Integrated Treatment: Part 2 – The Approach
The integrated treatment approach to psychiatric and substance use disorders makes sense from the standpoint of viewing recovery from a holistic approach.
Medication-Assisted Treatment (MAT) is a common approach used in Opioid Treatment Programs (OTPs) throughout the United States. MAT is defined by SAMSHA as the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach for the treatment of Opioid Use Disorders. There are three common FDA-approved medications used in MAT for opioid addiction treatment: Methadone, Buprenorphine, and Naltrexone. Due to some of these medications being controlled substances with a potential for abuse, there has been much controversy regarding their long-term use in recovery. However, individuals can use medication for opioid treatment safely for months, years, and sometimes life.
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Methadone Maintenance Treatment is commonly used for long-term treatment for individuals with an addiction to opioids, such as heroin. Methadone was approved as a treatment for opioid addiction soon after it was approved as a pain reliever in the United States in 1947; however, the first Medication-Assisted Treatment program was not established until 1971 with Methadone Maintenance Treatment (MMT). Methadone is used to treat adults with opioid use disorders by providing medication maintenance and therapy.
A newer Medication-Assisted Treatment (MAT) for Opioid Treatment Programs (OTPs) includes Buprenorphine. Buprenorphine, commonly known as brand names, Suboxone or Subutex, was approved by the FDA for treatment of opioid use disorders in 2002. Buprenorphine was previously used as a pain reliever, as it is a partial opioid antagonist that binds with opioid receptors in the brain which reduces pain. Although it is not considered a full opioid, it acts much like one, causing moderate receptor site activity. It does not create a state of euphoria, as long as it is used as prescribed. Buprenorphine is, however, a controlled substance that can lead to dependence or addiction. It is beneficial because it prevents withdrawal symptoms while reducing cravings for opiate drugs and prescription painkillers.
Suboxone is a synthetic opioid with the ingredients Buprenorphine and Naloxone and is effectively used during the detoxification process of opioid treatment and for maintenance therapy. When an individual uses Suboxone, they are unable to feel euphoric effects from opioids if they were to have a relapse due to the Naloxone. If a relapse were to occur, it could also precipitate withdrawal symptoms if someone is taking Suboxone and attempts to use another opioid. Subutex does not have Naloxone as an ingredient, making it easier to abuse. Subutex or Suboxone are often given during the first few days of detox to reduce withdrawal symptoms. They can both also be used for long-term opioid maintenance treatment.
Many individuals prefer to take another form of Medication-Assisted Treatment for Opioid Use Disorders that is not a controlled substance, called Naltrexone. Naltrexone is the generic form of the brand-name drug Vivitrol. Naltrexone is used to prevent substance abuse in individuals who have opioid or alcohol use disorder by reducing cravings. Naltrexone comes in a tablet form and is taken orally once per day. Vivitrol can only be administered by a physician and is administered intravenously, lasting in the body for 30 days. Naltrexone is only one part of a complete treatment program for opioid treatment that should also include lifestyle changes, counseling, and support. As an opiate antagonist, it works by blocking the effects of opioids. It has shown to be very useful in helping reduce relapse in recovering opioid addicts.
There are many benefits to Medication-Assisted Treatment. Methadone is a synthetic opioid that remains active for 24 hours (or longer) in the body due to its ability to metabolize differently than other opioids. It builds up in an individual’s body and remains active for long periods of time. This is very beneficial for individuals using Methadone, as the drug blocks the effects of other opioids while reducing the cravings and withdrawal that an opioid addict would have to overcome daily due to use of other drugs.
Individuals with opioid use disorders typically use opioids multiple times per day. This increases tolerance and results in the need to increase the dosage and frequency of the drug. In general, they get stuck in the cycle of repeating the process of finding drugs, using, being high, and recovering from withdrawal symptoms. When involved in an MMT program, they are free from this cycle. Methadone and Buprenorphine specifically help “break the cycle” of addiction by allowing individuals to focus on their recovery, relationships, family, jobs, and improve psychological health.
Methadone Maintenance Treatment (MMT) programs offer psychotherapy and counseling with each methadone dose to improve psychological health and behaviors. Individuals in MMT programs can address co-occurring disorders and, if needed, receive medication to treat these disorders as well. These programs encourage education on healthy coping strategies to prevent relapse, as well as learning to manage stress, anxiety, depression, and conflict. Individuals taking Buprenorphine are recommended to take part in psychotherapy while taking their medication.
According to the National Institute on Drug Abuse, there has been an improvement shown through the reduction in certain behaviors of many individuals in Medication-Assisted Treatment programs, including Methadone, Subutex, and Suboxone, such as:
Medication-Assisted Treatment Programs offer successful strategies that prevent and treat severe, chronic medical conditions such as Hepatitis B or C, HIV, AIDS, and Tuberculosis, all of which are common among opioid addicts due to either intravenous drug use or repeated exposure to environments where this type of drug abuse is common. Also, eating habits and other healthy habits are shown to improve in individuals in MAT programs.
Some Medication-Assisted Treatment Programs, such as Methadone Treatment programs, provide support to individuals by offering education, resources, referrals, and access to various support groups. This additional support helps the recovering addict find healthy alternatives to negative environmental issues, such as housing, financial, employment, education, medical, social, or legal difficulties. Having this kind of support is not only beneficial for the recovering addict but also their families and loved ones.
Most MAT programs also offer drug monitoring and other interventions to help guide the individual throughout the program. With Methadone Maintenance, all individuals must comply with rules in order to remain eligible to participate. All OTPs require participants to refrain from the use of all mood-altering substances and to participate in treatment programming. According to the National Institute on Drug Abuse, “No matter how ideologically attractive the notion of time-limited methadone treatment for heroin abusers, longer-term methadone maintenance treatment is far more effective.”
There are also downfalls to Medication-Assisted Treatment Programs.
Methadone Maintenance Treatment (MMT) programs are heavily regulated and must be held at specially licensed treatment centers. MMT programs are limited to geographical areas with the highest rates of addiction. One of the problems with MMT is finding a program close to where the patient resides, as the majority of these programs are still limited to urban areas where addiction rates are more abundant. Methadone is also only dispensed at specially licensed treatment centers.
Another shortcoming of using medications for medication maintenance of opioid addiction includes the reported side-effects of medications. While Buprenorphine is reported to have fewer side-effects, and be less intense of an opioid, Methadone is reported to have more side-effects with higher rates of dependence and/or addiction. Methadone side-effects may include nausea, constipation, frequent urination, sexual dysfunction, and addiction. Many find that MAT is risky because Buprenorphine and Methadone are controlled-substances.
Another concern with MAT is that since the most common medications used are controlled substances; there is a risk of abuse by addicts who abuse other drugs while on MAT or sell their medication to buy other drugs. With proper monitoring of medication, this can be reduced; however, not all clients on MAT have this kind of structured support, as it depends on which MAT program the individual has chosen.
A big issue with MAT is that many addicts have overdosed while on MAT due to the co-administration of other frequently abused illegal or prescribed drugs. Methadone, for example, is commonly abused with benzodiazepines. This is dangerous for all MAT medications because they depress the Central Nervous System (CNS). Using other CNS depressants, such as benzodiazepines and alcohol, significantly increases the probability of respiratory failure, overdose, coma, and fatal complications. Many believe that since MAT is considered a harm reduction treatment, it is best used as a long-term treatment specifically for addicts with a history of chronic relapse.
Members of the community have reported concerns that opioid addicts are substituting one drug for another when using Medication-Assisted Treatment. The controversy of medication-assisted treatment is whether a physician should prescribe opioid-based medicine that continues the opiate habit in order to allow the client the ability to recover and focus on responsibilities and their personal self-growth. There is also debate as to whether a physician should insist on using buprenorphine (or methadone) as an interim solution where individuals should only use it to taper off their opioid of choice in detox, even though withdrawal and higher rates of relapse (often with fatal consequences) threaten the client’s life.
If you or someone you love are struggling with opioid addiction and think that Medication-Assisted Treatment could help, the best thing you can do is to get an evaluation from a treatment professional. Contact a treatment provider today for more information.
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