Myths vs. Facts: The truth about medication assisted treatment for opioid addiction
By Mark O’Brien, Senior Criminal Justice Policy Associate
ARTICLE OVERVIEW: There are many misconceptions and myths about medications that treat strong addictions. This article presents the facts about buprenorphine, methadone, and naltrexone.
TABLE OF CONTENTS:
- What Is Medication Assisted Treatment
- Myths And Facts
- Myth #1: Cold turkey is better than MAT.
- Myth #2: MAT substitutes one addiction for another.
- Myth #3: Medications are a crutch.
- Myth #4: MAT is not effective
- Myth #5: MAT should not be used long-term.
- Myth #6: Drug courts are in a similar position to doctors for MAT Rx.
- Myth #7: Methadone overdoses are common and increasing.
- Myth #8: Required MAT tapering is helpful.
- Myth #9: MAT is expensive.
- Myth #10: Medications should be avoided in pregnancy
- Bonus Myth: Treatment is available to everyone.
- Your questions
What Is Medication Assisted Treatment
Medication assisted treatment (MAT) for opioid addiction is the use of medications such as buprenorphine, naltrexone, and methadone (in combination with counseling and behavioral therapies) to provide a whole-person approach to treatment. MAT works to:
- Block the euphoric effects of opioids.
- Normalize body functions.
- Relieve physiological cravings.
- Stabilize brain chemistry.
Studies have shown that MAT reduces illicit drug use, disease rates, and related harmful behaviors, including criminal activity. People who are enrolled in MAT programs are up to 75% less likely to die from a cause related to their addiction. Despite what the National Institutes of Health says is “unequivocal” evidence of MAT’s effectiveness and safety, many myths persist about MAT. As a result, people are denied potentially lifesaving addiction treatment.
Myths And Facts
The following are some common myths about MAT and the facts that can give people a better understanding of these powerful addiction treatments.
Myth #1: MAT is not better than cutting opioids consumption cold turkey.
Fact: Cold turkey withdrawal can provoke adverse events such as extreme discomfort , distorted thinking, or relapse. Studies show that people facing opiate/opioid addiction who follow detoxification with complete abstinence are very likely to relapse, or return to using the drug.
While relapse is a normal step on the path to recovery, it can also be life threatening, raising the risk for a fatal overdose. Thus, an important way to support recovery from heroin or prescription opioid use disorder is to maintain abstinence from those drugs. MAT does this. In fact, MAT medications reduce the negative effects of withdrawal and cravings without producing the euphoria that the original drug of abuse caused. New medicines are effective for this. For example, the FDA recently approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms. Methadone and buprenorphine are other medications approved for this purpose.
Myth #2: MAT is just substituting one addiction for another.
1. Agonists (Methadone). Agonists turn on the same receptors as other opioids but their lower intensity and longer duration prevent the withdrawal and escalation that are part of addiction.
2. Partial agonists (buprenorphine). Partial agonists work similarly but produce a weaker effect.
3. Antagonists (injectable naltrexone). Antagonists work by blocking the opioid receptors in the brain so that opioids have a diminished or completely eliminated effect on them.
Appropriately prescribed agonist addiction medications reduce drug cravings and prevent relapse without causing a “high.” Although people treated with agonist medications are physically dependent on them, agonists are different from short-acting opioids such as heroin and prescription painkillers. Instead, both agonist and antagonist medications are proven to help people disengage from drug seeking behavior and criminal activity, and become more receptive to behavioral treatments.
NOTE HERE: To be most effective, medications like methadone and buprenorphine should be combined with behavioral counseling for a “whole person” approach.
Furthermore, Vivitrol, an antagonist medication, does not cause physical dependence. This makes it possible for the person to function normally, attend school or work, and participate in other forms of treatment or recovery support services to help them become free of their substance use disorder over time.
However, because maintenance medications (methadone and buprenorphine) are themselves opioids can manifest euphoria in people who are opioid-naive, many people have assumed that this form of treatment just substitutes a new substance use disorder for an old one. This belief has unfortunately hindered the adoption of these effective treatments. In 2011, rates of implementation of medication-assisted treatment for opioid use disorders were just 34.4%. In the past, even some inpatient treatment programs that were otherwise evidence-based did not allow persons to use these medications, in favor of an “abstinence only” philosophy.
Myth #3: Medications are a crutch that prevents true recovery from addiction.
Fact: People in MAT can and do achieve “true recovery.” Science shows that people whose addictions are treated with MAT:
- Are less likely to use illicit drugs.
- Do not experience euphoria, sedation, or other functional impairments.
- Do not meet diagnostic criteria for addiction, such as loss of volitional control over drug use.
As the name medication assisted treatment implies, medications are only one part of MAT. Medication normalizes brain chemistry so people have more success participating in counseling and behavioral interventions that support their recovery.
Myth #4: MAT is not effective.
MAT decreases opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission. After buprenorphine became available in Baltimore, heroin overdose deaths decreased by 37 percent. In a trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation.
You can see a full review of the efficacy of MAT in chapter 3 of the book the publication: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Program, Treatment Improvement Protocol (TIP) Series, No. 43. published by the Center for Substance Abuse Treatment.
Findings from Starting Treatment with Agonist Replacement Therapies (START), a study from the Journal of Studies on Alcohol and Drugs, compares treatment outcomes with the type of treatment medication used.
MAT also increases social functioning and retention in treatment: In November 2017, the U.S. Food and Drug Administration approved Sublocade, the first once-monthly buprenorphine injection for moderate-to-severe opioid use disorder in adult persons who have initiated treatment with the transmucosal buprenorphine-containing products. This medication, in addition to Probuphine®, an implantable buprenorphine formulation approved in May 2016, eliminate the need for daily dosing and improve treatment retention.
Additionally, treatment of opioid-dependent pregnant women with methadone or buprenorphine improves outcomes for their babies; MAT reduces symptoms of neonatal abstinence syndrome and length of hospital stay.
Myth #5: MAT should not be used long-term for the treatment of opioid dependence.
Fact: There is no one-size-fits-all duration for medication assisted treatment. For some persons, MAT could be indefinite. In fact, the FDA states: “There is no maximum recommended duration of maintenance treatment, and for some patients, treatment may continue indefinitely.” The National Institute on Drug Abuse describes addiction medications as an “essential component of an ongoing treatment plan” for people to “take control of their health and their lives.” Further, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends three phases:
PHASE 1: A beginning stabilization phase (withdrawal management, assessment, medication induction, and psychosocial counseling).
PHASE 2: A middle phase emphasizing medication maintenance and counseling.
PHASE 3: A third phase of “ongoing rehabilitation,” during which the person and provider can taper off medication or pursue longer term maintenance based on the person’s needs.
Chapter 7 of SAMHSA TIP 43 summarizes the long-term nature of treatment: “MAT is a relatively long-term process, often with no fixed endpoint and with a variety of possible approaches, and partly because patients often leave and then return to MAT, which makes systematic studies difficult.” Some doctors even talk of a minimum of 6 months of treatment on medicines like methadone.
Keep in mind that recovery is a life-long process. Many of us risk relapse once being released from a treatment center, let alone if we come off our meds. Regular, in- person follow-ups with your prescribing doctor are key! Physicians run check-ups and tests, and perform random or scheduled drug testing as part of treatment.
Myth #6: Courts are in as good of a position as a doctor to determine the appropriate treatment for a person’s addiction.
Fact: Determining the appropriate treatment for an opioid addiction is a health matter that should be between a doctor and patient. Doctors know the relevant medical standards and can assess and respond to the individual characteristics of the person. Just as judges would never decide that a person must treat her diabetes through exercise and diet alone rather than with the insulin her doctor prescribed, courts should avoid making medical decisions with respect to medically-accepted substance use disorder treatments like MAT.
Denying access to MAT in the criminal justice system is unwise. It may also be illegal. Courts are in a position to motivate people to succeed in treatment and help them access it, but they should leave assessments and treatment planning and execution to addiction professionals.
Myth #7: Overdoses from methadone used for the treatment of opioid dependence are common and increasing.
Fact: Methadone used as treatment is highly regulated and results in little diversion and few deaths. Methadone does interact negatively with several medications, another reason it is highly regulated. Additionally, an expected tolerance to methadone occurs after regular dosing.
Tolerance is the process of brain receptors’ desensitization and downregulation caused as an effect of brain´s continual exposure to high levels of opioids and dopamine, which is released in the reward circuit following opioid receptor activation. Brain cells respond to methadone by reducing their response to receptor activation and by removing opioid and dopamine receptors from the cell membrane, resulting in fewer receptors that can be activated by the drug. These mechanisms result in a lessened response to the drug, so higher doses are required to elicit the same effect.
Tolerance to methadone is the reason that people diagnosed with addiction do not experience euphoric effects from therapeutic doses of buprenorphine or methadone, while people without opioid use disorder do. It is also the reason why people are at increased risk of overdose when relapsing to opioid use after a period of abstinence: They lose their tolerance to the drug without realizing it, so they no longer know what dose of the drug they can safely tolerate.
Myth #8: Requiring people to taper off MAT helps them get healthy faster.
Fact: Requiring people to stop taking their addiction medications is counter-productive and increases the risk of relapse. Because tolerance to opioids fades rapidly, one episode of opioid misuse after detoxification can result in life-threatening or deadly overdose.
Myth #9: Medication assisted treatment is expensive.
Fact: Opioid Treatment Programs (OTP) price comparisons follow:
Buprenorphine for a stable person provided in a certified OTP, including medication and twice weekly visits: $115.00 per week or $5,980.00 per year.
Methadone treatment, including medication and integrated psychosocial and medical support services (assumes daily visits): $126.00 per week or $6,552.00 per year.
Naltrexone provided in an OTP, including drug, drug administration, and related services: $1,176.50 per month or $14,112.00 per year.
To put these costs into context, it is useful to compare them with the costs of other conditions. According to the Agency for Healthcare Research and Quality, annual expenditures for individuals who received health care are $3,560.00 for those with diabetes mellitus and $5,624.00 for kidney disease.
It is also important to remember the costs associated with untreated opioid use disorders, including costs associated with:
- Criminal justice.
- Greater transmission of infectious diseases.
- Injuries associated with intoxication (drugged driving or fighting).
- Lost productivity.
- Treating babies born dependent on opioids.
- Treating overdoses.
The amount paid for treatment of substance use disorders is only a small portion of the costs these disorders impose on society. An analysis suggested that the total costs of prescription opioid use disorders and overdoses in the United States was $78 billion in 2013. Of that, only 3.6 percent, or about $2.8 billion, was for treatment.
Myth #10: Medication assisted treatment should be avoided during pregnancy.
Fact: Treatment with methadone or buprenorphine improves infant outcomes by:
- Stabilizing fetal levels of opioids, reducing repeated prenatal withdrawal.
- Linking mothers to treatment for infectious diseases (e.g., HIV, HBV, HCV), reducing likelihood of transmittal to the unborn baby.
- Providing opportunity for better prenatal care.
- Improving long-term health outcomes for the mother and baby.
Compared to untreated pregnant women, women treated with methadone or buprenorphine had infants with:
- Higher gestational age, weight, and head circumference at birth.
- Less severe NAS.
- Lower risk of NAS.
- Shorter treatment time.
Bonus Myth: Treatment is available for everyone.
Fact: Less than 1/2 of privately funded substance use disorder treatment programs offer MAT and only 1/3 of persons with opioid dependence at these programs actually receive it. The proportion of opioid treatment admissions with treatment plans that included receiving medications fell from 35 percent in 2002 to 28 percent in 2012. Nearly all states in the United States do not have sufficient treatment capacity to provide MAT to all persons with an opioid use disorder.
Researchers are exploring how the health care system can reach more people in need of treatment and helping providers understand which treatments will be most effective for which persons. Where can you get more information now?
Have aware of any other myths? Do you want us to clarify any points we’ve made? Please leave your questions below. If you need help finding the best addiction treatment program for your needs, please let us know. Learn more about available rehabilitation options, what the process looks like, and what to do after rehab to in our comprehensive GUIDE to Opioid Addiction Treatment.
Reference Sources:  CDC: Confronting Opioids
MEDLINE PLUS: Opiate and opioids withdrawal
NCBI: Effective treatments for opioid addiction
NCBI: Maintenance medication for opiate addiction
NCBI: Medicines used in alcohol and opioid dependence
NCBI: Pharmacological treatments for opioid dependence
NCBI: The neurobiology of opioid dependence
NIDA: America’s addiction to opioids
NIDA: Effective treatments for opioid addiction
NIH: Principles of Drug Addiction Treatment: A Research-Based Guide
NIH: Treatment Approaches for Drug Addiction
SAMHSA: Treatments for substance use disorders
Surgeon General: Opioids
About the author: Mark O’Brien is a Senior Criminal Justice Policy Associate at Legal Action Center advocating to expand access to addiction treatment in the criminal justice system and opportunities for people with criminal records and addictions.
Photo credit: The Clinic by Dr H