Treating Substance Use Disorder
Is Medication Assisted Treatment Good or Bad?
Research shows that pharmacotherapy helps improve quality of life.
Posted Oct 09, 2018
With more than 800 people dying from an opioid-related overdose in the United States each week, there's no denying we have an opioid crisis.
And we’re losing.
At essentially every public talk I give, I meet a father or mother who has lost a child, or multiple children, to this epidemic. At a recent talk in Cincinnati I met a mother who had lost two of her three boys and was struggling to hold onto her third. Her pain was palpable and obvious and all I could do was reach out for a hug. It was gut-wrenching.
Apart from overdoses and death, when misused, opioids can have a devastating socioeconomic impact: Their use can spread diseases like Hepatitis and HIV, individuals who use them heavily are often unable to maintain jobs and in pregnancythe drugs can lead to neonatal abstinence syndrome and low birth weight.
Opioids are a group of legal and illicit drugs that come from the opium poppy plant. For the longest time, heroin was the one to come to mind, but other opioid medications such as oxycodone and hydrocodone and fentayl that treat pain have entered the lexicon as well, while methadone and buprenorphine are used to treat opioid drug addiction (and less frequently pain).
It may seem odd to supplement an illicit opioid for a prescription opioid, but this treatment method has been around for decades, and it can be highly effective, particularly when accessed in conjunction with individual or group psychological therapies, also known as Medication Assisted Treatment (MAT1) or pharmacotherapy (its less stigmatizing label2), so all aspects of the addiction are addressed.
Interestingly, less than half of opioid-dependent individuals in the United States access medical treatment for their addiction.
How does medication treat opioid dependence?
I've previously talked about the disease model of addictions, and the idea that the brain is changed by drug use and therefore we need treatments that target these changes. These treatments need to be effective, but they also need to consider the struggle people have in giving up drugs because of the neurological and physiological changes they’ve experienced.
But, aren't these medications just substituting one drug addiction for another? This is the most common objection to pharmacotherapy. Quite simply, the answer is no. Because when an individual is treated for opioid dependence, at an appropriate dose, the medicine does not get them high. It does take care of the biological urge for the drug to some extent by activating the same receptors that reinforce the addiction. Not only that, but it relieves cravings and withdrawal symptoms while helping to repair damage to the brain circuits caused by the addiction. This means that while the individuals' brain is healing, the symptoms associated with opioid addiction are controlled, and the person can begin to work toward recovery.
Does it really work?
Opioid medicines have been around for some time, and there's plenty of research, internationally, to support its effectiveness.
Research suggests that people who have a combination of medication and psychological therapy are at less risk of overdose compared with those who only access psychological treatment.
Vermont has proven this approach works by consistently being below the national average for drug overdose deaths. With a strong commitment to recovery, Vermont residents with an opioid addiction have access to medicine (buprenorphine) and MAT. Vermont has less opioid-related fatalities compared to its neighboring states of New Hampshire and West Virginia.
In an attempt to tackle the opioid epidemic in 1995, France permitted doctors to prescribe buprenorphine to individuals with opiate addiction. The decision paid off, with a 79% decline in opioid-related overdoses in the subsequent four years. Not only that, but the severity of newborn opiate withdrawal was lessened when mothers were treated with buprenorphine compared to mothers whose babies were exposed to illicit opioids in utero.
Similar effects have been observed in the United Kingdom and the Netherlands as well as in the U.S.
Medicine has been proven to help people with an opioid addiction recover faster than traditional methods (like abstinence), prevent overdoses, improve functioning (study or work), and keep them from committing crimes.
While medicine is not the be all and end all of opioid treatment, what it often does is allow treatment professionals to start helping where the individual is at rather than setting them up to fail. Most importantly, this approach keeps people alive. And while it would be nice to have everyone recover without help, that is simply not always realistic and sometimes we can use all the help we can get.
Potential problems with MAT
No approach is perfect, and MAT certainly involves risk. The drugs used for substitution can be abused and there is a black market for them. At high enough quantities and using different administration methods, the drugs can get users high and can be addictive in their own right. Nevertheless, as with all addictive substances, this diversion makes up a small percent of the total medication used.
Additionally, withdrawal from these synthetic opioids is as, and sometimes more, severe that withdrawal from morphine or heroin. Lastly, individuals have been known to continue using while on these drugs, although research generally shows that their use is greatly reduced.
The key ingredient in opioid treatment
There may be a lot of stigma around medicine for opioid dependence, but this is just not a case of substituting one drug for another.
The key factor in successful recovery is engaging with those who need help at a level they feel comfortable with. If an individual is not ready or capable of complete abstinence, but they do want to get their lives back on track, then phamracotherapy or MAT can help them. It controls cravings and withdrawals and can significantly impact their quality of life. It means they no longer have to worry about how they are going to feed their addiction while putting food on the table at the same time. I’ve met dozens of individuals who, after years of daily struggles with opiates which left them homeless and destitute, are now using MAT successfully and have regained housing, employment and family relationships while reducing criminal involvement. I consider that a win.
When combined with psychological therapy, MAT has been proven to reduce fatal overdoses and keep more people alive than other traditional addiction treatments.
When you meet someone where they are at, rather than where you want them to be, you give them a better chance at recovery and success, and that's the ultimate goal of treatment.
The principle of meeting people where they’re at is central to the IGNTD philosophy. If you know someone who is struggling with opiates, or if you struggle yourself, what has been the attitude you’ve seen around MAT or pharmacotherapy?
Copyright 2018 Adi Jaffe
1. Center For Substance Abuse Treatment. Medication-assisted treatment for opioid addiction in opioid treatment programs. 2005.
2. Ashford RD, Brown AM, Curtis B. Substance use, recovery, and linguistics: The impact of word choice on explicit and implicit bias. Drug Alcohol Depend. 2018;189:131-138.
3. Pierce M, Bird SM, Hickman M, et al. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016;111(2):298-308.
4. Auriacombe M, Fatseas M, Dubernet J, Daulouede JP, Tignol J. French field experience with buprenorphine. Am J Addict. 2004;13 Suppl 1:S17-28