If none appear, the MAT program can continue. Progress will be consistently assessed. A physician may halt the program or adjust the medication when necessary.
Some manner of counseling is a requirement for any MAT program. The lowest level is brief physician counseling, where the trained prescribing physician provides basic counseling in support of the medication regimen. This is mainly for those who are unwilling or unable to attend a specialized counseling program. However, attending specialized counseling while receiving medication to assist in recovery greatly increases the likelihood of success. Those in MAT programs that attend self-help groups like AA find that their ability to persist in the program and maintain their sobriety is increased due to cravings being decreased. As specialized counseling alone achieves similar or superior results to the most basic MAT treatment, combining the two is one of a patient’s best options for success in their journey of recovery.
There are a few types of MAT medications – some are used to treat alcohol dependence while others are used by those suffering from opioid dependence. With different methods of administration, regularity of doses, and effects, it is important to understand the specifics of each before beginning treatment.
Alcohol Dependence Medications
Injectable naltrexone is used to treat patients suffering from alcohol dependence. In MAT programs, an extended-release formulation is used. Many people know this form of naltrexone by the popular brand name Vivitrol. This medication must be administered by intramuscular gluteal injection (injection into the muscles in the buttocks). Unlike this drug's mechanism for treating opiate dependency, the exact mechanism of its therapeutic effects on alcohol dependency is unknown. However, patients report the following:
- A reduced desire to have a drink
- Reduced desire to continue drinking if they do imbibe
- An increased ability abstain from drinking
Naltrexone must be administered by a trained health professional with a frequency of about once monthly.
This is another medication used to treat alcohol dependence. Unlike naltrexone, the patient must already have abstained (and detoxed, if necessary) from alcohol. It is a tablet that is taken orally three times a day. It is believed to reduce cravings by working on neurotransmitters whose balance has been disturbed by prolonged, heavy drinking.
While this was the most commonly prescribed pharmaceutical treatment for alcohol dependence up until the end of the 20th century, it has been surpassed by both naltrexone and acamprosate, which are often co-prescribed even when disulfiram is used. This is because of disulfiram’s somewhat controversial method of action. This drug produces an acute sensitivity to ethanol – in short, it makes drinking alcohol extremely unpleasant. Patients compare the effect to that of a severe hangover. Also, since it does not reduce cravings, the major problem with disulfiram is extremely poor compliance – patients simply stop taking the drug. That being said, some patients find the treatment effective, especially from a psychological standpoint.
Opioid Dependence Medication
Methadone may be the most well-known MAT medication. Long used as part of opioid dependence treatment programs, it lessens the incredibly painful effects of opioid withdrawal, which are often a major barrier in the recovery process. Methadone also helps block the euphoric effects of the opiate drugs being abused. When used as prescribed, it does not provide a ‘high’ like the abused drugs, but rather allows the patient to feel normal and continue in the recovery process. Because it can be addictive, methadone use must be carefully measured and monitored. It is taken orally; generally in liquid form as a powder mixed into a palatable drink.
This is the medication preferred by many physicians and treatment programs for the treatment of opioid dependence. Buprenorphine is an opioid partial agonist/antagonist. In other words, it has the ability to cause regular opioid effects like euphoria and respiratory depression, but only up to a certain, considerably lesser extent. This so-called ‘ceiling effect’ reduces the likelihood of abuse, dependence and side effects. Buprenorphine is taken orally – most often as a sublingual (under the tongue) film. To prevent attempts of misuse through injection, buprenorphine is combined with naloxone. When taken orally, buprenorphine’s effects are dominant and naloxone further blocks cravings and withdrawal symptoms. If the medication is crushed or melted and injected, however, the naloxone becomes dominant, and withdrawal symptoms are actually precipitated (brought on quickly and severely). It is important to note that buprenorphine use should begin only after the patient has abstained from opioid use for 12 to 24 hours and is in the early stages of opioid withdrawal. Beginning use while a patient still has other opioids in his or her bloodstream can precipitate dangerous acute withdrawal. It is also dangerous to combine buprenorphine with alcohol, sleeping pills or other sedatives.
Naltrexone blocks the euphoric effects of abused opioid drugs, indirectly reducing cravings. It is most often administered as an extended-release injection, but it also available as a pill. Due to the relative ease of non-compliance with daily pills, injection is the preferred route. One warning to patients going this route is that the combination of time away from abused opioids as well as naltrexone’s ability to block opioid effects can have a deceptive effect if a patient relapses. Their lowered tolerance may be harder to perceive, increasing the risk of overdose.
Although MAT has been shown in studies to improve the chances of successful drug and alcohol dependence treatment, it continues to be underused throughout the country. This is because there are a number of barriers that prevent widespread adoption of this treatment.
It is very common for communities to express concern or out-and-out opposition to treatment centers or physicians in their neighborhood providing MAT services. This is largely due to the common misconceptions about methadone clinics – “these programs are simply dispensing legal drugs that are identical to the illegal or abused ones they are ‘replacing.’” To combat this, it is important to educate the community on the actual workings of the medications provided, the careful way in which they are administered, and to provide success stories for them to see with their own eyes.
Recovery Staff Resistance
Though it may seem surprising, it is not uncommon for both professionally trained and amateur staff of treatment centers to be opposed to MAT programs. With some being in recovery themselves and having done so through self-help groups or counseling, they may also see MAT as ‘replacing one drug for another.’ Because of their experiences, they may be steadfast in their belief that abstinence and counseling is the only ‘right’ way. Here, training, which plainly shows the medication directly treats what they already know to be a mental health disorder, can help correct this misconception.
MAT is very attractive to drug and alcohol-dependent individuals who do not want to enter an inpatient or outpatient specialized counseling program. However, the MAT induction process does take a considerable amount of time, and due to the structure of most family and general practices, this can be a deterrent to physicians who need to see many patients a day. Both Vermont and Maine have implemented programs that ingeniously address this issue. Hospital physicians, medical directors at treatment centers, and dedicated detox program physicians can carry out the relatively lengthy induction process, after which patients are referred to general practitioners who will perform maintenance administration and monitoring.
Even when physicians are willing to become involved in the MAT process, there are limitations that exist. Demand greatly outstrips the supply of physicians trained in the basic counseling which accompanies the administration of medication. Further, federal regulations limit the amount of medication that can be prescribed as well as the number of patients one physician can treat with these drugs. With a common maximum patient number being 30, physicians must come to satisfy certain criteria in order to treat up to 100 patients.
The Case for MAT
MAT has been shown to bring many advantages to the recovery process. Increased survival rates and treatment retention, decreased illicit drug and alcohol use, as well as a reduction in other forms of criminal activity, an increased ability to gain and sustain employment, and improved birth outcomes in mothers with substance abuse disorders, are just some of the effects of medication-assisted treatment. At Clean & Sober Recovery Services, we work with your physician in order to properly manage your medication and align our treatment services with your existing MAT program. Our services include intervention, detox, residential and outpatient treatment for a variety of addictions including alcohol, opioids and methamphetamines, and transitional living. To find out more about how we can assist in the success of your or a loved one’s MAT program or about any of our services, please contact us today.