Cornerstone of Recovery and M.A.T.: What we do and why we do it

Cornerstone of Recovery and M.A.T.

When it comes to Cornerstone of Recovery and M.A.T. (Medication Assisted Treatment), our clinicians, therapists, administrators and medical staff members are on the same page: There are no wrong doors when it comes to treating those who suffer from the disease of addiction, particularly those who are addicted to opioids.

According to the Provisional Overdose Death Counts released recently by the Centers for Disease Control and Prevention [1], the numbers of those who lose their lives to the disease of addiction continue to exceed the combat deaths of U.S. service members during the entirety of the Vietnam War. According to the CDC’s preliminary data, drug overdose deaths increased 4.6 percent in 2019 to a high of 70,980 — 50,042 of which involved opioids. On top of that, excessive alcohol use is estimated by the CDC to contribute to more than 95,000 lives each year [2] — meaning that drugs and alcohol kill roughly 160,000 people annually.

For that reason alone, we pass no judgment on any of the “doors” that might lead an individual to a way of life that includes freedom from active addiction, in whatever form that may take. M.A.T. provides an invaluable tool for those seeking recovery from addiction (and, to a lesser extent, alcoholism), and we use two of the three federally approved M.A.T. medications — naltrexone maintenance and a short-term buprenorphine during the Medical Detox process — as part of the treatment regimen here at Cornerstone of Recovery.

Recovery is About a Disease, Not a Substance

Cornerstone of Recovery and M.A.T.However, as a facility where the treatment philosophy is built on the traditional model of abstinence — a method that’s served our patients well for more than three decades — we also recognize that M.A.T. is exactly that: a tool that has a place as part of the treatment regimen, but no substitute for the behavioral health therapies that are critical for those who want to get clean and sober.

“Whatever led you into addiction first, those issues have to be addressed,” says Dr. Fred “Kip” Wenger, the Medical Director at Cornerstone of Recovery. “Genetics, behavioral disorders, physical or sexual abuse as a kid — whatever happened to you, those things have to be addressed. This is a medical illness, and in response to the drugs you are taking, whether it’s alcohol or opiates, the brain chemistry changes, and to get sober, it has to heal.”

And because the brain is such a complex organ, that “healing” involves a great many neurological processes that are much more complicated than the healing of other bodily systems — a cut, for example, or a broken bone. One of the ways that opioids affect the brain is that extended use causes the brain to self-regulate to a point of tolerance: nerves reduce the numbers of opiate receptors on their surface, according to a 2001 article in the journal Addiction [3], which reduces “both the effect of the drugs and of the natural transmitter,” which is known as drug tolerance.

“However,” the article goes on to point out, “if morphine or heroin is now rapidly removed, the nerves that have downregulated their opiate receptor proteins are left with a below-normal input” from the brain’s natural opioid transmitters, and until those aforementioned can adapt and increase the opiate receptors back to their normal levels, the individual “is predicted to suffer the consequences of an under-active opioid system (dysphoria, anxiety, hyperalgesia, etc.). We know this as the ‘opiate withdrawal syndrome.’”

This downregulation of receptors, Wenger says, is what drives the obsession and compulsion of addicts to continually pursue the euphoria that accompanied early use, before that downregulation occurred, and it can be a powerful neurological phenomenon to overcome.

“When you stop, for a period of time, it’s not uncommon to need some help, chemically, whether that’s Vivitrol (naltrexone) to reduce the cravings or Suboxone (buprenorphine) or methadone,” Wenger says. “It would be nice to get people off of all drugs, but that may not be realistic — or safe — for some people.”

“If you’re an active addict, you’re more likely to die in your addiction than you are if you switch to methadone or long-term Suboxone maintenance,” adds Dr. Scott Anderson, the Clinical Director at Cornerstone of Recovery. “If the idea is to reduce the harmful effects of opiate addiction, it makes perfect sense to use Suboxone or methadone. I believe that it does save lives, because there are some people who would be dead if they weren’t on a maintenance program.”

Cornerstone and M.A.T.: Building a Life Instead of Just Staying Alive

However, if avoiding death is the only baseline, then recovery would be a far less attractive proposition. Yes, keeping addicts and alcoholics alive is paramount, because recovery doesn’t exist in a lifeless void, but when it comes to Cornerstone of Recovery and M.A.T., we believe that life involves so much more than simply existing. It’s far too easy to draw parallels between a meaningless existence in active addiction, when those who suffered did little more than hang on from one day to the next, and the listless monotony of a life in which the issues, traumas, family of origin problems and emotional dysregulation continue to cause mental, spiritual and psychological damage.

And that doesn’t even begin to touch the vast numbers of patients who seek addiction treatment for multiple substances. It is rare, Anderson points out, that those who come to Cornerstone for help have a problem with a single drug.

“Opioid addiction is just part of a larger addiction picture,” Anderson says. “So much emphasis has been placed on it in the past few years that many people have lost sight of the big picture — which is that addiction is the problem, not just opiates. Many people who abuse opiates also abuse other substances, and I think that’s an overlooked aspect of a problem that M.A.T. can’t fully address.”

That’s one area where M.A.T. can and does fall short. While there are a great many long-term maintenance programs that provide behavioral health therapy in addition to methadone and buprenorphine, there are also many that provide no wrap-around behavioral health care whatsoever. And even when there is, the efficacy can sometimes be questionable, says Dr. Lane Cook, Chief of Psychiatric Services at Cornerstone of Recovery.

Cornerstone of Recovery and M.A.T.“There have been studies of Suboxone (maintenance) alone and Suboxone with therapy, and they both had the same outcomes — because even if they were attending the therapy, they just wanted the Suboxone,” Cook says.

And the very nature of addiction, adds Travis Pyle — Director of Medical Services at Cornerstone of Recovery — means that those on Suboxone (or methadone) maintenance have a greater chance of abusing those drugs, or who want to eventually taper and quit those drugs but find they’re unable to because of just how strong they are.

“Those are the hardest drugs to detox from, and it’s because the withdrawal portion happens later, because of the extended half-life of both of those drugs,” Pyle says. “They come in, and they don’t even start withdrawal until 7 to 10 days in, a lot of times, and by that time, they’re already through Medical Detox, and we can’t push them back to it because of insurance, so we’re just treating the symptoms.

“We have higher AMA rates (meaning patients leave treatment abruptly, or Against Medical Advice) with those drugs in particular, because they are two of the nastiest detoxes I have ever seen. And those who do get off of those drugs tell us it’s the hardest thing they’ve ever done. And most of the time, we hear the same thing: ‘My doctor told me this was a good thing and that I wouldn’t get addicted!’ Or, ‘My doctor said if I wanted to stop I could stop, but he never tapered me down!’”

The Many Considerations of M.A.T.

And then there are financial considerations to such decisions: According to a 2019 study in the journal Addiction [4], “U.S. doctors who receive direct payments from opioid manufacturers tend to prescribe more opioids than doctors who receive no such payments.” In 2019, Reckitt Benckiser Group, the parent company of Suboxone manufacturer Indivior, agreed to pay $1.4 billion to end federal criminal and civil investigations that, among other things, alleged that the company “marketed a version of Suboxone (Suboxone Film) to medical professionals as less addictive and safer than other drugs containing its active ingredient, the opioid buprenorphine,” and that the company promoted an online and phone hotline “as a resource for opioid-addiction patients, which they alleged was actually a method of connecting those patients to doctors the company knew were already prescribing Suboxone and other opioids ‘to more patients than allowed by federal law, at high doses, and in a careless and clinically unwarranted manner.’” [5]

“It’s economics — it’s a lot cheaper to give somebody a pill, keep them alive and send them on their way, and it’s a lot easier than addressing their myriad problems,” Anderson says. “It does keep people alive, but I think it’s over-utilized and over-emphasized, and many people who could go on and live a drug-free life in recovery don’t get an opportunity to because they become dependent on another drug. And, they function well enough that they’re not willing to go through the pain and effort involved with getting off of them.”

In addition, Cook points out, it’s important to keep in mind that enrollment in a methadone or Suboxone clinic keeps patients who visit those facilities for regular doses of their medication in constant contact with other addicts — some of whom may have ulterior motives to the procurement of such prescriptions. Diversion of M.A.T. medications is a very real issue, and federal oversight has wrestled with it over the years.

As an abstinence-based treatment center, Cornerstone of Recovery’s goal, Anderson says, is to acknowledge that recovery can be a difficult, and sometimes painful, transformational process — but on the other side of it is a life unencumbered by the shackles of any substance, illicit or prescribed. And thanks to the myriad therapies and programs offered by Cornerstone, as well as the employment of recovering addicts who have a keen and empathetic understanding of the process through which patients go to get to that point, that pain isn’t carried alone.

“As an abstinence-based treatment model, we believe that’s the best path to restore a person to wholeness, to what they are capable of becoming,” Anderson says. “Most of the studies around harm reduction focus on death, which is of course important and something we should all be battling against and are battling against. Basically, there’s a place for everything, but the main problem right now is that (Suboxone maintenance) is over-touted and marketed as the solution.

“Even though people say there are many paths to recovery and many ways to treat addiction, right now, I believe we’re seeing a movement to force people to use (methadone and buprenorphine) because they’re seen as the only scientific or evidence-based practices for that treatment. But the reality is that evidence-based has to do with following a scientific methodology in which you can randomly assign people to groups and study the impact of a particular intervention on those groups to see if one works better than another.

“With something like traditional, residential treatment, or even people attending 12 Step recovery groups, it’s impossible to randomly assign people to those types of interventions vs. medication interventions and study them via the scientific method,” he adds. “That’s much easier to do with a medication.”

Cornerstone of Recovery and M.A.T.: Abstinence Through M.A.T.

Cornerstone of Recovery and M.A.T.In other words, as a 2014 paper in The Journal of Behavioral Health Services and Research pointed out [6], “Although it is acknowledged that ‘abstinence is the safest approach for those with substance use disorders,’ recovery is often described as a hard, fraught individual journey.” But it’s one that Cornerstone has helped thousands of patients undertake since first opening its doors in 1989, and during that time, administrators and clinicians have embraced opportunities to work within the abstinence model framework to ensure that Cornerstone of Recovery and M.A.T. can work together for the benefit of those patients.

Cornerstone and its sister facility, Stepping Stone to Recovery, use two of the three federally approved M.A.T. drugs: A buprenorphine taper is frequently used in the Medical Detox process for opioid patients, and the facilities offer Vivitrol, an injectable, extended-release form of naltrexone, a non-narcotic opioid antagonist that blocks the opioid receptor sites in the brain and has been shown to combat cravings in recovering addicts and alcoholics.

“It’s one of three medications approved by all parties, and the reason we prefer it is that, because it’s an antagonist, it fits our philosophy better,” says Cornerstone CEO Steve McGrew. “We believe that with the changes drugs make in the brain, it can take months, and in some cases years, for the brain to repair itself, and it takes even longer if you have another drug, even one that’s less harmful, in your system.

“There probably are people that would benefit from Medication Assisted Treatment maintenance, but what we’ve found is that the ‘M’ part is being emphasized more than the ‘A’ part. We believe in the bio-psycho-social-spiritual nature of treating the whole person, and some of these programs do a good job on treating the biological component, but not so much on the other three. And that’s what we offer.”

To that end, Vivitrol has become a crucial component of Cornerstone’s treatment protocol over the past several years. It’s shown moderate success in subduing the cravings of alcoholics, but it’s been a lifesaver — literally — for patients who come to Cornerstone addicted to opioids.

“Insurance loves it, TennCare loves it, and the medication copay is what each patient is responsible for,” Pyle says. “If insurance approves it, we try to get their first injection within two weeks of their admission, because it sits on the (opioid) receptors in the brain and prevents other opiates from activating it, but natural dopamine can get through. We tell patients that when they decide to stop taking Vivitrol, for whatever reason — whether it’s a month in or two years in, they will not have withdrawals. There is no change to their moods.

“The biggest thing they’re going to see, if they stop taking it too soon and they don’t have a recovery program in place, is that the cravings will come back, and they’re not going to know how to deal with them.”

Which is why, at Cornerstone of Recovery, Vivitrol is used in conjunction with the facility’s bio-psycho-social-spiritual approach to recovery. As a 2018 paper in the journal Cerebrum points out [7], “naltrexone can be an extremely helpful medication for opioid and alcohol use disorders. But it is a conceptual error to think that it (or any current FDA-approved medication) should suffice as a standalone treatment for either illness.”

“Addiction is a complex disease, and it’s influenced by your genetics, your environment, your development, your social factors and a lot of other things,” Wenger says. “Ultimately, recovery is a lifelong process. It’s not a ‘one pill and done’ kind of thing. For people outside looking in, they think it’s simple: ‘Just stop!’ But it’s much more complicated than that.”

When it comes to Cornerstone of Recovery and M.A.T., we recognize that complication, which is why we understand that M.A.T. is a much more complex issue than a maintenance program. Is there a place for such programs? Again, our philosophy is that there are no “wrong doors” — but that maintenance shouldn’t be the first and only door that those who wish to recover from addiction consider.

As Dr. Benjamin Srivastrava and Dr. Mark S. Gold write for Cerebrum [7], “Addiction is an enduring illness that characteristically develops over time, yet treatment often is administered in time limited settings. Short-term interventions give patients and families the idea that treatment is some sort of quick fix, but in truth abstinence and long-term recovery are the goals of treatment.”

At Cornerstone of Recovery, we believe we’ve found a place where tradition, science, medicine, psychiatry and innovation meet. We are a M.A.T. facility, but not a maintenance one. We use buprenorphine, but not long-term. We champion and use naltrexone but recognize its limitations and the overwhelming need for wrap-around behavioral health treatment and a long-term recovery plan.

In other words, we offer what we believe is the best path forward for those who seek freedom from active addiction. This is our “door,” and it is open for anyone who has the desire to step through it and experience the life of independence that awaits on the other side.

SOURCES

[1]: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[2]: https://www.cdc.gov/alcohol/features/excessive-alcohol-deaths.html

[3]: https://pdfs.semanticscholar.org/0a15/dc6fea9b6d54b6c4708329530f81e8286474.pdf

[4]: https://www.sciencedaily.com/releases/2019/01/190122084356.htm

[5]: https://abcnews.go.com/Business/suboxone-maker-reckitt-benckiser-pay-14-billion-largest/story?id=64274260

[6]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675178/

[7]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353110/#!po=19.2308