The Complete Guide to Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD)

Part of the Complete Guide to Understanding Addiction

Common Addiction Treatment Models

Treatment models essentially fall into two categories. Abstinence based treatment is focused on achieving sustained recovery, without the use of any medication, to treat withdrawal and addictive symptoms. It is completely based on stopping to use. Therapy will help a client overcome any ambivalence about terminating substance use and achieve the level of motivation required to derive maximum benefit. A therapist can help an individual recognize potential risk factors and maladaptive coping skills. Proper clinical work helps develop more productive ways of thinking and behaving and achieve the  level of self-awareness necessary to overcome struggles and maintain positive lifestyle changes.

Medication assisted treatment for opioid addiction includes various medications to help reduce debilitating withdrawal symptoms, ward off cravings, and to tamp down temptations. This can  increase the likelihood of retention and engagement in treatment and recovery for many. It is important to be under the guidance of addiction treatment professionals and physicians when deciding the proper course of action for each individual client.  

The Minnesota Model

Two men working in a state mental hospital in 1950’s Minnesota established the basis of substance use treatment as we know it today. Using the 12 steps as a baseline, it broadened treatment and included professionals like doctors and psychiatrists in the treatment plans for individuals battling addiction. It focused on the now widely accepted foundation that addiction must be viewed as a disease rather than a moral failing. The idea of individualized treatment, tailored to each person’s unique background and struggle was originated, as well as the concept of including family as very active members of the journey to recovery.

 Although at inception it was used exclusively in inpatient settings, its core principles were eventually adapted for outpatient rehab as well.

One of the important elements of the Minnesota model is its insistence on clients completely stopping any use of mind-altering substances. For this reason, the model, along with its many outgrowths and variations, has come to be known as the abstinence model.

Understanding Medication Assisted Treatment (MAT)

In recent years, the concept of addiction as a disease rather than a moral failing has become fully accepted across the medical and addiction treatment establishment. With that realization, the option of MAT has become much more integrated within mainstream treatment philosophy.

It must always be remembered that as of now, there is no cure for addiction. Recovery requires an understanding of what drives the addiction in each individual and a well-constructed management plan. Because of this, medication by itself is almost never enough to fully resolve addiction. However, when used as a supplement and aid to evidence-based treatment modalities and carefully administered by medical and addiction professionals, it can provide great benefits.

Forms of MAT: The Medications

Opiate Replacement Therapy (ORT)

There are a number of options for medication assisted treatment for OUD. Correctly choosing which one works best for a particular user needs careful consideration and the guidance of doctors and professionals trained in the recovery field. The following provides a broad overview and answers to some of the more frequently asked questions about many of the very popular MAT options. As with so many things, the more knowledge the more equipped you will be to make the proper choices. Personalized substance abuse treatment plans are the most effective way to gain positive outcomes that last.

Buprenorphine

                Brand names

1. Subutex (oral tablets)
2. Sublocade (monthly injection)

 What it is and how it works

Buprenophine is partially agonist and partially antagonist. Simply put, this means that in its role as antagonist, it blocks opioids from brain receptors. While on this medication, an addictive opioid, such as heroin, will not produce the usual effects on the addicted individual, thereby discouraging use. Because it also has the properties of agonist, it will provide feelings of normalcy and even levels of euphoria associated with illegal drugs, thus reducing withdrawal symptoms common in people beginning to practice abstinence.

When and How is Buprenrophine Taken?

Subutex is taken in the form of a tablet. It is administered sublingually, which means it is placed under the tongue and dissolved. When chewed or swallowed, it is ineffective.

Sublocade is an extended-release form of buprenorphine injected into the belly once a month. Generally. a patient will not be prescribed Sublocade until he or she as used Subutex for at least seven days.  

Subutex and Sublocade can cause severe withdrawal symptoms if used while under the influence of other opioids. Therefore, a doctor will only prescribe Subutex once the substances have completely left the body. It should only begin once withdrawal symptoms have appeared. Each drug varies in how it cycles through the system.  Subutex should be administered accordingly. Doses generally start at 4mg daily. It can be adjusted by physicians to a maximum of 32mg, depending on individual response to the treatment.

 Can Buprenorphine cause dependence and addiction?  

Although it can create physical dependence, its combined properties greatly lessen risk, reduces withdrawal symptoms, and is not prone to causing overdose because of its limited status as an opioid agonist.

How long should people take Subutex?

Any decision regarding discontinuation of the drug should only be made while viewing the entire           treatment plan designed for each individual patient and with the input of doctors and treatment counselors. There is a potential for relapse and the clients stability and progress in recovery is a significant factor in making that decision.

Do I need a prescription to get Buprenophine?

Yes. Buprenophine is a regulated substance and a prescription from your doctor is necessary. Pharmacies and Physicians need to acquire a waiver to dispense and administer Buprenophine.

 Subutex side effects

Some common side effects of Subutex include:

• headache
• stomach pain
• nausea
• vomiting
• constipation
• chills
• increased sweating
• weakness
• back pain

Suboxone

What it is and how it works

Suboxone is a mixture of buprenorphine and a drug called naloxone. Naloxone, also known as by its brand name, Narcan, is an opioid reversal medication. By combining a partial opioid agonist (buprenorphine) with a pure opioid antagonist (naloxone), it gives people with addiction a path to weaning off narcotics while easing withdrawal symptoms. It reduces withdrawal symptoms while lessening cravings simultaneously. Again, as always with MAT, it can be a supplement for staying abstinent while engaging in the clinical treatment necessary to create lasting positive outcomes.

When and How Suboxone is taken

Like Subutex, Suboxone is taken primarily sublingually. It is placed under the tongue and dissolved.  Naloxone has no effect when injected.

Avoiding Precipitated Withdrawal

If opioids are already in the system, it will expel them from the receptors at a speedy pace and cause withdrawal symptoms, due to the antagonist component in buprenorphine. This is called “precipitated withdrawal” and must be avoided. Suboxone should only be administered once organic withdrawal has begun due to abstinence. Doctors will use the Clinical Opiate Withdrawal Scale (COWS) system to determine if this has already occurred and it is safe to begin a suboxone regimen. No less than a score of 5 or 6 is acceptable and a 7 is recommended.

Can Suboxone create dependence and addiction?

Although Suboxone can be addictive, it carries less risk than other opioids like methadone or morphine. Because it is only a partial opiate agonist there is a limit to the highs it can produce and to the effect it has on the body. This decreases risk of overdose as well.

For how long should people take Suboxone?

The length of time Suboxone should be taken varies with each individual. If it is decided that it would be beneficial to start weaning off the medication, incrementally decreasing dosages is often the best route. Many people experience forms of withdrawal from suboxone. Having your doctor and treatment team involved is the best way to go.  They will create a tapering schedule and reduce withdrawal and relapse risks.

Methadone

What it is and how it works

Unlike Suboxone and Subutex, Methadone is a full opioid agonist. It activates the opioid receptors in the brain and causes the highs and euphoria common in all opioids. Effectively, it is a substitute for other more dangerous substances, like fentanyl and heroin.  Its effectiveness is due to its stability and length of onset. Although it latches on to opioid receptors like other opioids, it acts much slower, widening the gap between required doses. Its half-life is between 24 and 36 hours, fending off withdrawal for detox patients.

When and How Methadone is taken

Most often, Methadone is taken orally. It comes in the form of dissolvable tablets, or solutions. It is also found as an intravenous (IV), but in that form can only be administered by a proper healthcare provider.

Where can Methadone be administered?

As a highly addictive substance, Methadone is strictly regulated. With proper supervision, it can be effective, but taking it on your own without oversight from doctors is very dangerous. Methadone Medication Assisted Treatment certification is needed with the Substance Abuse and Mental Health Services Administration (SAMHSA) as well as registration with the DEA. A provider dispensing methadone, popularly known as methadone clinics, is absolutely required to get these.

There are both private and public methadone clinics. Although public clinics are usually cheaper, there can be long waiting lists and other inconveniences, due to the limitations of government funding. Currently there are more than 400,000 people in the USA taking methadone at close to 20,000 clinics across the country.

Care should be taken to find a methadone or treatment facility of integrity with properly qualified medical professionals who have the necessary medication assisted treatment training.

Can Methadone create dependence and addiction?  

Because Methadone is highly addictive and causes dependence, it has been the subject of intense controversy regarding its safety as an opiate replacement therapy (ORT). Many studies have been dedicated to the pros and cons of methadone treatment. Some benefits include a reduction of the use of injection, and thereby HIV spread. Other studies have shown a significant lowering in the death rate in relation to opioids such as heroin and fentanyl. Criminal activity decreases among methadone users as well.   However, the significant risk of overdose and threat of dependence has others suggesting other forms of MAT like vivitrol and suboxone. Both sides of the debate contain merit. It should only be pursued upon the advice of credible physicians and in the context of an effective treatment plan.

For how long should people take Methadone?

Although a goal of reaching abstinence is strongly recommended, the duration of Methadone Maintenance Programs varies greatly from patient to patient. There are no timelines set in stone and again a primary care physician in conjunction with addiction health professionals should be consulted.

Methadone Side Effects

• Constipation
• Lightheadedness or dizziness
• Sleepiness or drowsiness
• Nausea or vomiting
• Impaired cognition or confusion
• Forgetfulness
• Impaired balance or coordination

Naltrexone

Brand name

 Vivitrol

What it is and how it works

Vivitrol is an extended-release form of Naltrexone and an opioid antagonist. This means that the medication blocks the effects of opioids and does not allow the user to get high. It is the only approved medication for drug and alcohol dependence that is not a controlled substance.

Both Naloxone (discussed above) and Naltrexone are opioid antagonists and do not create highs or euphoria. Vivitrol is used as a longer-term option to ward off cravings while in recovery, while Narcan is an effective short-term treatment.  To make it simple, Narcan removes the opioid from the place where it is lodged in the brain and Vivitrol blocks it from ever getting there.

When and How Vivitrol and Naltrexone is taken

Vivitrol is typically injected monthly and works as an extended-release intramuscular injection. In rare cases, where a patient is seen to metabolize the drug quickly, it can be given every 21 days. In its oral form, called Naltrexone, it needs to be taken daily.

For people who are scared they will miss days while on Naltrexone, either due to forgetfulness or lack of discipline, Vivitrol is probably the better option. Although it is more expensive than the a Naltrexone regimen, insurance is likely to cover it. Talk to your treatment providers and discuss the options best for you and your situation.

Can Vivitrol create dependence and addiction?

No. As mentioned, it is not addictive and cannot be abused. It has been shown to significantly lower relapse risks and cravings.

For how long should Vivitrol be taken?

Vivitrol, like every other MAT, is not a cure for addiction or SUD. Taking it independent of clinical treatment will many times lead to relapse. It is important to find a treatment provider who can guide you as to how long Vivitrol will be beneficial while doing the work of addiction recovery. Whether it is short-term or long-term, it should be accompanied by good clinical treatment. This will allow for sustained recovery.

Can Vivitrol be taken while drugs are still in the system?

While there are opioids in your system it can be dangerous to take Vivitrol. It can bring severe withdrawal symptoms and precipitate sudden opioid withdrawal. Checking into a treatment facility to carefully monitor when it is safe to begin is the best way to go about it.

Naltrexone and Vivitrol Side Effects

• Headache
• Nausea
• Diarrhea
• Constipation
• Stomach pain
• Dizziness
• Anxiety
• Nervousness
• Restlessness
• Irritability
• Drowsiness
• Insomnia
• Loss of appetite
• Increased thirst
• Muscle or joint pain
• Weakness
• Pain, bruising, swelling, itching, and infection (at the site of injection)

Naloxone

Brand Name

Narcan

What it is and how it works

Many drugs affect the central nervous system. When the body takes on more opioids than it is used to, other normal functions get compromised. This can slow down heart rates, breathing, and blood pressure. Eventually, the system will get so overwhelmed that these functions shut down completely. This is the point where overdose is reached.

Naloxone is an opioid antagonist used to reverse the life-threatening effects of addiction overdose. Blocking the receptors in which opioids find a home lessens the strain the body is under and allows it to resume its regular functions. Learn more about how Narcan can help reverse an overdose.

How long does Naloxone need to take effect?

It normally takes two to three minutes for Narcan to to act. In the event that the patient is still unresponsive, a second dose should be given. Naloxone wears off in 30-90 minutes. It is very important that emergency medical personnel should be called to the scene immediately.

How is Narcan given?

There are three general ways Naloxone is administered. Doses can be given through injection, intravenously, or with a nasal spray.

Do you need to be a professional to give Narcan?

Usually not.

In most areas, first responders are trained in the use of Narcan . As awareness is growing, more and more states have allowed and even advocate for the training of laypeople. Family members of people struggling with addiction are encouraged to get trained in how to give Narcan. Availabilty and knowledge of Naloxone use can be the difference between life and death.

Is Narcan addictive?

No.

Narcan Side Effects

• Fatigue
• weakness
• nervousness
• restlessness
• irritability
• body aches,
• diarrhea
• stomach pain
• nausea
• fever
• chills
• goosebumps
• sneezing
• shortness of breath
• runny nose.

Medicine for Alcohol Withdrawal

As well as medicated treatment for opioid addiction, there have been developments in the region of medicine and alcohol withdrawal. Two medicines have been found to be a good option for alcoholics who wish not to enrol in an inpatient treatment program. These drugs are called Acamprosate and naltrexone, two of the many in circulation for people who are dealing with addictions to alcohol and other substances.

One of these is a helpful medicine for alcohol cravings – it reduces urges to drink and helps people to cut back on very heavy drinking, while the other showed better results with helping alcoholics who hadn’t been drinking in a while to stay sober and prevent relapse.

Insurance Coverage of Medication Assisted Treatment

Medication Assisted Treatment is just like any other aspect of substance use disorder treatment. Insurance companies are obligated to cover when a doctor certifies that the course of treatment is needed. Medicaid and Medicare covers MAT too. At Avenues Recovery, an insurance expert will help you understand your policy and even talk to your insurance rep to make sure that everything is taken care of. Financial constraints should never be an obstacle to getting the addiction treatment you need. Your insurance coverage rights for medication assisted treatment are protected by law.