There’s a common misconception that MAT is a “crutch” or simply substitutes one drug for another and is inferior to complete abstinence. In this paper, RCA’s Chief Scientific Officer, Dr. Deni Carise, explains the research behind the numerous benefits of MAT and why RCA supports and offers this treatment option.
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According to The Substance Abuse and Mental Health Services Administration, the federal agency in the U.S. Department of Health and Human Services responsible for leading the nation’s efforts in substance abuse prevention and treatment, Medicated-Assisted Treatment (MAT) is the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. Although numerous medications have been shown to significantly decrease cravings for alcohol and other drugs, reduce the harm from substance use, and even save lives, there remains significant controversy, stigma, and resistance to using these medications as part of a comprehensive treatment for individuals with substance use disorders.
A common misconception is that medications, even when appropriately used as part of a comprehensive treatment program, simply substitute one drug for another, or that the medications are “a crutch.” In reality, these medications have shown numerous benefits to a large group of stakeholders, across a variety of uses and stages of recovery. Some effectively relieve withdrawal symptoms, others reduce physiological and even psychological cravings, some block the effects of abused substances in the brain, some provide an ongoing safe, and controlled level of medication to overcome the use of an abused opioid.
Recovery Centers of America’s position is that substance use disorders are chronic medical illnesses and like any other illness, we should rely on the science when deciding on treatment options to provide to our patients. And further, that every type and form of treatment, including psychosocial services and medications that have been proven effective in valid scientific studies should be offered to all appropriate patients just as is the case in the treatment of other chronic illnesses such as diabetes, asthma, depression or anxiety.
To adequately discuss and provide rationale and supporting facts for RCA’s position on Medication-Assisted Treatment or MAT, a review of the medications available to assist with substance use disorder treatments is necessary. Below is a list of the most studied and used FDA (Food and Drug Administration) approved medications for treatment of alcohol, tobacco and opioid use disorders. Currently there are no FDA-approved MAT treatment options available for amphetamine, cocaine, or marijuana.
Primary Medications for Treatment of Alcohol Use Disorders
Disulfiram or Antabuse – Approved by the FDA in 1951, this medication has no effects until the person drinks alcohol. When alcohol is consumed, the person experiences acute sensitivity resulting in nausea, vomiting, headaches and other acutely uncomfortable symptoms. For someone having difficulty with abstaining from alcohol, this medication helps them not to drink during periods of cravings or impulsive desires to drink.
Naltrexone – Oral Naltrexone, approved by the FDA for the treatment of alcohol use disorders in 1994, works by decreasing cravings for alcohol and by blocking some of the euphoric effects and feelings of intoxication. This makes alcohol less rewording resulting in reduced frequency and volume of drinking. The injectable form of Naltrexone (Vivitrol) was first approved by the FDA in 2006 for the treatment of alcoholism.
Primary Medications for Treatment of Nicotine Use Disorders
Bupropion – Known by its most commonly prescribed trade names Zyban or Wellbutrin in the treatment of depression, bupropion products have also been shown to reduce nicotine cravings and withdrawal symptoms in adult smokers making quitting smoking and maintaining recovery easier.
Nicotine Replacement Therapies (NRTs) – Often available over the counter in the form of gum, lozenge, or inhaler, NRTs help smokers wean off cigarettes by activating nicotine receptors in the brain in an increasingly lower dose over time. This alleviates many of the withdrawal symptoms experienced when tobacco users try to quit abruptly.
Varenicline – Better known by its trade name Chantix, this prescription medication works on three areas – it reduces the pleasurable effects of cigarettes (or other tobacco products), decreases cravings for nicotine, and decreases withdrawal symptoms by mildly stimulating nicotine receptors in the brain.
Primary Medications for Treatment of Opioid Use Disorders
Methadone – Approved by the FDA for use in treating opioid addiction in 1972, methadone is a weak to modest opiate agonist. An opioid agonist imitates the action of other opioids (including prescription opioids, heroin, fentanyl, etc.) by binding with the opioid receptors in the brain but have a lower level of affinity with the receptors resulting in less of the rewarding properties of other opioids like euphoria. The effectiveness of methadone treatment for individuals struggling with heroin or other opioid problems has been established in numerous studies conducted over four decades. When used while a patient is detoxifying from opioids (heroin, fentanyl, morphine, codeine, oxycodone, hydrocodone, etc), it lessens the painful symptoms of opioid withdrawal and allows the patient to detox safely over a period of time increasing the chance that the patient will be able to achieve a complete detoxification. Patients on methadone for ongoing treatment (methadone maintenance) have shown improvements in a number of outcomes including decrease or cessation of heroin/opioid and other drug use, reduced crime, decreased transmission of HIV and HEP C viruses, and improved personal and social functioning.
However, in addition to the benefits to the individual, methadone has two additional objectives including enhancing public safety, and safeguarding public health. It is agreed that these outcomes are achieved by the combination of methadone when provided with counseling. Methadone is used in specially licensed residential substance abuse detoxification programs or for maintenance, is dispensed in clinic-based opioid treatment programs.
Buprenorphine – Approved for clinical use in October 2002 by the FDA, buprenorphine is the most recently developed medication for treatment of opioid use disorder and the first medication to treat opioid dependency that can be prescribed or dispensed in physician offices, significantly increasing treatment access and privacy in treatment. Suboxone, the most commonly prescribed buprenorphine product prescribed for maintenance therapy is an opioid agonist/antagonist that blocks other narcotics while reducing withdrawal risk and is used in a daily dissolving tablet, cheek film, or 6-month implant under the skin. As with all medications used in MAT, buprenorphine is prescribed as part of a comprehensive treatment plan that includes counseling and participation in social support programs.
Naltrexone – First approved in US in 1984 in pill form, Naltrexone is a non-addictive opioid antagonist that blocks the euphoric and sedative effects of opioids including heroin, fentanyl, morphine, codeine, and prescription opioids. It works differently in the body than buprenorphine and methadone, which have agonist properties and activate opioid receptors in the body. Naltrexone is a pure antagonist meaning without delivering any of the reinforcing properties of opioids, it binds to the opioid receptors and essentially blocks any opioid from attaching to the receptors and having a pleasurable or pain-relieving effect. Because it does not provide any reinforcing properties like the euphoria that may come with the use of opioids, there is no abuse or diversion potential with naltrexone.
The injectable extended-release form of the drug (Vivitrol) was approved for treatment of opioid dependence in 2010 (and in 2006 for treatment of alcohol dependence). Unlike methadone or buprenorphine, it can be prescribed by any health care provider who is licensed to prescribe medications.
It’s worth mentioning the effectiveness and value of the medication Naloxone. Approved by the FDA for the treatment of opioid overdose in 1971 and sold under the brand name Narcan as a nasal spray, Narcan blocks the effects of opioids within 2-5 minutes, reversing an opioid overdose. However, it must be noted that Narcan is a medication for the treatment of the opioid overdose, not opioid dependency. It saves lives to be sure, but it does nothing to address the opioid problem.
It is with this review as background that we provide the rationale and supporting facts for RCA’s Position on the Use of Medication-Assisted-Treatment. We also make a number of analogies among these medications and between these medications and medications for other chronic diseases to show examples of the stigma that keeps people, including families, employers and many well intentioned treatment providers, from adopting the use of some proven effective medications in the treatment of addiction.
Substance use disorders, or addiction to drugs or alcohol are chronic medical diseases with notable similarities to numerous other chronic medical illnesses. As with other medical diseases such as asthma, hypertension and diabetes, addiction has proven genetic factors, and these factors are not limited to just becoming addicted. At least half of a person’s susceptibility to drug addiction can be linked to genetic factors. In fact, with tobacco, genetics account for about 75 percent of a person’s inclination to begin smoking, 60% of the tendency to become addicted and 54 percent of one’s ability to quit. Like all chronic medical disorders, environmental and behavioral factors also play a role, so susceptibility isn’t destiny. Not everyone will express their genetic loading to any illness.
Just like other chronic medical disorders, there is no cure for addiction, but the illness can be managed over the lifespan with a variety of medical and psychosocial treatments as well as continued commitment to behavioral change and social supports.
Similar to quality healthcare professionals treating other diseases, Recovery Centers of America will always endorse any treatment method that has been shown scientifically to effectively address the chronic medical illness of addiction in an effort to give our patients every possible chance at success.
Why wouldn’t treatment professionals offer every type of treatment?
Is it Stigma? Financial incentive? Moral judgement?
We want our physicians and treatment providers to present all of the options for treatment when we are diagnosed with an illness. Imagine for a moment, a physician who believed that hypertension should always be managed with diet, exercise, and behavior. Most of us would be outraged if our physician withheld discussions on the availability of various medications to help control our blood pressure. We would call this malpractice. Withholding the availability and option of various medications approved for the treatment of substance use disorders, particularly due to a personal belief or bias, is no different.
Consider, too, that many substance abuse treatment providers are willing to offer some medications for the treatment of substance use disorders but not other medications, even when they have the same FDA approval and sometimes an even longer record of scientific studies showing their effectiveness. What could possibly be the reason a provider would accept and endorse some medications but not others?
Again, imagine your treatment provider told you about the medications for diabetes that are available in pill form like metformin, but chose not to mention or offer injectable form medications like insulin? You would be outraged. We trust our healthcare providers to present us with all available proven-effective options for our illnesses when discussing our treatment. They can, and often do, suggest one over the other, but ethically they are bound to let us know about all of our treatment options, not just the ones they like to provide, not just the ones they make the most profit by providing, and not just the ones they feel are morally appropriate. They are obligated to discuss all our options with us.
So why is it that many substance abuse treatment providers will offer medications such as Chantix or the patch for nicotine dependence or Vivitrol for alcohol cravings or supporting abstinence from opioids, but will not even let their patients know about other medications such as Antabuse for alcohol dependence or methadone for opioid dependence or, if asked by patients, will not present the benefits and risks for these medications the same way they present the benefits and risks for other medications? Could there be financial motives as well as stigma?
One study of over 14,000 treatment programs showed that if the treatment provider offered all three treatment settings (inpatient, residential and outpatient), it was nine times more likely to offer medications for alcohol use disorders than a facility that only offered residential treatment. That’s the equivalent of a cancer doctor offering only radiation and chemotherapy but not surgical treatment for cancer because they only provide radiation and chemotherapy.
Sounds like the residential programs only want to let patients know about the services they provide, not about all treatment options. Again, we would be outraged at this if it happened in cancer, diabetes hypertension or treatment for any other illness.
Some treatment providers feel so confident in their decision to withhold proven effective medications based on “moral beliefs” that they will openly disparage the use of medications, calling them a “crutch”. If I break my leg, does anyone think it would be ethical to withhold a “crutch” to assist me in walking while my leg healed? A common medication that is disparaged this way is Antabuse. People will call the use of Antabuse a crutch and say that the person isn’t committed to recovery. Imagine that you want to stop drinking and you tell yourself every day that you won’t drink today. Then the weekend comes and you find it too difficult to fight the cravings and the urges and you drink. You show up for treatment on Monday and discuss this with your counselor. This goes on for weeks with some success but not 100% abstinence for long periods of time. Then you say you want to try Antabuse to help you to maintain your abstinence. How can anyone not see the dedication and commitment of a patient who continues to attend treatment despite multiple relapses (often looked at as failures), and eventually says “I so much want to quit drinking that I am willing to take a medication that will make me violently ill any time I use any alcohol at all.” I call that patient profoundly committed to treatment and to quitting alcohol. I mean, I really want to start exercising and I just can’t seem to find the time – if you said to me “I have a medication that would make you violently ill if you don’t exercise” – I’d have to say ‘no thanks’. Why? Because I’m just not that committed to exercising.
Perhaps stigma, financial inducements, personal bias, and other factors all play a role in the minimal use of medications proven effective for the treatment of substance use disorders. At RCA, we offer medication-assisted treatment in our detoxification, residential, and various outpatient treatment programs, including opioid treatment programs with Vivitrol, suboxone and methadone maintenance. Because we never want our treatment recommendations to be biased toward just those treatments we can provide and we never want to hide, minimize or inappropriately guide a patient away from a specific type of proven-effective care based on financial considerations, personal bias or our own belief system. At RCA, we are about the science, and the science shows that there are numerous medications and numerous psychosocial treatments that can have a role in helping someone struggling with a substance use disorder. We owe them these options.
For comments or discussion, please contact Dr. Deni Carise, Recovery Centers of America’s Chief Scientific Officer at firstname.lastname@example.org