What is Medication Assisted Therapy (MAT)?
Medication assisted therapy: MAT is a unique opportunity of medication based therapy to treat opioid use disorder by pharmacologically replacing heroin or other opioid drug misuse with a controlled medication with generally less euphoric or abusive potential which can reduce or eliminate withdrawal symptoms and cravings for drug misuse. Significant variability in response to MAT and significant diversion or misuse of prescribed MAT limits its effectiveness. It is difficult to determine the individuals who are truly dedicated to MAT compliance versus those whose attention are misuse or diversion either at the time of prescribing or after leaving the support within the clinical environment. Well intended individuals are hard pressed to maintain a rigorous MAT schedule in the face of their daily life challenges, pressures from their communities and homes (or lack of), and temptation from past dealers or friends who are still actively misusing drugs.
Methadone is an opioid has been available for several decades, but notoriously abused by simply taking a higher dose than needed to resolve withdrawal symptoms and craving. Because effective dosing varies by individual, abuse potential is easy. Because of this, methadone is typically dispensed as a once daily dose that requires individuals to appear at their methadone clinic each day for their daily dose. For many individuals, this provides a needed structure and forced limitation in drug access to curb abuse. For others, this system has drawbacks because people metabolize the medication at variably and some people will struggle with withdrawal symptoms well before the 24 hours until they are able to access their next dose. Methadone clinics typically dispense over a finite period each morning and tardy appearance to the clinic may result in missed dosing and struggling with withdrawal symptoms for the duration of the day. These physical pains of withdrawal will send many individuals into relapse. Even individuals on an established routine with a methadone clinic may relapse easily because only a small additional dose of an opioid often from social pressures of an illicit source is needed to send an individual into relapse.
Buprenorphine is a newer generation opioid that is a partial mu opioid receptor agonist that is offered as a combination with naloxone as either a tablet or sublingual (under the tongue) film. Naloxone is an opioid antagonist incorporated with buprenorphine as a combination drug (Suboxone; Indivior) with the intention to prevent abuse potential of the opioid partial agonist. Although this pharmacology may make sense and does work for many individuals, in fact, this medication is easily abused as well. Sometimes this is unintentional as many individuals describe feeling euphoric at low dosage intended to treat withdrawal symptoms. Some individuals describe feeling simply unwell and over time develop a blunted personality (“zombie” effect), losing interest in life or in interacting with others. Yet others who are prescribed buprenorphine/naloxone are not truly seeking sobriety can easily abuse the medication by crushing, snorting, IV injecting, or smoking. Combined with other medications, this medication misuse has led to many fatal overdoses. Despite the drawbacks of medication assistant treatment, it remains the most immediate means to safely control an active addict’s symptoms of withdrawal which may be helpful when needing to assess and administer other medical care, such as lifesaving IV antibiotics for an infection or for providing cancer treatment.
Naltrexone is also a mu opioid receptor antagonist that has been available for many years used predominantly to reduce craving to improve maintenance in alcohol sobriety. It now has a large role in promoting opioid use abstinence. It is contraindicated in people requiring opioid therapy or with known liver disease. It is most effective in highly motivated people and otherwise fraught with challenges as less motivated individuals can overcome naltrexone effects by simply taking a larger opioid dose and in doing so, they risk overdosing. Monthly injections result in taper of drug levels at the end of the month which also becomes a time of increase risk for overdose, especially when there is a false sense of security.
Detoxification and rehabilitation: The combination of a 3-7 days of detoxification followed by transition to a clinical stabilization service (CSS) or transitional support service (TSS), transient holding, and eventually formal residential rehabilitation service has been the traditional offering for drug and alcohol recovery for decades. The greatest limitation of these programs is the lack of standardization of programs and necessary individualize length of each phase of program. Whereas the acute symptoms of withdrawal may resolve in 1-2 weeks from onset of detoxification taper, the cravings, emotional scarring, and habitual fallback to drug use remains to some degree changes for life. To break into these ingrained habits to the point that the individual may be able to effectively override the compulsion and cravings for use, often a standard 28-day rehabilitation program is inadequate. From reviewing multiple rehabilitation programs and people in successful recovery, longer rehabilitation programs are generally more successful with ideal lengths of time ranging 6-24 months. That said, this is not currently a financially viable option for most programs. Thus, we promote a minimum of a 6-month program which is the most vulnerable phase for people in recovery as they re-confront their senses and feelings which have been numbed by drug use. This is the time period when individuals must learn to make initial difficult decisions and interactions with society without falling back to drugs as their coping mechanism which otherwise does provide a reliable escape from reality. The program should include integrated steps of recovery of detox followed by additional clinical support as needed, and an individualized stepwise process including individual sessions and group classes focused on topics of recovery. As the individual progresses in his/her recovery, topics may move from anger management, coping with frustrations, to improving reading skills, learning to manage one’s finances, such as balance rent, utilities, groceries, and taxes with income. Additional vocational training, skill training, opportunity to complete GED, and guidance to access higher education should also be provided before discharge from rehabilitation. Additional transitional support into independent society living is a useful model. 12-step fellowship programs inherently provide this but similar professional programs can be better suited for some individuals or complementary for others.
Methadone is an opioid has been available for several decades, but notoriously abused by simply taking a higher dose than needed to resolve withdrawal symptoms and craving. Because effective dosing varies by individual, abuse potential is easy. Because of this, methadone is typically dispensed as a once daily dose that requires individuals to appear at their methadone clinic each day for their daily dose. For many individuals, this provides a needed structure and forced limitation in drug access to curb abuse. For others, this system has drawbacks because people metabolize the medication at variably and some people will struggle with withdrawal symptoms well before the 24 hours until they are able to access their next dose. Methadone clinics typically dispense over a finite period each morning and tardy appearance to the clinic may result in missed dosing and struggling with withdrawal symptoms for the duration of the day. These physical pains of withdrawal will send many individuals into relapse. Even individuals on an established routine with a methadone clinic may relapse easily because only a small additional dose of an opioid often from social pressures of an illicit source is needed to send an individual into relapse.
Buprenorphine is a newer generation opioid that is a partial mu opioid receptor agonist that is offered as a combination with naloxone as either a tablet or sublingual (under the tongue) film. Naloxone is an opioid antagonist incorporated with buprenorphine as a combination drug (Suboxone; Indivior) with the intention to prevent abuse potential of the opioid partial agonist. Although this pharmacology may make sense and does work for many individuals, in fact, this medication is easily abused as well. Sometimes this is unintentional as many individuals describe feeling euphoric at low dosage intended to treat withdrawal symptoms. Some individuals describe feeling simply unwell and over time develop a blunted personality (“zombie” effect), losing interest in life or in interacting with others. Yet others who are prescribed buprenorphine/naloxone are not truly seeking sobriety can easily abuse the medication by crushing, snorting, IV injecting, or smoking. Combined with other medications, this medication misuse has led to many fatal overdoses. Despite the drawbacks of medication assistant treatment, it remains the most immediate means to safely control an active addict’s symptoms of withdrawal which may be helpful when needing to assess and administer other medical care, such as lifesaving IV antibiotics for an infection or for providing cancer treatment.
Naltrexone is also a mu opioid receptor antagonist that has been available for many years used predominantly to reduce craving to improve maintenance in alcohol sobriety. It now has a large role in promoting opioid use abstinence. It is contraindicated in people requiring opioid therapy or with known liver disease. It is most effective in highly motivated people and otherwise fraught with challenges as less motivated individuals can overcome naltrexone effects by simply taking a larger opioid dose and in doing so, they risk overdosing. Monthly injections result in taper of drug levels at the end of the month which also becomes a time of increase risk for overdose, especially when there is a false sense of security.
Detoxification and rehabilitation: The combination of a 3-7 days of detoxification followed by transition to a clinical stabilization service (CSS) or transitional support service (TSS), transient holding, and eventually formal residential rehabilitation service has been the traditional offering for drug and alcohol recovery for decades. The greatest limitation of these programs is the lack of standardization of programs and necessary individualize length of each phase of program. Whereas the acute symptoms of withdrawal may resolve in 1-2 weeks from onset of detoxification taper, the cravings, emotional scarring, and habitual fallback to drug use remains to some degree changes for life. To break into these ingrained habits to the point that the individual may be able to effectively override the compulsion and cravings for use, often a standard 28-day rehabilitation program is inadequate. From reviewing multiple rehabilitation programs and people in successful recovery, longer rehabilitation programs are generally more successful with ideal lengths of time ranging 6-24 months. That said, this is not currently a financially viable option for most programs. Thus, we promote a minimum of a 6-month program which is the most vulnerable phase for people in recovery as they re-confront their senses and feelings which have been numbed by drug use. This is the time period when individuals must learn to make initial difficult decisions and interactions with society without falling back to drugs as their coping mechanism which otherwise does provide a reliable escape from reality. The program should include integrated steps of recovery of detox followed by additional clinical support as needed, and an individualized stepwise process including individual sessions and group classes focused on topics of recovery. As the individual progresses in his/her recovery, topics may move from anger management, coping with frustrations, to improving reading skills, learning to manage one’s finances, such as balance rent, utilities, groceries, and taxes with income. Additional vocational training, skill training, opportunity to complete GED, and guidance to access higher education should also be provided before discharge from rehabilitation. Additional transitional support into independent society living is a useful model. 12-step fellowship programs inherently provide this but similar professional programs can be better suited for some individuals or complementary for others.