Medication-Assisted Treatment (MAT) Options for Addiction

Medication-assisted treatment (MAT) is quite possibly the most effective tool in the fight against drug and alcohol addiction. It is supported by research and medical professionals alike. But is MAT right for you?

What is Medication-Assisted Treatment?

Medication-Assisted Treatment, or MAT, is the use of FDA-approved medications and counseling to treat substance use disorders. It provides options to aid in both the detox process as well as relapse prevention. However, long-term success of MAT is largely dependent on the continued utilization of behavioral therapies like counseling, support groups and aftercare programs.

A common myth about medication-assisted treatment is that it just trades one addiction for another. Yet most medications used are not addictive and those that are incorporate harm-reduction to reduce accidental overdoses and allow you to return to daily activities. MAT, while often associated with rapid opiate detox and maintenance therapy, also includes medication management and counseling for alcoholism, cocaine and benzodiazepine addictions. For now, we will focus on common medications used in the treatment of opioid and alcohol use disorders.

MAT for Opioid Addictions

Buprenorphine and Naloxone

One of the most widely used medications approved by the FDA for the treatment of opioid use disorder (OUD), buprenorphine serves two main purposes. It can be beneficial during both stabilization to ease withdrawal symptoms as well as throughout the maintenance phase by minimizing cravings. In fact, recent studies by the U.S. Dept. of Health and Human Services have actually found better outcomes with maintenance therapy than by tapering buprenorphine. The drug can also be combined with naloxone, the popular medication used to reverse the effects opioid overdose, in order to help prevent misuse.

Buprenorphine, or bupe, is an opioid partial agonist, meaning it can produce similar, although weaker effects than full agonists like heroin and Vicodin. Furthermore, these effects have a ceiling at moderate dosages which deters abuse. The drug works by binding to and partially activating mu opioid receptors in the brain, enough to suppress the effects of withdrawal and cravings. For MAT, it is prescribed as either a dissolvable film which also contains naloxone (Suboxone), sublingual tablet containing only buprenorphine (Subutex), a once monthly injection (Sublocade), or six-month implant (Probuphine).

It may seem as though, since buprenorphine is partial agonist and naloxone is a full antagonist, the two would interact and send the user into opioid withdrawal. However, the naloxone has poor bioavailability when taken orally and thus only helps deter abuse of buprenorphine. But it is absorbed better when when injected. Thus, if the oral bup/naloxone tablets were to be crushed and injected, the user would likely enter full opioid withdrawal.

Naltrexone

Available as either a once-daily oral tablet or monthly injection (Vivitrol), naltrexone is approved by the FDA for treatment of both alcohol and opioid addiction. Like naloxone, naltrexone is an opioid antagonist, meaning it completely blocks the effects of opioid agonists such as oxycodone and methadone. This discourages future use of opioids, as one would not receive the high produced by opioid agonists.

As a medication-assisted treatment option, Naltrexone offers several benefits. When combined with individual and group therapy, it can prevent relapse through deterring opioid use, as you know getting high is not possible. Naltrexone has also been reported by SAMHSA (Substance Abuse and Mental Health Services Administration) to reduce cravings, although other studies suggest that it may not be as strong at reducing urges for opioids as it is for alcohol. But the science says that if you are aware opioids are no longer rewarding, cravings should logically subside.

Another benefit of naltrexone is that it has virtually no potential for abuse. Since it is an opioid agonist, the drug will not produce the same euphoric effects of opioid agonists. And when the monthly injectable form is used, you are limited to only receiving the medication in a doctor’s office. However, in order for naltrexone to work, you must be completely detoxed from opioids from starting the medication. And because it essentially blocks the high you would normally receive from opioids, there is a potential for overdose with a relapse. Therefore, as with all medications used in MAT, prescriptions should be used in conjunction with counseling and psychosocial support for relapse prevention.

Methadone

The oldest of current FDA-approved medications for medication-assisted treatment of opioid addiction, methadone can be effective for both withdrawal management and maintenance. Methadone is opioid full agonist that works by binding to and activating the Mu-opioid receptor, producing milder, longer lasting effects than agonists like heroin or prescription pain-killers. It can reduce withdrawal symptoms as well as block the euphoric effects of other agonists. When combined with counseling and behavioral therapies, methadone is an effective treatment for opioid addiction, allowing you to once again partake in daily actives.

Once the “gold standard” in opioid addiction treatment, methadone has recently been overshadowed by newer forms of MAT. Though methadone clinics still exist, those offering buprenorphine and/or naltrexone have grown at a much higher rate. In order to prescribe buprenorphine, or suboxone, a qualified healthcare provider must only complete an eight-hour certification class and apply for a waiver. Naltrexone can be prescribed by any physician licensed to prescribe medications. Methadone, on the other hand, can only be dispensed at SAMHSA-certified Opioid Treatment Programs (OTPs).

Another reason for the push toward buprenorphine and naltrexone is that methadone can be addictive. Doses are customized to each individual, often adjusted and readjusted, so adherence to the prescription is vital. Methadone also can present a fair amount of side effects, some serious, such as difficulty breathing, faint and hallucinations. As with all opioids, its effects can be increased, often to dangerous levels, when combined with alcohol, benzodiazepines and other opiates. Despite the controversy and dangers associated with methadone still maintains a large user base that has grown to over 350,000.

MAT For Alcoholism

Naltrexone

As previously discussed, naltrexone is an opioid receptor antagonist more commonly known for treatment of opiate abuse and dependence. However, it can also reduce the dopaminergic effect of endorphins secreted after alcohol use, thus reducing the stimulating effect of alcohol. And as it can for opioid users, naltrexone can reduce craving for alcohol in those with alcohol use disorder.

A meta-analysis of 19 studies found that total abstinence was achieved more often among naltrexone users. In those who did not reach lasting recovery, the period until relapse was longer. Additionally, the number of drinking days, number of drinks consumed per day, and total amount of alcohol consumed during the treatment were lower.

How exactly does naltrexone reduce cravings? It likely does this by reducing the reward effect that drinking alcohol produces on the dopamine pathway. This prevents the “buzz” from drinking, thus gradually preventing cravings from ever occurring.

Antabuse

Otherwise known generically as disulfiram, Antabuse has been used to treat alcohol use disorder for more than 60 years. The medication is an aldehyde dehydrogenase inhibitor, or drug which blocks the enzyme aldehyde dehydrogenase. It does this before acetaldehyde can be converted to acetate in the second step of the metabolizing of alcohol in the liver.

If you’re currently taking Antabuse, you will experience uncomfortable side effects after drinking alcohol such as vomiting, diarrhea and dizziness. It’s primary purpose is to deter you from drinking in order to not experience these symptoms.

Surprisingly, there are few studies on the effectiveness of disulfiram as a treatment for alcohol dependence or abuse. One study, however, examined 122 you with concurrent cocaine and alcohol use disorder receiving either disulfiram or no medication. It found that participants taking disulfiram had “better treatment retention and longer abstinence duration for both cocaine and alcohol.”

Campral

Acamprosate, or campral, works by blocking the dopamine spike in the nucleus accumbens which typically results from alcohol consumption. It acts by upregulating glutamate systems and downregulating inhibitory effects produced by GABA, thereby reducing the excitatory effects of alcohol withdrawal. Research has shown that Campral is most beneficial in relieving cravings related to irregularities in the GABA and glutamate systems.

One recent study found that Campral is actually more effective in users who, at the beginning of treatment, had a high serum level of glutamate. However, it also been found to work predominately in those whose primary goal is abstinence, rather than reduction of drinking. Campral can have minor side effects, including upset stomach, rash and acne, although these are rare and not as severe as those associated with Antabuse.

Which MAT Option is Best For Me?

Before starting on any medication-assisted treatment plan, you should complete a comprehensive assessment with a qualified physician or licensed addiction professional. Lab and blood work should also be measured in order to assess for potential negative interactions.

You can then discuss which medications and treatment plan would work best. Your usage and relapse history will likely determine the length of detox, which could include a taper or maintenance phase in more serious cases.

The Future of Medication-Assisted Treatment

Since 2006, researchers have been conducting clinical trials on the combined use of naltrexone and buprenorphine for the treatment of opioid and cocaine addictions, along with depression. While we cannot yet recommend using both at the same time, unless prescribed by a doctor, the results have been promising.

Unfortunately, drug overdoses are daily occurrence, taking 64,000 lives in 2016 alone. Barriers to treatment like stigma adverse reactions, especially prior to detox, create un uphill battle for patient participation in MAT. Yet more and more addicts have been looking toward medication-assisted treatment as their preferred option to achieve long lasting recovery.

Resources:

U.S. Department of Health and Human Services
National Institute on Drug Abuse

Sublime Wellness Center can provide you with a combination of medication-assisted treatment and counseling services tailored for your needs. Give us a call today!