Medication Assisted Treatment for Opioid Dependence

May 12, 2021

What is MAT (Medication-Assisted Treatment)?

For patients struggling with addiction to opiates (oxycodone/Percocet, hydrocodone/Vicodin, Dilaudid, fentanyl, and heroin) Medication-Assisted Treatment (also known as MAT) is life-saving, evidence-based, recommended treatment.

How does MAT work?

People who use opiates every day become dependent on them; their brain’s opioid receptors are used to being covered with opioids. If they are not able to get opioids and their receptors go “empty”-- they will feel awful symptoms of withdrawal--body aches, nausea, diarrhea, and sweating to name a few.

People who use opiates every day also have cravings for them. They think about opioids all day long and this can interfere with their ability to leave a normal life--- they are often not able to work, take care of their kids, engage in normal social activities, be responsible-- because life becomes consumed with getting their next dose of opioids.

And, finally, people who use opioids every day are at risk for taking too many- overdosing.  This can lead to respiratory depression (meaning, they cannot breathe) and ultimately death.

The evidence-based medicines that treat opioid addiction cover the brain’s opioid receptors so that people do NOT feel withdrawal symptoms, they do NOT have cravings, and they are at a much lower risk of overdosing.

People taking MAT appropriately should thus feel NORMAL. (1,2)

MAT essentially frees people from a life revolving around obtaining and using potentially dangerous opioids, allowing them to resume a happier, productive life in recovery. 

How do we know MAT works?

MAT has been rigorously tested and is scientifically proven to be effective treatment for people with addiction to opioids:

Many patients enter detox facilities to come off opioids in a safe way. After they are detoxed, if they leave and are NOT started on MAT, 90% of them will relapse within 3 months, putting them at high risk for overdose and death. However, when patients are started on MAT, 50% of them will remain in recovery 1 year later. (3,4)

Other studies have demonstrated that patients NOT on MAT are more than THREE TIMES as likely to overdose and die compared to those who remain on MAT. (5,6)

So, these medications work and they save lives.

What medications are used to treat opioid addiction?

The three FDA-approved, evidence-based MAT medications include: buprenorphine-naloxone (Brand name: Suboxone), methadone, and naltrexone (monthly injection brand name: Vivitrol). 

1- Buprenorphine/naloxone (Suboxone) and Buprenorphine (Subutex) works as a partial opioid agonist. This means that it partially binds to the brain’s opioid receptors, stimulating them enough to prevent withdrawal and cravings. But, it has a ceiling effect-- taking too much should not make people feel “high” and very rarely leads to an overdose. Thus, it is considered both EFFECTIVE and VERY SAFE.

2- Methadone works as a full opioid agonist. This means that, like oxycodone, heroin, and fentanyl, it fully stimulates the brain’s opioid receptors. When it binds to all the receptors, it blocks the other opioids so they cannot bind, preventing a relapse.

3- Naltrexone (Vivitrol) is a monthly injection that is NOT an opioid. It works as an opioid antagonist (a “blocker”). This means that it binds to the brain’s opioid receptors and blocks them so that other opioids (like oxycodone, fentanyl, and heroin) will not work. It also prevents cravings from opioids.

Comparing different MAT options

Buprenorphine-naloxone (Suboxone) & Buprenorphine (Subutex)

  • How it works in the brain: Partially stimulates the brains’ opioid receptors
  • How it helps with addiction to opioid: Prevents cravings, withdrawals, and overdose
  • Safety profile: Very safe; has ceiling effect; VERY difficult to overdose
  • Typical dose & formulation: 12-16 mg buprenorphine/ day, taken sublingually: dissolves under tongue in ~15 minutes
  • Where medication is obtained & taken: Prescription from a physician with a Suboxone “waiver” (license); can take at home
  • Amount of Structure: Usually requires weekly appointments, patients doing well may be spaced-out to bi-weekly or monthly appointments
  • Safe in pregnancy: Yes- considered first line treatment
  • Other pearls: Also works as a mild antidepressant/ improves mood

Methadone

  • How it works in the brain: Fully stimulates the brain’s opioid receptors
  • How it helps with addiction to opioid: Prevents cravings, withdrawals, and overdose
  • Safety profile: No ceiling effect, risk of overdose if too much is taken; Requires regular heart monitoring
  • Typical dose & formulation: 60-120 mg/ day, taken orally: in liquid, powder and diskettes formulations
  • Where medication is obtained & taken: Must take at “methadone clinic” which are highly regulated by federal & state accreditation; take under supervision
  • Amount of Structure: Usually requires daily visits; after months-years in recovery, patients meeting specific federal criteria can earn “take homes” and not have to come in as often
  • Safe in pregnancy: Yes- considered first line treatment

Naltrexone 

  • How it works in the brain: Blocks the brain’s opioid receptors
  • How it helps with addiction to opioid: Prevents cravings and overdose
  • Safety profile: As an opioid blocker, it does not stimulate the opioid receptors; VERY safe
  • Typical dose & formulation: Vivitrol: long-acting version containing 380 mg injected monthly into the buttocks muscle, Oral naltrexone: 50-100 mg taken daily as a pill
  • Where medication is obtained & taken: Does not require special license, can be provided in outpatient and specialty clinics
  • Amount of Structure: No associated regular structure; at minimum, patient receives monthly injection and programs decide how often the patient is required to attend appointments 
  • Safe in pregnancy: We do not know as there is not enough evidence as of yet  
  • Other pearls: Also used for patients with alcohol addiction, so it is a good choice for patients struggling with opioids and alcohol

Barriers to accessing MAT

Despite MAT’s effectiveness, patients with addiction to opiates frequently experience multiple barriers to accessing MAT:

First, they must find a provider who will prescribe Buprenorphine-naloxone or find a methadone clinic that is convenient to attend.  Once they find a provider, they may experience long-wait times.  

Additionally, patients often face logistical obstacles, such as time and transportation to attend appointments, difficulty getting prescriptions filled, and financial barriers paying for MAT based on their insurance status and coverage.

Many may also face societal stigma from family and friends who are well-intentioned, but do not understand opioid addiction. These loved ones may also view addiction as a curable disease rather than a life-long disease often interspersed with periods of relapse. They may also view addiction as a moral failing rather than a chronic disease like diabetes and high blood pressure that requires life-long treatment. They may view MAT as “trading one drug for another”  rather than a life-saving medication that helps patients enter and stay in recovery.  Feeling judged and shamed can make it difficult for patients to pursue MAT. 

Patients treated with MAT should know that their health information is considered private and confidential by federal laws and regulations and will NOT be shared with family, friends, employers or anyone else without the patient’s permission (unless required by a court order or for emergency purposes).

What else should I know about treating my opioid addiction?

MAT is clearly considered a cornerstone for treating addiction to opioids. Additionally, it is important that people with opiate addiction also seek out mental health, social support, and healthy living.

People struggling with addiction often have depression, anxiety, PTSD and may have experienced trauma (physical, verbal, and/or sexual abuse).  Most often struggle with daily life stressors. Learning how to cope and manage stress and mood in both safe and healthy ways often requires attention to one’s mental health--- seeing a therapist or a psychiatrist (who prescribes medications for mood) can help patients more fully address their mental health and set them up for a successful recovery.

Addiction can also be a disease of isolation, so developing a support network is an important part of recovery. Attending 12-step meetings (like AA, NA), getting a sponsor, connecting with friends and family who do not struggle with addiction AND distancing oneself from friends who are using drugs are all important parts of recovery.

Finally, it is important for people to have “me” time--making time for themselves to engage in healthy activities, like sports and exercise, listening to music, relaxation (like mediation and yoga), and other hobbies that they enjoy.

Putting it all together

MAT is evidence-based, FDA approved medication to treat opioid addiction and is considered an essential part of recovery. It prevents cravings, withdrawal symptoms, overdose, and death.  It makes people feel normal and embrace a life in recovery where they can reconnect with their values and goals.   

It is important for patients to also address their mental health care needs.

While there are many obstacles to obtaining MAT, it is important to navigate through these.

One new innovation that supports increased access to MAT is the use of telehealth appointments. These allow patients to obtain buprenorphine-naloxone (Suboxone) entirely through their phone and video formats, oftentimes without ever needing to step into a doctor’s office.

Bicycle Health is a telehealth company that provides buprenorphine-naloxone (Suboxone) to patients across the country. Patients can get started on MAT quickly and receive support for their opiate addiction without ever having to leave their homes.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.


Photo Courtesy of National Cance on Unsplash.

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(1) Treatment in French Office-Based General Practice: A 7-Year Cohort Study. Ann Fam Med 15(4): 355–358.
Evans E, Li L, Min J, et al. 2015.
Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006–2010. Addiction 110(6): 996–1005

(2) Sordo L, Barrio G, Bravo MJ, et al. 2017. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal 357:j1550.

(3) Treatment in French Office-Based General Practice: A 7-Year Cohort Study. Ann Fam Med 15(4): 355–358.
Evans E, Li L, Min J, et al. 2015.
Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006–2010. Addiction 110(6): 996–1005

(4) Sordo L, Barrio G, Bravo MJ, et al. 2017. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal 357:j1550.

(5) Dupouy J, Palmaro A, Fatséas M, et al. 2017. Mortality Associated With Time in and Out of Buprenorphine Treatment in French Office-Based General Practice: A 7-Year Cohort Study. Ann Fam Med 15(4): 355–358.
(6) Evans E, Li L, Min J, et al. 2015. Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006–2010. Addiction 110(6): 996–1005.

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