Medication Assisted Treatment for Opioid (Opiate, Heroin, Painkiller) Addiction

Someone who is addicted to heroin or oxycotin often follows a treatment path that looks like this:

(1) trouble at home, school, or work (which may include an arrest (which may or may not lead to jail)

(2) 2-10 days in at a medical detox

(3) rehab (if they have insurance or enough money)

(4) intensive outpatient counseling (again, if resources are there)

(5) 12-step meetings

But this plan (or variations of it) are sometimes just not enough to help someone quit and stay away from opiates. There is an ever-growing body of scientific evidence that Medication Assisted Therapies are effective in helping treat people with opiate addictions. Despite this evidence, numerous people have risen to decry MAT. These opponents include people in 12-step programs, insurance companies and concerned professionals who think they aren’t handled properly at all times (this last group is different from the first two).

Methadone (a schedule II drug) was the first modern MAT and it was created in Germany in the 1930’s and introduced to America  in the late 1940’s. By the 1960’s, it was the defacto treatment for heroin addicts, especially ones in the cities. Critics of it consider it state-sponsored addiction and they have some justifiable points. Many people experienced euphoric highs on methadone and other stayed on for 10 or 20 years, living a seemingly zombie-fied life. It is probably the existence and public experience of methadone that have turned many people against MAT’s.

In 2002, the Drug Abuse Treatment Act (DATA) was passed by Congress and buprenorphine was introduced to the American public as the new MAT for the treatment of opiate addiction. Buprenorphine is better known as Suboxone or Subutex and has had much better success rates than methadone. Patients see a doctor one to five days a week (depending how far along they are in treatment and how well they are doing). Patients are expected to submit weekly drug screens and to get weekly therapy from a licensed substance abuse professional (this is not required by law…but it should be). Buprenorphine is classified as a controlled dangerous substance by the FDA (schedules III, IV and V, depending on the type and dosage) and can only be prescribed by medical professionals who have gone through a very specific multi-day training.

Suboxone diversion concerns some doctors.  These concerns are valid. The best article about buprenorphine I’ve come across appeared in the NY Times last November. Some medical professions are very loose when prescribing it, while others run a very tight ship. I prefer the latter group.

Vivitrol is injectable naltrexone. Because there isn’t any opiate or synthetic opiate in it, it is not a controlled substance. Any doctor can prescribe it. Patients get a shot 1x a month. Vivitrol helps reduce cravings and it mostly blocks the euphoric effects of opiates. When combined with therapy, 12-step meetings and/or other lifestyle changes, it can be quite effective. This is the MAT that I prefer and try first with people that see me.

There have been numerous instances where people in 12-step programs (AA or NA) have told new members that they shouldn’t take medication or that they “aren’t really clean” if they are using medication to assist their recovery. Those individuals are flat-out wrong. Dr. Lou Baxter, the past president of the American Society of Addiction Medicine (ASAM) recently wrote an article about MAT’s. His most recent article refutes false statements by self-appointed people that claim to speak on behalf of 12-step programs that people in recovery shouldn’t take medications to help quit drugs. Dr. Baxter argues:

Although there is no dispute that abstinence from alcohol and other drugs with potential for addiction is the foundation for sustaining recovery in most instances, there are other cases where MAT, especially for persons with co-occurring illnesses, is essential to obtain and sustain term recovery.

In the late 1980’s it was discovered by NIH that addiction was a brain disease. Since that time, medications with FDA approval have been developed to target those areas of the brain. These medications have shown great efficacy in assisting patients into and sustaining recovery. Every other chronic medical disease employs and encourages the use of medications in concert with life-style changes. Addiction medicine should examine the benefit of following suit.

MAT in addiction treatment is not required for everyone, but used in conjunction with 12- step programs and other biopsychosocial interventions, for those that need it, has shown to be invaluable in appropriate cases.

Another barrier to effectively using MAT’s has been that insurance companies rarely pay for them. Stuart Gitlow is the current president of ASAM and has been speaking and writing about the importance of MAT’s for the last several years. Last winter, he wrote an article about the barriers created by insurance companies (and some other impediments as well). Some directly-quoted highlights:

(1) …state governments and insurance companies regularly deny patients access to FDA-approved medications that could help reverse the epidemic of opioid addiction and overdose deaths. A new report released by ASAM examined the effectiveness of opioid medications and found these medications to be effective, safe and cost-effective when used for long-term maintenance treatment.

(2) Restrictions vary widely from state to state and from insurance company to insurance company, with almost none of them adhering to best practices research-based protocols for these medications.

(3) Addiction is a treatable chronic disease with success and relapse rates comparable to other chronic diseases such as diabetes and hypertension.

(4) None of the medications by themselves should be considered effective treatments for opioid dependence.

(5) Treatment professionals need to overcome their own prejudices against addiction medications and begin using them in comprehensive treatment protocols for the disease of addiction.

Bunavail was recently approved by the FDA. It is a lower-dose of buprenorphine that acts more effectively because of some improvements in the delivery method. I’m almost always in favor of coming up with advancements in medication that allow for lower doses. Lower doses leads to less side effects, which leads to better patient compliance. But this is all for naught if:

(1) medical professionals don’t require counseling and drug screens and recovery supports with the medication

(2) people in 12-step programs continue to speak out against MAT’s, pretend they are medical professionals and shame people in recovery who are using MAT’s

and (3) most significantly, insurance companies continue to not pay for MAT’s.