Medically-Assisted Treatment also known as Medication-Assisted Treatment (MAT)
By Mel Pohl, MD, DFASAM The recovery industry is moving, in many cases has already moved, to embracing MAT as a treatment option, why is this? I believe the main reason for this is the increasing opioid overdose rate. Over 70,000 drug overdose deaths occurred in the U.S. in 2017. Opioids—particularly synthetic opioids are currently the main driver of drug overdose deaths. This is especially problematic with the surge of heroin use and more recently the promulgation of illicit fentanyl mixed with other opioids. Because of the potency of fentanyl and other synthetic opioids, the overdose rate has spiked in the last few years. In 2017, 59.8 percent of opioid-related deaths involved fentanyl compared to 14.3 percent in 2010. The recovery industry has embraced MAT because it is a “medical treatment” of a brain disease (addiction). Finally, the pharmaceutical manufacturers of medications have supported a movement to use medications to treat the complex bio-psycho-social-spiritual disease of addiction. Addiction Treatment Background Traditional treatment for opioid use disorder (opioid addiction) is to detoxify the client off of habit-forming drugs and teach the client to deal with “life on life’s terms” without mood-altering drugs, which result in addiction. Recidivism, with this treatment methodology, is high. The field of addiction medicine hasn’t studied the efficacy of what’s been called “abstinence-based treatment” sufficiently to note the rate of successful treatment and prolonged abstinence from opioids. Of note is that physicians who’ve been treated with a rigorous, well-monitored program based in abstinence have been remarkably successful – as high as 80 percent staying clean from drugs, proven by negative urine toxicology screens for five years or more. These results have not been reliably reproduced in the treatment programs, so the assumption has arisen that abstinence-based treatments don’t work. This is simply not true, witnessed by the successful lives of millions of alcoholics and addicts who have discontinued using drugs and remained abstinent, living healthy happy lives. Buprenorphine, the mainstay of MAT can be prescribed from a doctor’s office and it has been found that clients on buprenorphine stay off of heroin and other opioids (around 60 percent of the time). Consequently, they don’t die from drug overdose nearly as often. This outcome is desirable of course – no treatment works if the client overdoses and dies. Some of the problems facing those on buprenorphine or methadone maintenance programs are the difficulty and costs of acquiring and continuing on the drugs, but more importantly that there is no plan for discontinuing the drugs. Some believe that an opioid addict’s brain requires doses of opioids to stabilize the brain – perhaps for life – like a diabetic requires insulin. Others are concerned about the need for an exit strategy for discontinuing buprenorphine or methadone. This exit strategy doesn’t exist. Both methadone and buprenorphine are tough drugs to come off of and require skilled detoxification for prolonged periods – as long as several months. Are there unethical practices associated with MAT? The most unethical practice I’ve seen is providing buprenorphine in a setting that has nothing to do with recovery. If buprenorphine is provided in such a setting, it is simply a medication, which is not likely to improve the life of the client. It should always be offered in an environment that teaches clients how to live and function better, introduces them to community supports, helps them deal with stressors and co-occurring psychological and psychiatric conditions, and facilitates a healthier, happier life. Are there evidence-based ways to use MAT to produce positive results? Typically, the positive result is that the client is less likely to return to their drugs of choice, like heroin or opioids. There is no data so far that tells us which clients will be less likely to return to drugs once the buprenorphine is discontinued. Simply offering medicine without introducing recovery concepts is unethical in my opinion.