In 2017, 1,043 Georgians died from opioid-related overdoses.1 People are now more likely to die from an opioid overdose than a car accident.2 This increase in overdose deaths has largely been driven by illicitly manufactured fentanyl powder, pressed into prescription opioid street pills or mixed with other drug supplies (e.g., heroin, cocaine).
To combat the opioid crisis, the National Institutes of Health and the American Medical Association have recommended the use of medication-assisted treatment (MAT). There are three FDA-approved medications for the treatment of opioid use disorder (OUD), which include methadone, buprenorphine, and naltrexone.
An abundance of clinical evidence has proven MAT’s safety and efficacy.3,4 MAT more than doubles abstinence rates in early recovery5 and is superior in treatment retention when compared to placebo.6
Methadone is a full µ-opioid receptor agonist that has been used for decades to treat OUD.7 Methadone binds to the µ-opioid receptor in the brain, thereby reducing cravings and alleviating withdrawal symptoms. Methadone is limited to federally regulated clinics when used in the outpatient setting for the treatment of OUD. These clinics must administer the medication on site (on a daily basis) until the patient has met specific treatment goals, such as attendance at a certain number of counseling appointments and negative urine toxicology results. Take-home doses can be eventually earned with ongoing adherence to the treatment plan.
In 2002, the FDA approved two sublingual formulations of buprenorphine, a partial opioid receptor agonist, for the treatment of OUD.8 Newer formulations include a once monthly buprenorphine injection, as well as implantable rods. Buprenorphine has been used as a pain management medication since 1981.9 In certain cases, buprenorphine has a better safety profile than methadone and has been found to be relatively protective against opioid overdose when taken as recommended. However, there is still the risk of overdose when combined with other agents, particularly benzodiazepines.
Buprenorphine is commonly combined with naloxone, an opioid antagonist, to reduce its potential for injection and nasal insufflation. Naloxone has low bioavailability as a sublingual/buccal agent compared to buprenorphine.
Naltrexone is an opioid antagonist that blocks the reinforcing effects of opioids. Naltrexone is available in a once daily oral formulation, as well as an extended-release monthly injectable. Naltrexone can be difficult to initiate because of the timeframe patients must be free from opioids (usually 7-10 days). Administration of naltrexone while opioids are still present can cause severe withdrawal symptoms. In addition, naltrexone reduces an individual’s tolerance to opioids, which may increase the risk of overdose if the medication is abruptly discontinued with return to opioid use.
Despite the strong evidence base for MAT, it remains widely underutilized due to common misconceptions and existing barriers to prescribing. Clinicians are required to obtain an x-waiver from the Drug Enforcement Administration (DEA) in order to prescribe buprenorphine for OUD (not formulations FDA approved for pain in patients without OUD). At this time, methadone is not available for office-based treatment of OUDs.
Unfortunately, many physicians have not received guidance on how to apply for a DEA waiver.10 For those who do possess a waiver, many do not advertise their ability to provide treatment. According to the Georgia Department of Audits and Accounts, Georgia buprenorphine providers served only 34 percent of their patient capacity despite a growing need for MAT.11 Of those with a waiver, roughly 40 percent did not write a single MAT prescription in 2017.11
Rural communities often lack treatment resources, resulting in long patient waitlists and travel time. In addition, funding sources may not reimburse physicians’ time or the cost of medication sufficiently, causing the out-of-pocket cost for MAT to be high.
Stigma and negative attitudes against MAT also play a tremendous role in some physician and patients’ reluctance to enter MAT treatment. For instance, physicians and patients often have false beliefs about MAT. Some common misconceptions about MAT:12,13
Myth 1: MAT just trades one addiction for another.
Fact: When properly prescribed, these medications do not cause a “high.†Individuals stabilized on MAT can achieve recovery, because they are not experiencing other signs of an active substance use disorder, such as a loss of control or giving up important activities because of drug use.
Myth 2: MAT should be taken for only a short period of time.
Fact: Evidence indicates that patients who receive MAT for longer periods of time have better functional outcomes and are less likely to relapse versus those that discontinue.14
Myth 3: MAT doesn’t work because people may still use opioids and other substances while taking it.
Fact: Addiction is a chronic disease. Just like patients with diabetes take insulin to manage their condition, MAT aims to manage the symptoms of a substance use disorder such as cravings and withdrawal. Even if a person is not fully abstinent, they may still be experiencing some substance-related benefits from MAT such as a reduction in the amount or frequency of use.
Myth 4: MAT increases the risk of overdosing.
Fact: Patients on MAT have a lower risk of overdose. Those who do not receive MAT have higher rates of all-cause mortality and overdose death.15
Myth 5: MAT is for people who do not have the willpower to stop using opioids on their own.
Fact: This is a common stigma associated with MAT. Addiction causes specific functional neuroplastic changes to the brain. Data demonstrates that 90 percent of people with OUD who detox only (and do not enter a residential setting) will drop out of treatment and/or resume opioid use within 2 weeks of detox.16
Myth 6: Pregnant women cannot use MAT.
Fact: When taken adherently in the context of prenatal care engagement, methadone and buprenorphine significantly improve both maternal and fetal outcomes.17,18 MAT also improves the likelihood that parents retain custody of their children.19
Myth 7: Insurance companies do not cover MAT.
Fact: The majority of insurance companies cover MAT costs.
More support is needed by the medical community to enhance the dissemination of MAT in Georgia. Advocacy is necessary to improve the coverage of MAT by private and public insurance payers, increase funding for MAT research and reduce the bias against MAT.
Physicians who regularly treat opioid-using patients are recommended to obtain DEA X waivers and the relevant training for MAT prescribing.11 As we look into the future of MAT, new data will hopefully elucidate the ideal length of treatment based on patient characteristics. For now, we know that MAT improves patient outcomes and saves lives.
References
1. Georgia Department of Public Health. Opioid Overdose Surveillance Preliminary Report, Georgia, 2017.
2. National Safety Council. For the First Time, We’re More Likely to Die from Accidental Opioid Overdose Than Motor Vehicle Crash. In the Newsroom. https://www.nsc.org/in-the-newsroom/for-the-first-time-were-more-likely-to-die-from-accidental-opioid-overdose-than-motor-vehicle-crash. Published January 14, 2019. Accessed February 26, 2019.
3. American Medical Association. The AMA and AAFP Urge Removing All Barriers to Treatment for Substance Use Disorder. 2018. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/BKG-AMA-AAFP-MAT.pdf.
4. National Institute on Drug Abuse. Effective Treatments for Opioid Addiction. https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction. Published November 2016. Accessed February 20, 2019.
5. Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23(2):63-75. doi:10.1097/HRP.0000000000000075
6. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2). doi:10.1002/14651858.CD002207.pub4
7. Doi S, Mori T, Uzawa N, et al. Characterization of methadone as a β-arrestin-biased µ-opioid receptor agonist. Mol Pain. 2016;12. doi:10.1177/1744806916654146
8. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series, No. 40. Substance Abuse and Mental Health Services Administration (US); 2004. http://www.ncbi.nlm.nih.gov/books/NBK64248/. Accessed February 20, 2019.
9. Drug Enforcement Administration Philadelphia Field Division. Schedules of Controlled Substances: Rescheduling of Buprenorphine from Schedule V to Schedule III. https://www.deadiversion.usdoj.gov/fed_regs/rules/2002/fr1007.htm. Published October 7, 2002. Accessed February 26, 2019.
10. Knudsen HK, Abraham AJ, Oser CB. Barriers to the implementation of medication-assisted treatment for substance use disorders: The importance of funding policies and medical infrastructure. Eval Program Plann. 2011;34(4):375-381. doi:10.1016/j.evalprogplan.2011.02.004
11. Griffin GS, McGuire L. Opioid Use Disorder – Access to Medication-Assisted Treatment. Georgia Department of Audits and Accounts Performance Audit Division. November 2017.
12. Legal Action Center. Medication-assisted Treatment for Opioid Addiction Myths & Facts. August 2016. https://lac.org/wp-content/uploads/2016/02/Myth-Fact-for-MAT.pdf.
13. The National Council. Challenging the Myths about Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD). 2016. https://www.thenationalcouncil.org/wp-content/uploads/2016/10/MF_1_30.pdf.
14. Parran TV, Adelman CA, Merkin B, et al. Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug Alcohol Depend. 2010;106(1):56-60. doi:10.1016/j.drugalcdep.2009.07.013
15. Ma J, Bao Y-P, Wang R-J, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. June 2018:1. doi:10.1038/s41380-018-0094-5
16. Smyth BP, Barry J, Keenan E, Ducray K. Lapse and relapse following inpatient treatment of opiate dependence. Ir Med J. 2010;103(6):176-179.
17. Lopian KM, Chebolu E, Kulak JA, Kahn LS, Blondell RD. A retrospective analysis of treatment and retention outcomes of pregnant and/or parenting women with opioid use disorder. J Subst Abuse Treat. 2019;97:1-6. doi:10.1016/j.jsat.2018.11.002
18. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. N Engl J Med. 2010;363(24):2320-2331. doi:10.1056/NEJMoa1005359
19. Hall MT, Wilfong J, Huebner RA, Posze L, Willauer T. Medication-Assisted Treatment Improves Child Permanency Outcomes for Opioid-Using Families in the Child Welfare System. J Subst Abuse Treat. 2016;71:63-67. doi:10.1016/j.jsat.2016.09.006.
