What is Medication Assisted Treatment? An overview of a complex recovery tool

what is medication assisted treatment?

What is Medication Assisted Treatment?

Simply put, Medication Assisted Treatment — or M.A.T. — “combines behavioral therapy and medications to treat substance use disorders,” according to the Substance Abuse and Mental Health Services Administration [1]. In the drug and alcohol treatment field, M.A.T. has emerged as an alternative to abstinence-based treatment, to the point that the two seem to be at odds.

However, they don’t have to be — because the goal of both M.A.T. and abstinence-based addiction and alcoholism treatment is the same: to help suffering addicts and alcoholics find a way out from under the yoke of oppression that drugs and alcohol have placed upon them, so that they’re able to enjoy a fulfilling life as responsible and productive members of society.

What is Medication Assisted Treatment? Early History

what is medication assisted treatment?While M.A.T. has been used to treat alcoholism for decades (and, in the case of methadone, equally as long for opioid/opiate addiction), it’s received much more focus in the past several years as the nation has grappled with a growing opioid crisis. Opiates, derived from the opium poppy, have a long history of both medicinal and recreational use, and according to a 2014 article in The Atlantic [2], opiate dependency, after alcohol, is “‘humanity’s oldest, most widespread, and most persistent drug problem,’ according to a 2004 Harvard Medical School report. The doctors of virtually every ancient culture we learned about in ninth grade relied on the plant whose Latin botanical name, papaver somniferum, means ‘sleep-bringing poppy.’”

While opium and its various derivatives have, over time, made countless contributions to medicine, they’ve also taken center stage in an addiction crisis that has very real, biological origins in the human brain, according to another Harvard Health report [3]: “In anyone who takes opiates regularly for a long time, nerve receptors are likely to adapt and begin to resist the drug, causing the need for higher doses. The other side of this tolerance is a physical withdrawal reaction that occurs when the drug leaves the body and receptors must readapt to its absence.”

In fact, one of the first examples of M.A.T. was used by an opiate addict: John “Doc” Pemberton, a chemist from Georgia whose career was put on hold while he served in the Confederate Army. A saber wound to the chest left him dependent on morphine, which was distributed liberally to soldiers of the American Civil War. As a result, “In 1884, he attempted to use his background as a pharmacist to cure this addiction by creating French Wine Coca, a predecessor to Coca-Cola made up of wine, cocaine, and caffeine-containing kola nuts,” according to a 2013 article in Business Insider [4]. Prohibition in Atlanta led to the removal of alcohol, but cocaine — more specifically coca leaves — remained as an ingredient until the early 1900s.

However, the article goes on to point out, “despite the claims made about the drink's restorative powers, Pemberton remained poor and addicted to morphine until he died of stomach cancer in 1888.” Around that same time, a newly synthesized opiate was introduced by the Bayer Corp. — heroin, marketed as a “safe, nonaddictive” alternative to morphine, according to a 2017 article in The Washington Post [5]. “Initially proposed as a pain killer and cough suppressant, it briefly gained a following among doctors who thought it a cure for morphine addiction and alcoholism. William White, a historian of the addiction field, notes that a well-meaning philanthropic organization known as the Saint James Society actually ‘started a campaign to provide free samples of heroin to any morphine addict who wanted to take the cure.’”

Even Dr. Sigmund Freud, the father of psychoanalysis, touted the curative properties of addictive drugs to treat other addictions: Cocaine, he felt, was another substance that could be used to treat morphine addiction [6], but not long after the turn of the century, the harmful effects of these “treatments” were better understood for what they actually were: substituting one drug for another.

What Is Medication Assisted Treatment? A Transitional Period

what is medication assisted treatment?As the 20th century progressed, however, there were individuals who approached addiction from a medical perspective — and the idea that those afflicted may be unable to stop using without some sort of supplemental aid. One of the earliest pioneers of M.A.T. was Dr. Willis Pollard Butler, whose “groundbreaking approach to treating chemical addiction improved the lives of hundreds of patients and was recognized as being eminently ahead of its time.” [7]

According to the Handbook of North Louisiana Online, “Butler opened his morphine maintenance clinic in Shreveport in 1919 to treat the many addicted sufferers in the area … he sought to treat the disease's underlying causes, and he treated these patients free. The patients received treatment as their conditions required. If the addicts were terminally ill, or otherwise incurable, they received maintenance doses as their addiction required. If the patients were otherwise healthy, they received a weaning dose of morphine in an attempt to affect a cure. For the curable sufferers, Butler's program included the requirement that they be employed, if possible, and that they receive a steady diet of fresh air and recreation. These men and women were encouraged to interact socially with non-users in the community. If the patient was poor, Butler assisted him ‘to get on his feet and become decent and at least respectable looking.’”

By that point, the Harrison Act of 1914 levied heavy taxes on opiates and cocaine as a result of international concern over the spread of opium from the Far East, and a decade later, heroin was outlawed completely. The legislation was amended over the next several decades, eventually evolving into the Controlled Substances Act of 1970, but at the time of the Harrison Act’s passage, morphine maintenance clinics that supplied the drug to war veterans were targeted: “The Treasury Department swiftly closed the clinics and made it personally and professionally risky for physicians to ‘maintain’ a narcotic addict for any reason.” [8]

This led to two developments that would evolve into the first federally approved M.A.T. drug, methadone. The first was the opening of two complexes that were a combination of voluntary admission and incarceration of addicted individuals in Lexington, Kentucky, and Fort Worth, Texas, the goal of which was “treating addicted persons, as well as searching for cures for narcotic addiction and developing nonaddictive pain medication,” according to the journal article “Methadone: History, Pharmacology, Neurobiology, and Use” [9]: “Under the leadership of Dr. Clifton K. Himmelsbach, a great deal was learned about the effects of various opiates and the symptoms that followed their use and cessation. The goal of finding a ‘cure’ or an effective long-term treatment remained elusive. In several prospective studies, it was shown that 70% to 90% of the patients who left the hospital relapsed within 2 years of their discharge.”

The second development occurred in the late 1950s and early 1960s, when a heroin epidemic in New York City led to numerous deaths that prompted federal advocacy for the reopening of “clinics that could distribute narcotics.” [9] Dr. Vincent Dole of Rockefeller University was tapped to chair the Narcotic Committee of the New York City Health Research Council, and in 1963 he began to shift studies in his laboratory “to the pursuit of pharmacotherapy for heroin addiction.” His team of researchers included Dr. Marie Nyswander, a treatment advocate who had spent a year working at the Narcotics Farm in Lexington.

What Is Medication Assisted Treatment? Contemporary History

In the early days of 1964, the Rockefeller researchers first experimented with morphine but soon turned their attention to methadone. Methadone, according to the College of Physicians and Surgeons of British Columbia [10], was first discovered in 1938 by German scientists Max Bockmühl and Gustav Ehrhart, who were working toward a synthetic substitute for morphine for German soldiers as Allied forces controlled parts of the world where most opium was harvested. Nine years later, “Harris Isbell and his colleagues, who had been experimenting extensively with methadone, discovered that methadone was beneficial in the treatment of opiate-dependent patients,” and other studies in the 1940s from the United Kingdom “described methadone’s efficacy in reducing heroin withdrawal symptoms.”

In their research, Dole and Nyswander “found that those who had received methadone behaved in a way that differed significantly from those on short-acting narcotics,” according to Mical Raz, writing for Cambridge University Press [11]. “In between doses, they were calm and functional and were not consumed by the need to obtain more drugs. This led the researchers to develop a maintenance program, based on the idea that addiction was a metabolic disease, with a physiological need for the narcotic, just as diabetics required insulin.” In addition, at sufficient doses, the scientists found, methadone produced a blockade effect that prevented those on it from experiencing intense euphoria if they used other opiates like heroin.

Dole’s team published its findings in 1965, and science and medicine immediately seized on the research as a possible solution to America’s growing drug problem: “Large-scale programs using more cost-effective induction methods opened in New York City, and the US Food and Drug Administration approved a limited use of methadone in large research programs,” according to one article in the Journal of the American Medical Association [12], and in 1971, the Nixon administration, as part of its declared “War on Drugs,” expanded the federal government’s role in treatment and M.A.T.: “In those first 2 years, more federally supported treatment capacity developed than in the previous 50 years. In 1974, two-thirds of the $750 million drug budget was devoted to treatment, research, and prevention, compared with the recent 25 years during which two-thirds of the budget targeted supply reduction.”

Over the next two decades, methadone maintenance was the only M.A.T. that was federally approved, but in the late 1980s, pushback led to “community complaints about loitering and bartering of drugs outside clinics exacerbated the hostile environment.” [12] Although the Office of National Drug Control Policy affirmed methadone as a legitimate component of addiction treatment in 1990, concerns over methadone as a “replacement” drug led to the gradual introduction of the other two federally approved M.A.T. therapies, naltrexone and buprenorphine.

The former “was first synthesized in 1963 by Endo Laboratories, which was later purchased in 1969 by DuPont Pharmaceuticals. Though the drug remained essentially dormant for several years, it attracted interest in 1972 when Congress passed the Drug Abuse Office and Treatment Act for the purpose of developing non-addictive (i.e., non-agonist) treatments for heroin addiction.” [13] Naltrexone binds to the opioid receptors on the brain’s neurons, blocking the effects of opioids like heroin, meaning that the use of such opioids don’t produce the desired euphoric effects. At the same time, the main difference between naltrexone and methadone is that naltrexone is an antagonist, meaning that it doesn’t active those receptors, while methadone — an agonist — does.

Buprenorphine “was discovered in 1966, at the research labs of a home products company, Reckitt & Colman” [14], and one of the chemists on the project, John Lewis, credited researcher Kenneth Bentley’s work with laying the “foundations” of the new drug during work to develop over-the-counter analgesics. Trials conducted in conjunction with the Addiction Research Center led to the publication of a “landmark paper” in 1978 announcing the addiction therapeutics potential of buprenorphine, which as a partial agonist “usefully combined the characteristics of methadone with those of a pure opiate antagonist and effectively blocked morphine” and produced “very little physical dependence” even when administered regularly. However, it would be another quarter-century, not until 2002, that buprenorphine was approved by the Food and Drug Administration for the treatment of opioid dependence [15].

How Does M.A.T. Work?

Few addiction treatment protocols are more vociferously debated than M.A.T., but despite the varying opinions, virtually all addiction treatment providers agree that in some form, M.A.T. deserves a seat at the table, so to speak. The federal government is one of the biggest proponents of M.A.T., primarily for addiction to opioids, because “the prescribed medication operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug,” according to the Substance Abuse and Mental Health Services Administration (SAMSHA) [16].

To understand how M.A.T. can serve a critical role in the treatment of opioid addiction — or opioid use disorder, as it’s referred to in the scientific community — it’s important to understand how opioids affect the brain when used. “Opioids act by binding to specific proteins, called opioid receptors,” according to a 2008 paper in the journal Experimental and Clinical Psychopharmacology [17]. “Receptors are widely distributed. Those involved in pain modulation are situated in both the central nervous system and the peripheral nervous system. These receptors also bind endogenous opioid peptides (endorphins), which are involved in pain modulation and numerous other functions in the body. Among these functions are those mediated by deep structures of the brain, which are involved in the modulation of reinforcement and reward mechanisms, mood and stress.”

Those reinforcement and reward structures are critical in encouraging and sustaining an addictive pattern of opioid use. The euphoria produced through the reward mechanism means that “powerful reinforcement occurs, expressed as efforts to repeat the administration, and these reinforcing outcomes may be associated with craving and with positive mood effects such as euphorigenic or pleasurable effect.” Dopamine, the chemical associated with pleasurable responses, is released in modest increments when pleasurable experiences take place — sex, food, roller coaster rides and any number of other normal human activities that make us feel good.

Opioids, however, act like a clinched fist around a soaking wet sponge: The receptors flood the brain with dopamine, and the intensity of that torrent triggers a demand in some individuals to repeat the experience. However, the body’s supply of dopamine is limited, and as a result, repeated use means it takes more opioids to achieve the desired effect. The absence of those drugs leads to intense cravings and physiological withdrawal symptoms, the combination of which make for incredibly powerful motivators to continue the use of such drugs. That’s the biggest reason that, according to a National Institute on Drug Abuse (NIDA) paper [18], many people relapse: “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. Someone in recovery can also use medications that reduce the negative effects of withdrawal and cravings without producing the euphoria that the original drug of abuse caused.”

What Is Medication Assisted Treatment? A Roundup

what is medication assisted treatment?The FDA has approved three drugs for the treatment of opioid use disorder, and SAMSHA goes to great lengths [16] to emphasize that “these medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body.”

Those drugs include:

  • Methadone, “a synthetic opioid agonist that eliminates withdrawal symptoms and relieves drug cravings by acting on opioid receptors in the brain — the same receptors that other opioids such as heroin, morphine, and opioid pain medications activate. Although it occupies and activates these opioid receptors, it does so more slowly than other opioids.” [18]
  • Buprenorphine, “a partial opioid agonist, meaning that it binds to those same opioid receptors but activates them less strongly than full agonists do. Like methadone, it can reduce cravings and withdrawal symptoms in a person with an opioid use disorder.” [18]
  • Naltrexone, “an opioid antagonist, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal … it treats opioid use disorder by preventing any opioid drug from producing rewarding effects such as euphoria.”

However, it’s important to note that what’s often lost in these discussions is the “A” part of M.A.T. — meaning that medication, as Cornerstone of Recovery Clinical Director Dr. Scott Anderson points out, isn’t meant to be the cure, but rather an aid in the process and a step in the right direction.

“Our experience and my belief is that addiction involves a lot more than just a physiological process — it involves the whole person, which is why we have a bio-psycho-social-spiritual and holistic method of recovery at Cornerstone,” Anderson says. “You can’t just give somebody a pill or a medication that’s going to make all these other aspects of being a human being suddenly be alright.”

In an ideal setting, that’s the gold standard, one required by the federal government: “Under federal law, MAT patients must receive counseling, which could include different forms of behavioral therapy,” according to SAMSHA [16]. “These services are required along with medical, vocational, educational and other assessment and treatment services.”

Those wrap-around behavioral health services are critical for the ultimate goal of M.A.T.: “full recovery, including the ability to live a self-directed life.” [16] Under the right settings, M.A.T., combined with evidence-based psychotherapies and behavioral health processes that have been used effectively at facilities like Cornerstone of Recovery, can be a game-changer for those seeking to find freedom from the bondage of opioid use disorder — providing that the medication remains one of the tools that helps facilitate that freedom, instead of a de facto “cure.”

“As M.A.T. has been increasingly touted, there has been lees emphasis placed on behavioral and psychological interventions and more emphasis placed on the medication,” Anderson says. “There are even studies that recommend switching from Medication Assisted Treatment to Medication Based Treatment, and I think this is what we’re seeing happen over time. There has been an increased emphasis on access to these medications, through primary care physicians or other providers who do not offer behavioral health services.

“In the beginning, of the Suboxone movement, there was the idea that this would be a short-term process to facilitate the individual becoming abstinent. Over time, the message has evolved into a long-term maintenance program that might never involve discontinuing the drug. This points to one of the problems with M.A.T., which is that people begin to see the drug as the solution to the problem, rather than as a short-term aid in addressing the problem.”

SOURCES

[1]: https://www.samhsa.gov/medication-assisted-treatment

[2]: https://www.theatlantic.com/health/archive/2014/02/heroin-addictions-fraught-history/284001/

[3]: https://www.health.harvard.edu/mind-and-mood/treating-opiate-addiction-part-i-detoxification-and-maintenance

[4]: https://www.businessinsider.com/inventor-of-coca-cola-was-a-morphine-addict-2013-12

[5]: https://www.washingtonpost.com/news/wonk/wp/2017/04/11/doctors-once-treated-alcoholism-with-heroin-now-they-want-to-treat-heroin-addiction-with-marijuana/

[6]: https://www.pbs.org/newshour/show/cocaine-how-miracle-drug-nearly-destroyed-sigmund-freud-william-halsted

[7]: http://nwla-archives.org/handbook/butlerWillisPollard.htm

[8]: https://www.ncbi.nlm.nih.gov/books/NBK232105/

[9]: https://www.westbridge.org/wp-content/uploads/2014/06/Enc-of-Neuroscience-Methadone.pdf

[10]: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Publications/Epid/Other/02_CPSBC-Methadone_Maintenance_Program_Clinical%20_Practice_Guideline.pdf

[11]: https://www.cambridge.org/core/journals/journal-of-policy-history/article/treating-addiction-or-reducing-crime-methadone-maintenance-and-drug-policy-under-the-nixon-administration/5C7779395D4B4AC7ECAB77F5D91BA455

[12]: https://jamanetwork.com/journals/jama/fullarticle/182898

[13]: https://www.dana.org/article/naltrexone-a-history-and-future-directions/

[14]: http://app.ihi.org/Events/Attachments/Event-2892/Document-6456/The_history_of_development_of_buprenorphine.pdf

[15]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994593/#:~:text=In%20October%2C%202002%2C%20the%20FDA,the%20treatment%20of%20opioid%20dependence.

[16]: https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

[17]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711509/

[18]: https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work