Episode 18 – The Opioid Epidemic
Dr. Ashish Bhatt ❘
What caused the Opioid Epidemic? And more importantly, what can be done to stop it? Dr. Bhatt, MD breaks it down.
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Hayley: Hello, my name is Hayley, and you are listening to Straight Talk with the Doc, a podcast that takes a real look at addiction, mental health, and treatment. I’m joined by our medical director, Dr. Bhatt and our content director, Jeff. How are you two doing?
Dr. Bhatt: Doing well, Haley. How are you guys doing?
Jeff: Doing good. It’s a good day.
Hayley: Yeah, it is. So as we make our way through the beginning of 2021, we’re all aware that the opioid epidemic is still going on as well as other substance use disorders in our country. And some of us may have heard of the acronym, MAT, to talk about treating addiction using medications. But what does that stand for? And what is it really? Dr. Bhatt, can you explain what MAT is and how it’s used to help people with an addiction?
Dr. Bhatt: MAT, or medication-assisted treatment, is when we use exactly that, medications to help people to treat addiction. It’s not new. I think it’s gotten a lot of attention more recently just because the opioid epidemic and drug addiction as a whole has gotten more attention. But we’ve been treating addiction with medications for quite a few decades. So medication assisted treatment is basically when we use medications to help somebody not use illicit substances. With pharmaceuticals prescribed by physicians can help stay sober, live a healthy life, and not use their substances to get high, and actually live a healthy lifestyle.
Hayley: Are these medications available to treat all types of substance use disorders or just specific classes of drugs?
Dr. Bhatt: Right now, we have available to us medications that can assist with opioid use disorders, alcohol use disorders, and nicotine use disorders with tobacco. There are some off label, non FDA approved medications that we are looking at, and there are being investigated for cocaine and methamphetamines. But for the most part we have for those first three classes, alcohol, and nicotine, and opioids, we do have FDA approved medications for.
Hayley: Can you tell me what some of these medications are?
Dr. Bhatt: Regarding opioid use disorders? We have medications that exist for that. One medication that has gained a lot of popularity is methadone. That’s because it’s been around for a long time, and it’s been around for decades. Methadone has helped a lot of people not use heroin, not use other illicit opioids, and prevent them from developing other sorts of negative consequences from using their opioids and HIV, hepatitis C, overdosing. That’s been around for a long time. Another medication that’s out there right now goes by the trade name, Subutex or Suboxone, and that ingredient in there is buprenorphine. That’s a medication that’s also used to help with opioid use disorders. That is something that’s helped people stay in treatment longer and as a form of harm reduction it has people stay abstinent from illicit substances.
Hayley: How are these medications administered? Does somebody have to go into a clinic to receive the drugs? Or is this something that they can take home?
Dr. Bhatt: Depends on which medication we’re talking about. So in terms of when we’re speaking about opioid use disorders, methadone, for example, is something that for the most part is given at a clinic. These are medications that people have to go to these clinics and retrieve daily versus buprenorphine, excuse me, that’s something that people can get at their doctor’s offices. They can get prescription bottles and based on the relationship that they have with the physician, the treatment plan, how the patient is being monitored and how the patient is progressing. The patient can go once a week to once a month and actually could have a lot of liberty with the medications. With the alcohol use disorders, medications that we spoke about, they can get one month supplies that they can pick up from their pharmacy or even more. So apart from methadone, most of these medications, they can be picked up from the pharmacy and held with the patient.
Hayley: Dr. Bhatt? Can you kind of explain the science behind these medications? How do they work?
Dr. Bhatt: Medications work differently. For one class of medication, they don’t necessarily work the same, as another. So we’re going to have to go case by case, but the point behind them is, if you can give somebody a prescribed medication with under the guidance of a physician that helps a patient go away from using a substance to get high, opposed to using a medication to get well, that’s kind of the premise behind it. If we look at the medications individually, for example, now Traxon. Now, Traxon is a medication that’s used both for opioid use disorders and for alcohol use disorders. And the essence behind it is it’s an opioid blocker. So it binds to the opioid receptor in your body. So as an opiod blocker, if it’s bound to your opioid receptors, if for example, heroin is introduced or an opioid pill is introduced to your body, you will not get that euphoria or that high, because that naltrexone is bound and is preventing that other drug that you’re trying to attempt to get high off of from actually doing that job. So that’s how naltrexone works. In terms of how naltrexone works for alcohol, I think I spoke about it a little bit earlier, is that it prevents you from getting that euphoria from when you use alcohol and releases that endogenous endorphins. So that person doesn’t get those positive reinforcing effects of it.
Hayley: So it kind of takes away the incentive to use the drug of abuse?
Dr. Bhatt: Especially with those medications. It can decrease cravings also. So a lot of people, they struggle. When people are having addiction and one of the biggest symptoms that they struggle with is the craving for it. Traxon is shown in multiple studies and in clinical practice to decrease cravings for people.
Hayley: Since these medications can be helpful for opioids and alcohol addiction, is everyone with an addiction to these substances, offered medication as an option?
Dr. Bhatt: Depends a lot on the philosophy of where the patient is, what they believe in, what the doctor sees is the best in terms of their treatment plan. Many people think that being on a medication, unfortunately also mimics being addicted to the drug itself and that’s not necessarily the case. We discussed and I can discuss further, not all of these medications that are used in MAT or medication assisted treatment are controlled substances. They’re not at all. But at the same time, there’s a lot of thoughts behind addiction as you’re not totally in recovery, unless you’re completely abstinent from everything, and that’s not necessarily true. So, in the end of the day, if you’re taking medication like you’re taking for any disease in order to be sober and to be free from getting high and living a healthy lifestyle, that’s really the ultimate outcome. That you want to have a good quality of life.
So these medications should be customized based on each individual’s trajectory in, in conjunction with the physician and the patient. So we look at, if a patient has, for example, been using intravenous drugs has been in and out of rehabilitation has a high risk for, developing or contracting infectious disease. This person might be a good candidate to get on medication assisted treatment, because they might not be able to benefit from other sorts of psychosocial modalities. So that could be one example for a patient that might see utility about using medication, as opposed to just strictly an abstinence based approach. In my opinion, a comprehensive, biological, psychological, and social approach to treating one’s addiction is really the best way.
Hayley: You mentioned using medications to help with a cocaine addiction earlier, but what about medication treatment for other substance use disorders, like methamphetamine or marijuana, is that an option?
Dr. Bhatt: Again, there aren’t any FDA approved medications right now for either one of those classes of drugs. There are some studies out that just were, that just came out. NIAAA has released some of that information for methamphetamines, that there is a combination of bupropion and Traxon that is showing some benefit. So I think if we look along the pipelines that we might see that come about. Similarly with marijuana, there are some studies out there, but there are no FDA approved medications right now to treat those who suffer with cannabis usage.
Hayley: And for the ones that are used to treat alcohol and opioid addiction, are some of these medications habit forming or addictive? Are there risks that are associated with these medications?
Dr. Bhatt: For some of them, the ones that are the opioid agonists or partial agonists. So I’ll use the names methadone or buprenorphine. They can become physically dependent, someone I’m sorry, can become physically dependent on these substances. So the way that somebody needs to use this as is really looking at this as a harm reduction perspective. Like any chronic disease addiction needs to be treated properly. People who go out and are using substances, they’re at risk for developing significant comorbid, contracting certain infectious diseases, overdosing and dying. Versus taking medications like this, which can, although physically dependent, if they’re titrated properly, and if they are supervised properly, these medications can be adequately and properly placed on a patient, controlled and taken off of that patient without any withdrawal. So this really has to be done again with collaboration with your physician and if done properly, although yes, they can be physically, habit forming these medications, can be of great utility.
Hayley: Because some of these medications can be habit forming. Is there any controversy surrounding them?
Dr. Bhatt: I think like anything, when we have medications that somebody can become addicted to, they also have the potential to get somebody high if they’re diverted or used in the wrong way. So when we look at, for example, methadone, is a medication, due to the way it’s pharmaceutically, its mechanism of action, if used properly and titrated properly, most people are not getting high off this medication. Similarly with buprenorphine, if you’re putting it correctly and dosing it correctly on somebody that has an opiate dependency already, these people aren’t going to be getting high. But people who want to divert medications, are not monitored correctly, who start to come up with ingenious ways to figure things out, instead of taking it orally, want to figure a way to crush it and liquefy it or inject it, these people can use it in a way to try and get high. But there are certain types of properties that these medications have that do limit the potential for getting high. But unfortunately, if there is a will, there’s a way, and some of these medications, if used inappropriately or given to people that might be somewhat naive, there is that possibility that these people might use that and get high off them.
Hayley: Are these medications available or suitable for everyone? How does someone know if this option, this medication is right for them?
Dr. Bhatt: Again, that’s a discussion they need to have with their medical provider. A lot of times it’s a case by case basis. This is something that somebody needs to look at and take again into their approach. How many times they’ve maybe been into treatment, is a conservative approach not working for them? Are they using intravenously? In my opinion, I don’t think avoiding medication should be something that people should be looking at at this point in time in the treatment of addiction. I think it should be actually incorporated as part of a comprehensive wellness plan. I think looking at medications, for the treatment of addiction should be part of everybody’s plan. It should be a consideration for everybody. So for example, people who have alcohol use disorders, if there’s no significant liver contraindications or mental health contraindications, medications such as Naltrexone or Campral, which is another one they should be considered on everybody that has an alcohol disorder.
Similarly, if somebody is suffering with a heroin use disorder or a significant other opioid use disorder, they should be considered for buprenorphine or even methadone. I’m not saying these are first-line and only options, but it definitely should be considered for everybody. So to answer your question, when somebody walks into their doctor’s office, I think they need to be asking that question. “Hey, is this something that is right for me?” And having that heart to heart conversation with their physician so they can explore all those options. It’s hard to have this conversation, here, but the doctor will know which is the right thing to do by teasing out specifics that are pertaining to that individual’s history.
Hayley: So if someone is placed on these medications, are they always taking part in other forms of treatment like therapies and counseling, or not necessarily?
Dr. Bhatt: I believe that a hundred percent, these people should have a comprehensive plan. Maybe people aren’t and that’s probably where some of these things are failing. People are getting started on medications and are thinking that they don’t need to be on counseling or the sort of group therapies and other psychosocial modalities, but that’s really only one part of it. Treating addiction takes looking at a holistic approach. You need to look at the biological side and how we can address it,? How can it reduce cravings, the physical withdrawals, the symptoms that are addressing the neuro receptor changes that happen from chronic exposure to drugs? That’s the biological part. That’s where our medications come in. But the psychological part needs to be dressed with therapies too and counseling. The social part needs to be addressed also, including the family and the environmental component. So all in all, when somebody is being treated for addiction, they need to look at the entire picture. Medication alone is not the right way to go.
Hayley: Do people who do medication assisted treatment have a higher recovery success rate than those who do not?
Dr. Bhatt: When you look at the statistics, it does demonstrate for many people who have opioid use disorders, for example, have shown to have to stay in treatment longer when they are buprenorphine, for example, and have prolonged rates where they relapse less frequently. So depending on which variable you’re looking at, we have seen better outcomes with certain people on medication assisted treatments, as it pertains to staying in treatment and often staying abstinent longer.
Hayley: What if someone wants to get off of these medications, is that possible? And how should they go about it?
Dr. Bhatt: Especially the ones that, again, these are case by case situations. When you’re trying to get off any medication, if it’s for high blood pressure, if it’s for asthma, if it’s for addiction, you need to have that discussion with your physician. These are medications that don’t necessarily have to be taken for the rest of your life. So if other parts of your lifestyle and other parts of your recovery have augmented and started to solidify, or then it’s an opportunity to take you off of those medications. That’s something that I think that if a physician and the patient and an entire treatment team, if it’s in a rehab look at all the variables. Yeah. That’s something that somebody can come off of. And I don’t believe somebody should go in there thinking they have to take it for the rest of their life. So it has to be open minded.
Hayley: Where should someone go to get medications to help with addiction? Do all treatment centers offer medication assisted treatment?
Dr. Bhatt: It’s like a two-part question. First, there are doctors, addiction specialists. There are physicians that have special waivers that can prescribe buprenorphine that they can go on an outpatient basis and get prescribed these medications to assist them. Certain other medications for alcohol use disorders don’t necessarily have to be prescribed only by an addiction specialist. People who are doctors who are comfortable seeing patients for mental health or behavioral health disorders, psychiatrist, even internists, they can prescribe naltrexone, Campral antabuse. These are medications that don’t need any sort of special licensing or considerations. So the ones with buprenorphine, even the DEA and those who regulate buprenorphine, they’re starting to see the need to deregulate those and actually allow those doctors who have regular DEA licensing, prescribing rights. To just not have any special requirements to have buprenorphine prescribing privileges. This way, doctors who can prescribe any controlled substance can prescribe buprenorphine.
This will open up the door for people to access physicians who can treat opioid use disorders as for treatment centers. Most treatment centers do have the capacity, especially detox to help detox with buprenorphine or methadone. As for those that want to, who might place patients on medications assisted treatment, I think that still depends on the treatment center. Many treatment centers now are having programs specifically tailored to medication assisted treatment tracks are offering this as part of their comprehensive treatments or those who want to stay without medications they’re making it open. There’s a variety out there depending on what the needs of the patients are and what the philosophy or the thoughts of the patients are. That access is there.
Hayley: Yeah, like you said, there definitely is a need for these medications. For some patients, do insurance companies cover these types of medications?
Dr. Bhatt: Yeah. We see insurance companies covering these medications, and it is something that should not be an obstacle. For the most part, it’s not. For some people they are going to struggle when it comes to finances. There are some programs that are available through pharmaceutical companies and through state programs that can help and assist. In general most insurance companies are covering these meds.
Hayley: That’s good. Dr. Bhatt, is there anything I didn’t ask you about medication assisted treatment that you think people should know?
Dr. Bhatt: At the end of the day, medications are there to help people live a better life, live a healthier life, and live more prosperous. I think there’s been a historical stigma that might be associated in the addiction community, that if you take medication, you’re just basically replacing one addiction for another. Trying to pursue a healthy life and taking medications versus a substance they’re two different things. When somebody uses heroin or takes cocaine or drinks for the purpose of getting high, that’s something that they’re trying to do, under the umbrella of their addiction. Versus taking medication to get well, to be healthy in order to not get high is something that they’re doing to stay in sobriety. So I think we need to have an open mind that when treating any chronic illness, medications need to be and should be considered as part of a comprehensive wellness and treatment package and not have that stigma towards it as as many people have had. I’m happy to see that, people are more open to taking medications and looking at the science behind it so they can live healthier and ultimately rid themselves of their illicit substance use,
Hayley: Reducing that stigma is important. So, I’m glad that we talked about this today. If someone listening wants to learn more about medication assisted treatment, you can go to Addictioncenter.com for more information, you can also find more podcast episodes there as well. Thank you for talking with us today, Dr. Bhatt, and thank you to everyone who listened to this episode of Straight Talk with the Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.