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As its name suggests, “MAT,” or “Medication-Assisted Treatment,” is an approach to treating addiction that uses certain medications approved by the FDA to relieve drug cravings and assist in recovery. The goal: to lower patients’ risks of relapse and improve their prospects of long-term recovery. (Patients’ rates of relapse are highest during the first year after detox.)
But the role of MAT is treatment is not without controversy. Much of that controversy centers around what MAT is administered in treatment, the mechanism by which it works to relieve cravings, and whether it is a short or long-term intervention. In a recent interview, FHE Health Chief Medical Officer Dr. Ahmed Howeedy addressed these and other common questions and concerns among patients and families.
What Role Does MAT Play in Our Overall Treatment Approach?
The use of medications to relieve withdrawal symptoms during detox is par for the course, according to Dr. Howeedy. He explained that when a person is going through detox, “we’ll use medications to help them through that process.”
“That’s important, because with a disease like substance abuse there are physiological processes and changes that occur,” he said. “You can’t tell someone going through detox to simply will themselves to get better, as they need medical intervention at that stage.”
And, the more comfortable a patient feels during withdrawal, the greater their likelihood of successfully completing detox. For this reason, if someone detoxing from Xanax is experiencing pain, headaches antd abdominal discomfort, Dr. Howeedy and his team will prescribe one or more comfort medications to relieve those symptoms.
Patients going through inpatient treatment/detoxification may also be administered medications such as buprenorphine or benzodiazepines, which are tapered down during their inpatient treatment. The goal in detoxification is to use such medications temporarily to get the patient to a place where they no longer need such medications, while they continue being engaged in their recovery through other behavioral therapies.
Some patients, however, despite other interventions, may still need to be maintained on certain medications to help prevent relapse. This is what is people typically refer to as MAT, i.e. maintaining patients on certain medications for extended periods of time.
When Is MAT Administered During Treatment?
Usually, when people talk about MAT, they’re referring to the practice of introducing a medication for cravings instead of detox, and or near the end or after their treatment program.
“When we say after treatment, we’re saying even after patients have completed a treatment program of 30-45 days. After completing treatment, patients are still in a very vulnerable time when they return home.” Dr. Howeedy said.
He explained that post-acute withdrawal symptoms, a phenomenon known as “PAWS,” can continue from six to nine months or longer. PAWS is one reason that rates of relapse are so high during the first year of recovery and why “in the context of post-treatment, there can be a need for MAT.”
But PAWS is not the only reality that many people in early recovery must contend with. Dr. Howeedy shared how it’s not uncommon for a person coming out of rehab to still be dealing with legal issues, relationship dynamics that need addressing, and financial and job placement issues. On top of this, “they may be going back to peers who may not be a good influence.” All of these factors can conspire to make a recovering addict highly vulnerable to cravings and relapse.
“To tell that person that they just need to be strong and fight through it may not be enough. Sometimes patients need something to help with the cravings, so that even with the stressors they won’t fall back.”
Who Is a Candidate for MAT?
MAT is “not for every patient,” Dr. Howeedy said. Some patients have a strong peer and family support group with no real legal or financial issues, in which case MAT would not be needed. On the other hand, “someone who has gone through treatment multiple times is more of the usual candidate for MAT.” They may be at a higher risk of relapsing, have struggled maintaing a healthy support group, have not bee able to make some of the necessary behavioral changes, all of which warrants the use of a MAT.
In these cases, the MAT protocol at FHE Health is to prescribe the drug naltrexone, which is for opiate or alcohol cravings. Naltrexone can be administered orally as a pill or in a monthly injection known as “Vivitrol.”
“We might start [a patient] on that in the PHP/IOP phase of treatment and give them a trial run if we feel they would benefit,” Dr. Howeedy said. (The PHP/IOP phase of treatment usually occurs after detox and prior to discharge.)
A decision in favor of MAT maintenance will always first entail a collaborative discussion between the patient and the medical team: “All of our decisions involve the patient as the center of our interdisciplinary team,” Dr. Howeedy said. “That patient is the center, so we’re working with the patient and making decisions with the patient … Some patients may think something is good for them, but it might not be— in which case we explain why it might not be the best thing for them at that time …. or why it might, in fact, be a good option. We have that discussion with them. A lot of times it’s the medical team that recommends it for the patient when they feel its in their best interest clinically.”
How MATs Help Patients and Assist in Their Rehabilitation
MATs like naltrexone help patients who may be at higher risk of relapse, by dulling the intensity of their cravings. Naltrexone achieves this therapeutic effect by totally blocking the opioid receptors which alcohol, heroin and/or other opiates activate.
And, “studies have shown that MAT therapy reduces relapse rates,” according to Dr. Howeedy. He has seen firsthand how MAT has helped patients overcome cravings that would otherwise have caused them to relapse.
Moreover, when administered correctly, MATs are really only one therapeutic component of integrated care. Dr. Howeedy explained why no MAT should be prescribed in isolation from other important medical, clinical and lifestyle interventions:
“With substance use, we think about what are the factors that are working against a person in their recovery. So part of that are the physiological factors happening in their body, any other medical issues hindering their recovery, changes in their brain from psychiatric issues or chronic substance use, the patient’s emotional coping and decision making skills, their peer and family support, financial and legal situation … all of these factors are part of recovery. So I as a patient, need to be working on all of them. When I am constantly working on all of these factors, I will ensure long-term recovery. If I only address one of these factors, I am bound to fail. Medications will address some of the physiological processes in my body and the chemical imbalances, but I can’t leave the other things unattended to … At FHE Health, we try to address each of these factors simultaneously to ensure the best long term outcomes for our patients. “
The Crux of the Controversy: Suboxone®, Methadone and Trading One Addiction for Another?
The concept of MAT has been around since at least the 1950s, when patients with heroin addiction were given methadone for their cravings. Methadone clinics soon sprang up to meet the need for long-term methadone maintenance among recovering heroin addicts, many of whom to this day rely on methadone as a form of “harm reduction,” in Dr. Howeedy’s words. He explained that methadone is a “full agonist” drug, meaning it “will fully stimulate the [opioid] receptors, has more drug interactions and the withdrawal is more difficult.” As such, methadone has been falling out of favor more recently in the context of MAT.
The same controversy regarding methadone also describes the use of buprenorphine (Suboxone®), to a lesser degree. Suboxone® is a partial agonist, so unlike opiates, heroin and methadone, it does not fully activate the brain’s opioid receptors. It does activate them partially, however.
In this sense, a recovering addict who is prescribed Suboxone® may still experience a certain degree of euphoria and may find Suboxone® habit-forming. (And, in fact, many Suboxone® users come to FHE Health for help coming off of Suboxone, Dr. Howeedy noted.) He acknowledged that some recovering addicts may need Suboxone, which is still significantly less dangerous than heroin or other potent opiates. But, in a similar vein to methadone, he described Suboxone® as a “harm reduction measure.”
“It would be wrong of us to say that MAT options such as methadone or Suboxone® are simply trading one addiction for another. They are medications administered by physicians in a controlled manner, and help patients during their most critical phase, especially for those who are most vulnerable. At FHE however, we don’t discharge our patients on such medications, and only use full agonists such as naltrexone/Vivitrol when needed, as our goal is to help patients move towards not needing such medications, and we feel that can be better achieved through our interdisciplinary and personalized medical, psychiatric, behavioral and neuro-therapeutic interventions.”
Despite its habit-forming potential, Suboxone® has enjoyed the support of much of the medical community and most especially the health insurance establishment, which wants to cut costs and sees Suboxone® as a way to do that. “Their (insurance carriers’) motivation is to avoid having to pay for treatment,” Dr. Howeedy explained. After all, studies suggest that Suboxone® reduces rates of relapse among recovering addicts; and lower relapse rates mean a lower likelihood of being hospitalized or admitted into a treatment program.
Dr. Howeedy said that if Suboxone® is necessary, the medication should only be administered for a specified duration and then carefully tapered (as opposed to being prescribed indefinitely), alongside as many other integrated therapies as possible (neurofeedback, integrated medicine, behavioral interventions, etc…).
New and Developing MATs on the Horizon
Thus far, only alcohol and opiate addictions have MAT options. The good news is there are “some new things on the horizon,” according to Dr. Howeedy. He cited new research into the psychoactive drug ibogaine as a potential MAT for opiates, methamphetamine and even cocaine. And, while there is currently no FDA-approved MAT for cocaine, researchers are studying three possibilities for the future: disulfiram (a MAT for alcohol), baclofen (muscle relaxant) and topiramate (an anti-epileptic drug).`
This is good news for anyone struggling with addiction. It means they have more medication options today than ever before. These, together with evidence-based therapies, can build a strong foundation for recovery.
